Research Paper
Abstract
Attention deficit hyperactivity disorder (ADHD) is defined as an impairment in neurobehavioral functioning that is characterized by constant and dysfunctional indications of inattention and hyperactivity. Individuals with ADHD usually have major disabilities in interpersonal, social, and academic performance. Moreover, ADHD is related to a number of co-morbid disorders and disabilities like learning impairments, disruptive behavioral patterns, and mood disorders. Numerous treatments have been studied by researchers, but most of them focused on pharmacological treatments. Generally, there is a lack of research on the effectiveness of behavioral treatments in treating ADHD. One of the potential treatments for ADHD-- positive and negative reinforcement intervention-- requires further research. Few of the studies on the effectiveness of reinforcement treatments in treating ADHD have largely found out that they are highly effective. This paper reviews existing literature on ADHD and the various treatments and the effectiveness of reinforcement interventions in treating ADHD.
Introduction
Attention-deficit hyperactivity disorder (ADHD) is considered as a serious public health problem in the United States, for it is the main cause of the need of numerous children to use mental health services. Favorably, both psychopharmacological and psychosocial treatments have been found to positively affect ADHD. According to recent studies, several school-aged children in the U.S. had been given some form of pharmacological treatment for ADHD, most of them being administered with methylphenidate (MPH), a psychostimulant (Swanson, 2008). Clinicians and experts reported that psychostimulants were able to reduce major symptoms of ADHD in most of the children who received the treatment. The medication's unusual effectiveness is the reason, to a certain extent, why credible studies in the area in the recent decade has concentrated on these treatments for research. This paper reviews existing literature on ADHD, the various treatments for the disorder, and the effectiveness of reinforcement interventions in treating ADHD.
Research Done on the Target Behavior
Instead of looking for new treatments, researchers have focused on a single medication-- methylphenidate-- to examine outcomes in children with both ADHD and mental retardation, unfavorable occurrences, the nonresponders' attributes, and the identification of 'normalization' in the course of the drug medication (Monastra et al., 2002). Another set of treatments for children with ADHD consists of training for parents and teachers in appropriate behavior-management methods designed to reduce the problem behaviors related to ADHD. Cognitive-behavioral therapy is a skill-based treatment frequently administered to adults with ADHD, and several studies have reported that CBT is highly effective in treating ADHD in adults (Coates et al., 2014).
The findings of Hodgson and colleagues (2012) show that two kinds of treatment--- correctly performed medication by itself or in combination with a comprehensive behavioral treatment course, such as parent training and therapeutic vacation-- were considerably more successful in mitigating ADHD symptoms that either regular community-based treatment or behavioral therapy by itself. Furthermore, research subjects who received both behavioral treatment and medication were administered with substantially reduced amounts of medication compared to those who received medication alone-- but research subjects in these two treatment groups exhibited the same mitigations in symptoms of ADHD (Hodgson et al., 2012). Thus far, these differences in outcomes have prolonged for several months.
Generally, in other aspects-- academic performance, parent-child relationship, social skills, aggressive/oppositional behaviors-- a small number of differences among the treatment groups were observed by Swanson and colleagues (2008), with several deviations: combined treatment was the most effective for behavioral therapy for parents' observations of the reading performance, aggressive/oppositional symptoms, and anxiety symptoms of their children. Combined treatment produced more positive results than community care for all aspects. On the contrary, behavioral treatment and medication alone were each more effective than community care in terms of parent-child relationship and social skills (Swanson, 2008). Nevertheless, parents showed higher satisfaction with the improvement in their children and the quality of the treatment and their children were less prone to withdraw from the treatment when they received both behavioral therapies and medication than when medication alone was administered.
The weaknesses, inconsistencies, and inadequacies of medication and established behavioral treatments for ADHD have led to new studies to look for more effective approaches to the treatment of ADHD subtypes. ADHD is generally identified as a behavior problem and there are indications that such symptoms of behavior disorder are significantly correlated to electrophysiological, circulatory, and metabolic anomalies (Kerson, 2013). Studies have used electrophysiological variations in patients with ADHD to create efficacious ways of treating ADHD patients on an individualized manner.
Over the recent decades, studies have discovered that children with ADHD typically have distinct brain wave activities. Numerous studies have demonstrated that individuals with ADHD usually have weak beta and alpha activities and an excess of sluggish brain wave activities. Normally, beta activity escalates during mental and physical exercises; yet, individuals with ADHD have reduced beta activity during mental exercises and an overall impairment of beta and alpha functioning (Kerson, 2013; Hillard et al., 2013). In the 1970s, the earliest neurofeedback operations were carried out as an intended treatment for such abnormalities and complications. Arnold and colleagues (2012) reported that neurofeedback is highly effective in reducing and treating behavioral disorders. According to his findings, neurofeedback is more effective in treating ADHD than stimulant medications.
Monastra and colleagues (2002) carried out a research with children to find out whether stimulant medication or neurofeedback was more effective in treating ADHD in children. The findings showed no considerable differences between neurofeedback and stimulant medication when performing a mean standard score assessment after treatment programs. Arns and colleagues (2009) reported that stimulant medication and neurofeedback are similarly effective in treating ADHD. Studies reviewed by Monastra and colleagues (2005) explained the impact of EEG operant conditioning on enhancing academic performance, improving performance in intelligence tests, and reducing behavioral and attention deficits.
The meta-analysis of Fabiano and colleagues (2009) is the first exhaustive empirical literature synthesis of behavioral treatments for ADHD that covers all research designs and behavior modification approaches since the earliest published research on ADHD treatment in the 1970s. The findings conclusively substantiate the efficacy of behavioral treatments for ADHD. Findings were coherent across study designs and methodologies, which indicates the findings' generalizability. Behavioral treatments are definitively superior to control groups across study designs, and the intervention's outcomes are significant (Fabiano et al., 2009). A significant ramification from this meta-analysis is that the several current studies that have been explained as suggesting that behavioral treatments are ineffectual are not a general representation of the literature in general.
It is clear that these studies seem to have been treated with different importance in several popular studies and in the most recognized ADHD treatment guidelines in the U.S., stressing the important administration of medication for the treatment and management of ADHD, while devaluing behavioral treatments or discarding them as mere complementary treatments. The current findings show that professional recommendations and guidelines must be changed to represent the present standing of all the studies on behavioral treatments (Coates et al., 2014) for ADHD.
Research on Reinforcement as Treatment for ADHD
Methodically managing or controlling the probabilities or effects of behavior can be a highly effective method of modifying the performance, functioning, and behavior of children with ADHD. The systematic and decisive use of teacher attention, recognition, and praise consistently has been reported to enhance students' behavior in the classroom. More particularly, recognizing students often for good behavior and neglecting them persistently for bad behavior typically will enhance the performance and behavior of school-aged children with conduct disorders (Miltenberger, 2011). Nevertheless, the systematic use of attention, recognition, and praise with students who have ADHD is not adequate. School-aged children with ADHD necessitate more comprehensive behavior modification intervention comprising regular and direct feedback through an integration of systematic application of negative consequence treatments and improved positive (Hodgson et al., 2012) reinforcement.
One technique of improving the outcomes of a positive reinforcement treatment is to use more precise reinforcement, such as gaining benefits, dependent on the observance or completion of desired behaviors, like accomplishing assignments or participating in class discussions. Usually it is unwise to provide actual reinforcers often and right away after a student carries out desired behavior. A more effective way of using improved positive reinforcement is to give small gifts or mementos like points or stars that can be accrued and swapped for substitute reinforcement of higher value-- for instance, ten points can be swapped for one hour of play time after school (Chronis et al., 2006; Maag, 2001). The benefit of these small gifts is that they can be dispensed regularly, right away, and cheaply. Such improved positive reinforcement programs have been discovered to be much more efficacious in enhancing academic performance and on-task behavior in comparison to treatments using only verbal praise.
The application of an all-positive reinforcement program mostly is not adequate to enhance the behavior and performance of students with ADHD. The systematic use of negative reinforcement usually is quite effective in creating behavior modification treatments for these children. A moderate type of punishment, verbal admonitions, is quite often exercised by teachers and can lead to positive results if used appropriately (Miltenberger, 2011; Plumer & Stoner, 2005). A number of studies have proven that admonitions can be useful if they are coherent, direct, solid, and terse. Furthermore, studies show that once a combination of verbal admonitions and praise is exercised to teach students about the rules, it is probable to sustain the impact of the treatment with an all-positive reinforcement system. It is almost instinctive to excessively use verbal admonitions with a student who is not paying attention and/or careless or impulsive. A useful guideline for teachers is to use positive reinforcement more frequently that verbal admonitions or other types of negative reinforcers.
Numerous school-aged children with ADHD need an improved negative reinforcement program to enhance their behavior and performance. 'Response cost' is one technique of improving a program of negative reinforcement, comprising the elimination of a reinforcer dependent on unfavorable or improper behavior. Coates and colleagues (2014) discovered that response cost was highly effective in enhancing the academic performance and on-task behavior of students with ADHD. However, even though response-cost treatments can be quite effective, possible aftereffects are related to their application. Response cost is a type of punishment. Response-cost interventions that are not integrated in a behavior modification program that is mostly positive could result in students becoming disheartened, and change in behavior could be negligible (Coates et al., 2014). Hence, it is important to thoroughly balance positive and negative reinforcement programs in treating ADHD in children.
Conclusions
ADHD among school-aged children has been considered a major public health issue in the U.S. Researchers have studied various forms of treatments for ADHD, particularly pharmacological and psychosocial treatments. However, most existing studies on this area have largely focused on pharmacological treatments for ADHD. Hence, more studies focusing on other treatments, especially behavioral treatments, should be carried out. A combination of positive and negative reinforcement interventions has been found by numerous researchers to be highly effective in treating ADHD among students.
References
Arnold, L.E. et al. (2012). EEG neurofeedback for ADHD double-blind sham-controlled randomized pilot feasibility trial. Journal of Attention Disorders, 17(5), 410-419.
Arns, M. et al. (2009). Efficacy of neurofeedback treatment in ADHD: the effects on inattention, impulsivity and hyperactivity: a meta-analysis. Journal of the EEG and Clinica Neuroscience Society, 40, 180-189.
Chronis, A. (2006). Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder. Clinical Psychology Review, 26, 486-502.
Coates, J. et al. (2014). Parenting interventions for ADHD: a systematic literature review and meta-analysis. Journal of Attention Disorders, 19(10), 831-843.
Fabiano, G. et al. (2009). A meta-analysis of behavioral treatments for attention- deficit/hyperactivity disorder. Clinical Psychology Review, 29, 129-140.
Hillard, B. et al. (2013). Neurofeedback training aimed to improve focused attention and alertness in children with ADHD. Clinical EEG and Neuroscience, 44(3), 193-202.
Hodgson, K. et al. (2012). Nonpharmacological treatments for ADHD. Journal of Attention Disorders, 18(4), 275-282.
Kerson, C. (2013). A proposed multisite double-blind randomized clinical trial of neurofeedback for ADHD need, rationale, and strategy. Journal of Attention Disorders, 17(5), 420-436.
Maag, J. (2001). Rewarded by punishment: reflections on the disuse of positive reinforcements in schools. Exceptional Children, 67(2), 173-186.
Miltenberger, R. (2011). Behavior modification: principles and procedures. Mason, OH: Cengage Learning.
Monastra, V.J. et al. (2002). The effect of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Applied Psychophysiology and Biofeedback, 27(4), 231-249.
Monastra, V.J. et al. (2005). Electroencephalographic biofeedback in the treatment of attention- deficit/hyperactivity disorder. Applied Psychophysiology and Biofeedback, 30, 95-114.
Plumer, P. & Stoner, G. (2005). The relative effects of classwide peer tutoring and peer coaching on the positive social behaviors of children with ADHD. Journal of Attention Disorders, 9(1), 290-300.
Swanson, J. et al. (2008). Evidence, interpretation, and qualification from multiple reports of long-term outcomes in the multimodal treatment study of children with ADHD. Journal of Attention Disorders, 12(1), 15-43.
