Running head: BEYOND MEDICATION

Beyond Medication: An examination of the effectiveness of socio-cognitive therapeutic techniques for adolescent and adult ADHD

Jamie Wilkinson Walden University PSY-8393 April 14, 2013 Robin Friedman

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Beyond Medication: An examination of the effectiveness of socio-cognitive therapeutic techniques for adolescent and adult ADHD

Within the past twenty years an increasing number of adolescents have obtained a diagnosis of Attention-deficit/Hyperactivity disorder (ADHD) (Alloway, Elliot, & Holmes, 2010; Sizoo, et. al., 2010; Polanczyk, de Lima, Horta, Biederman, & Rohde, 2007). Data gained for this diagnosis is typically obtained through secondary accounts of adolescent behavior over time via teachers and family in addition to clinical interviews (APA, 2000). Standard chemical treatment for ADHD involves the consumption of one or more different medications, usually amphetamine-based. There are currently seven different types of extended release medications used in the treatment of ADHD: Vyvanse, Adderall XR, Concerta, Daytrana, Focalin XR, Metadate DC, and Ritalin CA. These medications improve focus though delivering additional energy to neurons, thus increasing the overall neuron firing rate (Oades, et. al, 2010). While the use of stimulant medication has a proven record of providing relief from ADHD symptoms, there are corollary effects of the diagnosis that must be attended to in order to provide significant improvement to overall client quality of life and cognitive functioning (Safren, et. al, 2010). My capstone project involves a thorough evaluation of current psychostimulant, cognitive behavioral and social skills building therapeutic practices. This paper will evaluate the effectiveness of each practice by itself, and then develop a middle of the road therapeutic practice that incorporates the best of each of the current best practices. Through walking this middle path, Clinical Psychologists can offer clients not only relief from their pathology, but facilitate the development of the necessary coping and independent living skills that will lead to increased psychological resilience and an increase in overall quality of life.

BEYOND MEDICATION The critical considerations for this problem are as follows. First, to what extent has

psycho-stimulant medication provided symptomatic relief for those suffering from ADHD? How specifically do these medications provide such relief? Next, it is important to examine the sociocognitive therapeutic techniques being used to manage ADHD symptoms. Of primary importance is the use of cognitive behavioral techniques such as behavioral awareness and thought control to provide an awareness of environmental and social variables that could contribute to ADHD symptom exacerbation. The final critical consideration for this project involves the social variables that could exacerbate or reduce the overall symptoms of ADHD. Through an examination of these critical considerations, a systemic approach towards dealing with these problems can be developed and implemented. This theoretical approach will combine the best parts of each treatment program while various aspects compensate for the drawbacks of each program individually. The issue of ADHD symptom management was selected in part because of my own personal experiences. In addition to my own personal experiences as an individual who dealt with ADHD, I have also recognized that the various schools of psychological thought approach treatment of this condition in a variety of ways. Psychiatrists, having a biological perspective, prefer to prescribe medications that influence neurochemistry to manage the symptoms. Conversely, clinical psychologists that have a cognitive behavioral perspective will examine the thoughts leading up to ADHD behavioral expression and seek ways to make the client aware of such so the client can take control of their thoughts and behaviors. Finally, clinical counselors who are of neither the biological nor cognitive behavioral school may examine the social environments through which the client travels, looking for hidden triggers that may promote ADHD behavioral expression. Each school of thought has proven to be effective in their own

BEYOND MEDICATION particular way, but none has been able to provide a complete method for managing ADHD

symptoms across all systems: biological, cognitive, and social. That is the literature gap that my capstone seeks to address. Problem Statement In modern American society, anywhere from 3% to an upwards of 8% of school-aged children are diagnosed as having Attention-Deficit/Hyperactivity disorder (Alloway, Elliot, & Holmes, 2010; Sizoo, et. al., 2010). Up to 65% of school-aged children who are diagnosed with ADHD have symptoms that persist into adulthood (Mattingly, 2010). Current long-term treatment for ADHD involves the use of prescription drugs such as Vyvanse, Adderall XR, and Ritalin. These medications must be taken daily, often at numerous periods over the course of a day to maintain effectiveness (Thakur, et. al., 2010; Katz, et. al., 2010). Many of the drugs being used are amphetamine-based, creating opportunity for addiction (Svetlov, Kobeissy, & Gold, 2007; Steiner, Van Waes, & Marinelli, 2010). As a long-term treatment, the use of medication can create additional issues with addiction and substance abuse disorders further down the individuals lifespan (Svetlov, Kobeissy, & Gold, 2007; Steiner, Van Waes, & Marinelli, 2010). The problem, to be explored in this paper, is that all treatment options for ADHD are not being considered by treatment teams. Given the amount of neurochemical literature that exists on the effects of amphetamine-based medication on both children and adult sufferers of ADHD, the appearance is a professional trend towards administering medication to manage ADHD symptoms. The literature on cognitive-behavioral techniques as an ADHD clinical intervention is sparse, however what does exist indicates that cognitive-behavioral interventions build attentional resources and refine focus result in a reduction of overall ADHD symptoms (Tamm, et. al., 2010; Ramsay, 2010). This paper will explore what is currently understood regarding

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medication-based treatment and cognitive behavioral approaches and will put forth an integrative response towards ADHD treatment.

Integrated Literature Review Ritalin, also known as Methylphenidate, was first developed in 1944 (Svetlov, Kobeissy, & Gold, 2007). In 1950, Ritalin was clinically introduced to treat chronic fatigue, depression, and narcolepsy (Svetlov, Kobeissy, & Gold, 2007). In 2007, 2.5 million children or more have been diagnosed with ADHD and were prescribed Ritalin (Svetlov, Kobeissy, & Gold, 2007). Whether taken by individuals with a diagnosis with ADHD or not, Ritalin improves cognitive functioning, specifically in the domains of concentration and spatial working memory (Svetlov, Kobeissy, & Gold, 2007). Pharmacologically, Ritalin is chemically similar to amphetamine-based drugs such as cocaine (Svetlov, Kobeissy, & Gold, 2007). Svetlov (2007) indicates that regardless of these structural similarities, amphetamine and cocaine abuse is more prevalent among the general population, whereas methylphenidate does not have the same physical dependency issues, thus reducing the likelihood of abuse. Methlyphenidate bonds to dopamine transporters while at the same time reducing the overall reuptake of dopamine in the prefrontal cortex, limbic region, and striatum within the brain (Svetlov, Kobeissy, & Gold, 2007). The most significant concentration of methylphenidate tends to occur in the striatum (Svetlov, Kobeissy, & Gold, 2007). Svetlov (2007) puts forth that because the physiological response is not the same as the physiological response to cocaine, that physical dependence is unlikely. Beyond bonding to dopamine transporters, methylphenidate prevents monoamine reuptake (Svetlov, Kobeissy, & Gold, 2007). At peak, the concentration of methylphenidate in the brain remains stable for about 15 to 20

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minutes, as opposed to 2 to 4 minutes for cocaine. Svetlov (2007) indicates that methylphenidate addiction occurs when there is a rapid increase in dopamine in the brain. This article indicates that such would occur if the prescribing physician started the patient out with a higher dose than is necessary for therapeutic effectiveness (Svetlov, Kobeissy, & Gold, 2007). This article identified physician best practice of providing ADHD patients with a low prescription of methylphenidate then raising the dosage to the minimum necessary for therapeutic effectiveness (Svetlov, Kobeissy, & Gold, 2007). Svetlov (2007) assertively declares that no instances of Ritalin addiction have occurred in children, 13 or younger. However, after making such statement, Svetlov (2007) describes methylphenidate abuse as prescription sharing and misuse, and possession without a prescription. Furthermore, it is asserted that such illicit use is motivated by the positive performance enhancing qualities of the medication in the academic environment (Svetlov, Kobeissy, & Gold, 2007). Svetlov (2007) continues to indicate that non-prescription methylphenidate abuse occurs consequent of the drugs stimulant effects, specifically appetite suppression, fatigue reduction, and increased attentiveness/alertness. This article continues to cite statistics found in US Drug Enforcement Agency surveys that indicate that 30 to 50% of adolescents in drug treatment centers report having abused Ritalin, usually orally (Svetlov, Kobeissy, & Gold, 2007). Svetlov (2007) reports students abusing Ritalin as an academic performance enhancer and source of entertainment are correlated to the way in which amphetamines were abused on university campuses in the 1960s. Finally, Svetlov (2007) indicates that Caucasian males who were members of fraternities or sororities and had a low academic average were at greater risk of nonprescription use of Ritalin.

BEYOND MEDICATION While the information contained within the article is worthwhile, there are a number of problems with the overall analysis. The most glaring issue is that many of the authors claims contradict earlier claims. For example, Svetlov (2007) assertively states that there is little opportunity for methylphenidate abuse, yet continues to describe in rather specific detail the nature of methylphenidate abuse. In addition, Svetlov (2007) indicates that while methylphenidate does not create physical dependence, there are circumstances when physical dependence is experienced, contradicting his earlier claims. Also, this article fails to consider other avenues for psychological dependence specifically how positive reinforcement experienced by ADHD and non-ADHD users could lead to psychological dependence on the

drug. Whether continued use of methylphenidate is the result of psychological or physiological dependence, to state that addiction is not possible because physiological dependence is not present minimizes the overall potential for addiction. Through this minimization of potential harm, client risk is increased. This article also represents an increasing body of work that, at the time, supported the notion that long-term use of methylphenidate or amphetamine-based medications in the treatment of ADHD symptoms were relatively safe. Attention Deficit/Hyperactivity Disorder is prevalent within American and global communities. Attention Deficit/Hyperactivity Disorder (ADHD) affects 3 to 8% of children in the K-12 educational system (Alloway, Elliot, & Holmes, 2010; Sizoo, et. al., 2010). The number of children with ADHD symptoms that persist into adulthood varies from 40% to 90% (Biederman, et. al., 2010). ADHDs primary symptoms affect executive cognitive functioning (Tamm, et. al., 2010; Safren, et. al., 2010). Ramsay (2010) defines executive functioning as those self-directed actions of the individual that are being used to self-regulate. (pg. 38) Specifically, executive functioning within the brain assist in the collection and organization of

BEYOND MEDICATION various environmental stimuli that influence cognitive, affective, and behavioral functioning,

with the natural consequences inherent within everyday living (Ramsay, 2010). Several different aspects of executive functioning are affected by ADHD: behavioral inhibition, nonverbal working memory, verbal working memory, affect regulation, and reconstitution (Ramsay, 2010; Safren, et. al., 2010). Behavioral inhibition is the ability to control an action response to a positive or negative reinforce that is available in the short term (Ramsay, 2010; Safren, et. al., 2010). Nonverbal working memory is the ability to retain and relive experiential scenarios (Ramsay, 2010; Safren, et. al., 2010). Verbal working memory involves the development of an internal monologue that can be used to direct behavioral responses (Ramsay, 2010; Safren, et. al., 2010). Affect regulation permits experiential recognition of various emotional states, resulting in the ability to manipulate experienced feelings towards desired outcomes (Ramsay, 2010; Safren, et. al., 2010). Finally, reconstitution allows for analysis and synthesis of behaviors into overall behavioral patterns, a skill that is particularly important in planning and problem solving (Ramsay, 2010; Safren, et. al., 2010). Having explored the nature of executive functioning; now the question must be answered of why such is important. Executive functioning that is adaptive and functional permits the organization and execution of behaviors directed by goals along the continuum of time (Ramsay, 2010; Safren, et. al., 2010). Information taken in through the senses is analyzed and compared against that which has already occurred via the nonverbal and verbal working memory (Ramsay, 2010; Safren, et. al., 2010). Affect regulation is important in determining the proper course of action as the self can adjust the internal monologue of the verbal working memory as recognition of negative affect can have significant influence on the quality of the monologue (Ramsay, 2010; Safren, et. al., 2010). Behavioral inhibition permits the self with not only the opportunity to plan behavioral

BEYOND MEDICATION responses based on environmental stimuli, but also the ability to act on behaviors (Ramsay, 2010; Safren, et. al., 2010). Finally, reconstitution permits the analysis of past experiential scenario end-results, then in collaboration with the verbal working memory, future appropriate behavioral responses to similar environmental stimuli are incorporated into the overall behavioral response toolkit (Ramsay, 2010; Safren, et. al., 2010). This interlocking temporal model of behavioral and environmental response is important because any dysfunction within any particular skill set sets forth a cascading, downward spiral of functional impairment across the lifespan (Ramsay, 2010; Safren, et. al., 2010; Biederman, et. al., 2010). This spiral of

impairment is at the very heart of ADHD symptoms. To an extent, such impairment is the result of neurochemical imbalance, thus psychotropic medication has a significant impact on overall executive functioning (Biederman, et. al., 2010). Fixing the neurochemical imbalance within the biological systems that comprise the executive functioning portion of the brain is just as important as providing skill-based developmental opportunities for those suffering from ADHD (Ramsay, 2010; Safren, et. al., 2010). A major contributor to ADHD pathology is the prevalence of malformed behavioral schemas. Schemas are primary beliefs that develop as a result of the individuals attempt to better understand their environment and personal experience through extensive analysis and categorization (Ramsey, 2010; Safren, et. al., 2010). Ramsey (2010) puts forth that schemas begin influencing behavior in children, 8 years and older. Modifying existing schemas and developing new sets of cognitive skills is the purview of cognitive-behavioral therapeutic techniques. Cognitive-behavioral therapy (CBT) focuses on changing cognitions within an individual as a gateway for changing behaviors (Ramsey, 2010; Safren, et. al., 2010; Tamm, et. al., 2010). As it relates to ADHD, CBT techniques take into account the overall dysfunction of

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executive functioning systems, and seek to reconfigure the existing cognitive schemas into more functional behavioral patterns (Ramsey, 2010; Safren, et. al., 2010). Approaching executive functioning from a biological and a cognitive perspective, the path is paved for CBT techniques. Specifically, executive functioning training can take place. Attention Training (ATT) attempts to provide additional opportunities for ADHD suffering clients to practice increasing cognition regarding behavioral inhibition, verbal and nonverbal memory, and reconstitution (Tamm, et. al., 2010). This training takes the form of repetitive task completion, and is designed to increase overall client competence and skill in the use of executive functioning operations (Tamm, et. al., 2010). Participation in ATT resulted in statistically significant gains in the way of addressing the reconstitution aspect of the executive function dysfunction (Tamm, et. al., 2010; Ramsey, 2010). There was not a significant therapeutic effect found in the domains of behavioral inhibition, affect regulation, or working memory through participation in ATT (Tamm, et. al., 2010). In a comparison study, CBT provided a significant treatment effect in improving overall executive functioning for medication-treated adults compared to those who merely received relaxation techniques and educational support (Safren, et. al., 2010). Safren, et. al., (2010) noted that this executive functioning progress was retained over a 6 to 12 month period. These gains occurred in all areas of executive functioning (Safren, et. al., 2010). In the overall study of CBT on ADHD, a major methodological problem that exists is the small sample size used for the study. The Safren study, for example, only used 86 adults, no age range given, that met the diagnostic criteria for ADHD. On the lower end of the spectrum, the Tamm study involved only 29 participants between the ages of 8 and 14 years (Tamm, et. al., 2010). Beyond the age criteria, all participants within the Tamm study were Caucasian and had an IQ greater than 85 (Tamm, et. al., 2010). No information was provided regarding participant

BEYOND MEDICATION demographics for the Safren study other than 86 adults participated in the study. This lack of

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demographic information makes it difficult to determine the generalizability of CBT use across populations for ADHD symptom relief. The use of psychotropic medication and the prevalence of ADHD among the general population have a strong literature foundation supporting therapeutic effectiveness or prevalence across populations. The literature supporting the use of various CBT techniques to provide long term relief for ADHD pathology is still developing. If CBT techniques, based on the existing literature have shown to provide tangible gains in area of improving executive functioning, is to be considered a long-term viable therapeutic intervention on the same level as psychotropic medication, additional research with larger sample sizes that accurately reflect diverse populations will need to be conducted. Critical Analysis The use of psychotropic medication to treat ADHD is prevalent within society (Biederman, Petty, Evans, Small, & Faraone, 2010). This tendency complicates the overall problem explored in this paper, that all treatment options are not being considered. There are four main causes and four main effects for this problem. First, there is a certain amount of social stigma attached to seeking help for psychopathology. This creates the effect of client turning to their attending physician for relief. This reliance upon physicians for psychological care has caused research into psychopathology to be approached primarily from a biological perspective. Research conducted from this perspective has the effect of opening financial opportunities for pharmaceutical companies. A secondary effect of both this biological focus on research and pharmaceutical financial opportunity is that as the publics priorities shift towards a biological understanding of psychopathology, resulting in government research dollars not being evenly distributed to projects that may approach the same problem from a different clinical perspective.

BEYOND MEDICATION This results in potentially effective treatment research not being done, and elaboration on the effectiveness of existing research to not be completed. The fixation on a biological perspective and reliance upon physicians for psychopathological treatment has also caused a turf war between primary care physicians and psychologists, where both sides feel that the treatment of psychopathology is within the realm of their responsibilities. This turf war has the effect of reducing the tendency of physicians and psychologists to work together, thus there is little information being shared between the two.

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Within the context of this paper, the social stigma attached to seeking psychological care that is further complicated by a clients desire for privacy are two important causes. The effects of these causes are subtle but significant. To an extent, individuals suffer from internalized stigma regarding psychopathology and treatment; such has only served to reinforce the clients desire for privacy. As the relationship between client and doctor is very important, a secondary effect may be an over-reliance of the client on the doctor to treat psychological problems. This dependence feeds into the general biological fixation cause explored later in this paper. When considering whether or not to obtain treatment for psychological dysfunction, a prevalent thought in many clients is how such will be perceived by their community (Kranke, Floersch, Townsend, & Munson, 2010; Yanos, Lysaker, & Roe, 2010). There is a subtle internalized fear in individuals when conditions are being experienced that may impact their ability to positively interact with others (Brown, et. al., 2010; Yanos, Lysaker, & Roe, 2010). To alleviate this fear, clients will often turn to their attending physician for answers to various psychopathologies (Carragher, Adamson, Bunting, & McCann, 2010). This fear has an unintended consequence of reinforcing a clients desire for privacy regarding psychopathologyrelated concerns (Brown, et. al., 2010; Yanos, Lysaker, & Roe, 2010). The family doctor is often

BEYOND MEDICATION the first and last resort of the client in obtaining the necessary treatment (Carragher, Adamson, Bunting, & McCann, 2010; Yanos, Lysaker, & Roe, 2010). The professional tendency of medical professionals to view things through a biological perspective inevitably has led to

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research that reveals various psychopathology has a biological basis (Biederman, Petty, Evans, Small, & Faraone, 2010). This fixation on the biological basis for psychopathology has led to the development of the pharmaceutical industry. In an attempt to better understand the use of psychotropic medication to treat ADHD, it is important to recognize subtle influences on the development strategies of medical science and various industries. In modern pop culture, it is generally understood that werewolves, mythical half man-half wolf hybrids, can only be killed by a silver bullet. The use of this magic bullet is the most efficient way to deal with the menace. In the development of mental illness treatment strategies, the goal is often to maximize clinical effectiveness through symptom reduction (Briggs, Goeree, Blackhouse, & Obrien, 2002; Guidotta, et. al., 2005). Thus the cause of psychotropic medication as the prevalent treatment strategy is borne out of a desire to have a magic bullet treatment that will significantly eliminate or reduce most, if not all, symptoms of various psychopathologies. The effect of this subtle influence is the journey for the magic bullet treatment, resulting in further research into the effectiveness of various neurochemical combinations and the extent to which such provides relief for a variety of mental illness. Aside from furthering the collective humanitys understanding of the biological components involved in mental illness, secondary effects have also been experienced. First, individuals suffering from mental illness have been able to find relief for their symptoms (Svetlov, Kobeissy, & Gold, 2007). In addition, pharmaceutical companies have been able to recover the significant research and marketing costs invested in the development and manufacture of these medications. The use

BEYOND MEDICATION of psychotropic medications is both a profitable and efficient enterprise for businesses and

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patients (Novartis, 2010; Svetlov, Kobeissy, & Gold, 2007) that contributes to the development of treatment practices that reinforce the economic bottom line. In examining why CBT therapy is not as prevalent as psychotropic medication, it is important to examine a prevailing belief in psychological science, nearly 50 years old the great debate on whether psychological illness is based upon biological or environmental problems (Torgersen, 2009). Monozygotic (MZ) twin studies, as time has progressed, seem to indicate that there is a biological basis for many instances of psychopathology (Torgersen, 2009). Once this correlation has been established, the illness shifted domains. No longer just a psychological illness, but now a biological problem, psychologists and their treatment methods were shifted to the back burner as physicians and biomedical researchers began to further examine the biological basis for a variety of mental illness. Given the desire to find a magic bullet solution, pharmaceutical companies and medical researchers would conduct expensive research in the hopes of finding a method of relief for clients that is effective in the short-, mid-, and long-term (Briggs, Goeree, Blackhouse, & Obrien, 2002; Guidotta, et. al., 2005). This research led to the development of drugs that could be recommended by physicians and sold by pharmaceutical companies to consumers (Novartis, 2010). In terms of development, the successful research and marketing of CBT techniques is far more difficult than the dissemination of a pill. CBT requires interaction with a trained psychology professional, thus the money for such service is going into the hands of psychology professionals, not corporations. Researching effective CBT techniques does not have the same amount of economic impact as researching psychotropic medication. Neither the development nor marketing of CBT techniques will have the same profitability potential as a pill (Briggs, Goeree, Blackhouse, & Obrien, 2002). In regards to application, CBT

BEYOND MEDICATION has definitive goals and ultimately a termination date, which further limits the overall profitability (Bodden, et. al., 2008). The use of psychotropic medication to manage psychopathology has no such end result the client, if they do not want to experience the

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symptoms, they must take the pill. As a result, sufficient research into the effectiveness of CBT in providing long term treatment of various psychopathologies has not been conducted. This lack of research has the unintended side-effect of locking clients into one particular type of treatment, thus facilitating their dependence upon the drugs that the pharmaceutical companies develop and market (Biederman, Petty, Evans, Small, & Faraone, 2010). In addition to research that has confirmed that many forms of psychopathology have a biological basis, an effect of this research is something akin to a turf war between primary care physicians/psychiatrists, and psychologists (Ball, Kratochwill, Johnston, & Fruehling, 2009; Heiby, 2010). Typically taking the form of the debate regarding prescription privileges, both sides are intent on preserving their role in the treatment of psychopathology (Heiby, 2010). A further complication of this conflict between psychologist and psychiatrist/physician is the recognition that because neither side is really communicating with the other, there is a lack of collaboration to the benefit of the client (Bluestein & Cubric, 2009; Holloway & David, 2005). The inability of the psychiatrist/physician and the psychologist to communicate prevents the client from receiving the best standard of care as both sides use their respective techniques on an individual rather than collaborative basis to enjoy limited therapeutic success (Novartis, 2010; Svetlov, Kobeissy, & Gold, 2007; Briggs, Goeree, Blackhouse, & Obrien, 2002; Bodden, et. al., 2008).

BEYOND MEDICATION Problem Resolution All of the aforementioned problems spring from a single cause, the social stigma experienced by clients upon recognition of psychological distress. Thus, any attempted

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resolutions targeting that cause will have a cascading effect across the secondary problem causes. A potential resolution to address the problem of social stigma would be to better educate the general population as to the nature of psychological treatment and normalize the perception of psychological distress so potential clients do not feel so separated from society (Greenwood, Hussain, Burns, & Raphael, 2000). The advantage of this resolution is that there is greater public understanding of psychopathology which can lead to an increase in research funding as government officials will now place higher research priority on psychotherapeutic options. A real world example of this would be the current research being done on ADHD therapeutic techniques. Initially ADHD was treated using just psychotropic medication, however additional research projects exist that are examining the extent to which cognitive-behavioral therapies are effective. This therapeutic paradigm shift is occurring because the prevalence of ADHD in the community has normalized the perceptions of the general public (Biederman, Petty, Evans, Small, & Faraone, 2010). The downside of this particular resolution is that such is costprohibitive. An intense marketing campaign that makes use of all available media outlets such as the Internet, print sources, and audio/visual sources, likely funded through collaboration of the federal government and pharmaceutical companies would need to be undertaken in order to effectively change the hearts and minds of the community. A challenge to this particular resolutions implementation is the possibility that pharmaceutical companies may also be unwilling to participate in such an initiative because the long term effects would cut directly into their profitability as the layperson goes from the medical professional, which has a high

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probability of prescribing the companys psychotropic medication, to a psychologist, who does not have prescriptive authority and thus cannot contribute directly or indirectly to the pharmaceutical companys profitability. Having educated the public on the nature of psychological distress, thereby reducing the extent to which social stigma impedes treatment, the overall workload of primary care physicians and psychiatrists can be spread more evenly with psychologists and therapists. On a professional level, the prevailing attitude is that if medication alleviates the symptoms, the problem is gone (Biederman, J., Petty, C. R., Evans, M., Small, J., & Faraone, S. V. (2010); Bodden, et. al., 2008). This approach makes sense from a biological perspective. After all, if a client breaks their arm, it is important that the bone be re-set so there can be proper healing. With that said, the human mind is not like any biological system encountered. The unique interaction between biological control mechanisms and psychologically based perception of emotions and even social interactions influencing behavior can have significant ramifications if psychopathological treatment is not responded appropriately via multiple interventions (Katz, Levine, Kol-Degani, & Kav-Venaki, 2010; Ramsey, 2010; Safren, et. al., 2010). Therefore an additional resolution to the problem of all treatment options not being considered for ADHD is that when a client comes to a primary care physician, psychiatrist, or psychologist, a referral can be made to additional members of the treatment team. Working together, the PCP/Psychiatrist can evaluate the clients behaviors and psychopathology from the biological perspective. If medication is deemed necessary by the treatment team, then such can be made available. At the same time this is occurring, the psychologist can look at cognitive-behavioral therapeutic interventions as a way to address individual behaviors in the home and community. Through consistent communication between members of the treatment team, the client can receive the best standard of care. The

BEYOND MEDICATION application of medication will alleviate the biological basis for psychopathology while the CB therapeutic experiences with the psychologist will help the client develop the appropriate

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behavioral responses to environmental stimuli (Ramsey, 2010; Tamm, et. al., 2010; Bodden, et. al., 2008). There are very few disadvantages with this potential resolution. Perhaps the most apparent is the need for clear and concise lines of communication to exist between PCP/Psychiatrists and psychologists. Another potential barrier to implementation is the need for every professional involved to have a contact pool that includes individuals from multiple professions. Without this talent pool to make referrals and the existing professional relationship that will motivate all involved to develop and maintain clear and concise communication, this particular resolution will be quite difficult to implement. The primary advantage of this resolution is that the client receives a broad level of care that not only improves upon their immediate distress but also gives them the therapeutic tools necessary to maintain their success. Thus professional collaboration as a therapeutic intervention has immediate short term benefits to the client and reduces the possibility of long-term behavioral regression (Biederman, Petty, Evans, Small, & Faraone, 2010; Oades, Dauvermann, Schimmelmann, Schwarz, & Myint, 2010; Safren, et. al., 2010).

Conclusion Using medication to treat ADHD is effective in treating the immediate symptoms; however such does not adequately alleviate the longer term behaviors that come to be associated with the disorder. A child that displays impulsivity-related attention-seeking behaviors may gain some temporary benefit from being placed on medication, however such only provides the opportunity for improvement. The child can still choose to act impulsively, regardless of how

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much medication is coursing through their system. This personal decision is further complicated by biological tolerance, creating a scenario where the PCP/psychiatrist will need to be constantly increasing the childs medication dosage in order to achieve the same therapeutic effect, yet no apparent results are obtained. The result is a child that is over-medicated and long term therapeutic success has not been obtained. Recognizing the impact of personal choice is important in the treatment of psychopathology. Psychotherapists can capitalize on the immediate benefits provided by medication to help the client establish good behaviors, to empower them to take control of their lives, their thoughts, emotions, and ultimately their actions. Through this empowerment, the client can enjoy long term psychopathological relief. On a personal level, this Capstone project has helped me to better understand the treatment plans being developed by current professionals. I have a much greater appreciation for the role that PCP/psychiatrists have in the overall treatment of psychopathology. My understanding of ADHD, as well as various therapeutic interventions that are available has increased significantly over the past twelve weeks. With this understanding, I hope to apply this knowledge directly in my role as Therapeutic Support, working directly with kids who have an ADHD diagnosis. The insight and experienced gained through this Capstone experience will enable me to contribute to positive social change through helping my clients reach their therapeutic goals. Having met these goals, my clients will become productive, functional members of society. Thus as they move forward with their lives, interacting with the greater community, they will not only continually apply the knowledge and skills I have helped them to develop, but they will also share this knowledge with others. That is where the real change takes place people influencing and educating people to enjoy a higher quality of life.

BEYOND MEDICATION References

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: American Psychological Association. Alloway, T., Elliott, J., & Holmes, J. (2010). The prevalence of ADHD-like symptoms in a community sample. Journal of Attention Disorders, 14(1), 52-56. doi:10.1177/1087054709356197 Biederman, J., Petty, C. R., Evans, M., Small, J., & Faraone, S. V. (2010). How persistent is ADHD? A controlled 10-year follow-up study of boys with ADHD. Psychiatry Research, 177(3), 299-304. doi:10.1016/j.psychres.2009.12.010 Briggs, A. H., Goeree, R., Blackhouse, G., & O'Brien, B. J. (2002). Probabilistic analysis of costeffectiveness models: Choosing between treatment strategies for gastroesophageal reflux disease. Medical Decision Making, 22(4), 290-308. doi:10.1177/027298902400448867 Bodden, D. M., Dirksen, C. D., Bgels, S. M., Nauta, M. H., De Haan, E., Ringrose, J., & ... Appelboom-Geerts, K. J. (2008). Costs and cost-effectiveness of family CBT versus individual CBT in clinically anxious children. Clinical Child Psychology and Psychiatry, 13(4), 543-564. doi:10.1177/1359104508090602 Carragher, N., Adamson, G., Bunting, B., & McCann, S. (2010). Treatment-seeking behaviours for depression in the general population: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Affective Disorders, 121(1-2), 59-67. doi:10.1016/j.jad.2009.05.009 Cuffe, S. P., Moore, C. G., & McKeown, R. E. (2005). Prevalence and correlates of ADHD symptoms in the National Health Interview Survey. Journal of Attention Disorders, 9(2), 392-401. doi:10.1177/1087054705280413

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