Dr. Victor M. Pedro
Department of Clinical Sciences, University of Bridgeport, Bridgeport, Connecticut, U.S.A.
A case study is described of a 20-year-old right-handed Caucasian male with Attention Deficit Hyperactivity Disorder and associated depression. Prenatal trauma was noted. Infant was born three weeks early in conjunction with the mother’s fall. Developmental milestones were attained within expected age-limits. Attentional deficits initially noted at age 5. Homeopathic remedies were utilized between ages 6 and 9 and achieved a moderate degree of improvement in early school performance, but were discontinued when such treatments became implicated in sinus disorders. By age 10, distractibility, inattention, failure to complete work without considerable supervision, and organizational problems were often noted. Testing at this age was conducted revealing a significant difference between Verbal and Performance IQ scores – a primary indicator of ADHD. Later testing revealed low self-esteem and frequent depressive episodes requiring psychotropic intervention, in addition to continued struggles with ADHD symptomology. After fourteen years of special education and pharmacological interventions with limited improvements in most measurable areas of function, a multimodal approach using techniques aimed at facilitating inter-hemispheric communication was provided. At completion of the Cortical Integrative Therapy program, significant improvements were observed in academic coursework, changes in medication, personal demeanor, and affective moods.
KEY WORDS: Attention Deficit Disorder, low self-esteem, IQ differentials, depression, and Cortical Integrative Therapy.
Heinrich Hoffman M.D. first described Attention Deficit Hyperactivity Disorder (ADHD) in 1845. A physician who wrote books on medicine and psychiatry, Hoffman was also a poet who became interested in writing for children when he couldn’t find suitable materials to read his 3-year-old son. The result was a book of poems, complete with illustrations, about children and their characteristics. “The Story of Fidgety Phillip” was an accurate description of a little boy who had Attention Deficit Hyperactivity Disorder. Yet it was not until 1902 when Sir George F. Still published a series of lectures to the Royal College of Physicians in England in which he described a group of impulsive children with significant behavioral problems, caused by a genetic dysfunction and not by poor child rearing (Still, 1902). In the century-plus since, several thousand scientific papers on this disorder have been published, although the disorder/diagnosis has been historically expressed under such labels as Minimal Brain Dysfunction (MBD) (Wender et al., 1971). The principal characteristics of ADHD are inattention, hyperactivity, and impulsivity. Executive function deficits can also be co-morbid with ADHD. When this occurs, such disorders are likely to negatively impact academic success. ADHD is frequently co-morbid with learning disabilities, for instance, developmental reading disabilities with impaired working memory functioning are relatively rare, but do occur (Kibby M.Y. et al, 2004)(Wilcutt E.G. et al., 2000). More definitively, in one landmark U.S. study, a learning disability was present in 70% of the children and adolescents with ADHD, and a learning disability in written expression was two times more common (65%) than a learning disability in reading, math, or spelling (Mayes S.D. et al., 2000). Results suggest that learning and attention problems are a continuum, are interrelated, and usually coexist. In addition, a proven relationship exists between intelligence and performance on the test of variables of attention (TOVA) and associated intelligence quotient (IQ) measurements (Weyandt L.L. et al., 2002). Significant differences between verbal and performance scores on IQ testing can be a prime indicator for diagnosing ADHD in a child.
According to the official U.S. literature produced by the National Institute of Mental Health (NIMH), ADHD symptoms appear early in a child’s life. But because these symptoms vary so much from child to child, ADHD is not easy to diagnose (NIMH booklet, 2003). Because ADHD is presumed to be a biologic disorder and yet no pathognomonic biological marker exists to identify the condition (Barkley 1999, Todd, 2000), and because no assessment method is clearly defined and widely accepted (Kessler, 1980; LeFever et al., 2003), it is impossible to know how many children (or adults) are actually affected by the disorder (Gadow, 1997). According to the 2004 version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), patterns of behavior based on the aforementioned characteristics can also be divided into ADHD subtypes – predominately hyperactive-impulsive, predominately inattentive, and a combined type that may demonstrate a potpourri of symptomology – making accurate diagnoses extremely subjective in nature (DSM-IV-TR). Despite such demonstrative subjectivity in the crucial area of diagnosis, the assumed prevalence for this disorder may be as high as 8% of U.S. school-age children (Pedro et al, 2003). According to the DSM-IV-TR, the principal criteria for an ADHD diagnosis must involve the aforementioned symptomology in some combination present in a child or adult and manifesting in an age-inappropriate manner, thus suggesting rarity. Given that the definition of ADHD is based on statistical rarity, only a limited number of children can qualify as having the disorder (LeFever et al., 2003). In addition, the problematic behavior must also be persistent, pervasive, impairing, and not attributable to other conditions or factors. Consistent with this logic, some pediatric and behavioral experts argue that ADHD may affect as few as 1% to 3% of children and adults (Carey, 1999, 2000).
Complicating the subjective elements inherent to ADHD diagnoses are concerns related to medicating the suspected aberrant behaviors. This practice is a relatively recent phenomenon. Until the latter half of the 20th century, treating childhood behavior problems with medication was nearly a nonexistent practice. The current American proclivity toward psychiatric drug therapy for behavior-disordered children began in the 1960s, when the American medical profession deemed it acceptable to use psycho stimulants (especially methylphenidate, commonly and hereafter referred to as Ritalin) to ameliorate symptoms associated with Minimal Brain Dysfunction (MBD; Wender et al., 1971) or what is now described as Attention Deficit Hyperactivity Disorder. In the two generations since, the prescription of ADHD drug treatment has increased exponentially, effecting at least 5 to 6 million American children annually (Diller, 1998; Sinha, 2001). The high rate of prescription for Ritalin and expensive brand-name drugs such as Adderall, Concerta, Dexedrine, and Metadate reflect a more general reliance on psychotropic drugs in American healthcare practices. In fact, a 700% increase in U.S. psycho stimulant use that occurred in the 1990s justifies concern about potential overdiagnosis and inappropriate treatment of child behavior problems (LeFever et al., 2003).
To further compound the situation, ADHD is sometimes co-morbid with other dysfunctions, notably Tourette’s syndrome, chronic depression of biological origin, obsessive-compulsive disorder, and infrequently bipolar or manic depressive episode. Medication of children and adolescents with depressive symptomology (or suspected depressive symptomology) has also become increasingly prevalent, especially in conjunction with ADHD pharmacological treatment modalities. Between 1995 and 1998, antidepressant use increased 74% among children under 18, 151% among children between 7 and 12, and 580% among children younger than 6 years of age. Despite the significant number of preschool-aged children that are being diagnosed with ADHD, there are limited controlled data available on the pharmacological interventions being increasingly used in this population (Kratochvil C.J. et al, 2004). Mood stabilizers increased 400% among children under 18, while the use of new psychotropic medications increased 300% among the same age group (Diller, 2000). Between 1990-98, the increase in visits for concomitant pharmacotherapy in association with the stimulant class as recorded by the National Ambulatory Medical Surveys grew five-fold. Unfortunately, the growth in concomitant pharmacotherapy with the stimulants class has out-paced any corresponding increase in safety/efficacy data to inform the use of this practice (Bhatara V. et al., 2004). In the face of increasingly routine pharmacological intervention, most contraindications have received little scrutiny, especially when stimulants and antidepressants are prescribed concomitantly. There is increasing evidence that such regimes can lead to an increased risk of suicide and to more frequent suicidal thoughts (Fox L. et al., 2004).
Such outcomes may be especially prevalent with older adolescents and young adults with a history of being medicated for ADHD and co-morbid conditions. For instance, various manifestations of obsession-related anxieties can exist within such populations, including concerns about contamination and uncomfortable thoughts or doubts often related to low self-esteem (Mathews C.A. et al., 2004). While ADHD was previously believed to be a disorder of childhood, with symptoms attenuating at the onset of puberty, somewhat controversial follow-up studies suggest that the majority of children with genuine ADHD continue to manifest symptoms into adulthood (Weyandt L.L. et al., 2003). It is further stated that in older adolescents and adults, the disorder impairs academic, social, and occupational functioning and is often associated with co-morbidity including cigarette smoking and substance abuse (Wilens T.E. et al., 2004) – although factors for potential substance abuse may be linked as much with pharmacological interventions (“the cure”) as with ADHD (“the condition”).
The present paradigm of treatment instituted in the U.S. public school system is very much a flow chart approach, from referral for diagnosis to subsequent management and treatment strategies. Teachers detect a potential problem and suggest to the parents that a referral would be appropriate. When the diagnosis is made, the prescription of stimulant class pharmacotherapy, often coupled with therapy, has been the treatment of choice (Pedro V. et al, 2003). The most commonly prescribed drugs – Ritalin, Dexedrine, and Adderall – can cause nervous tics (not related to Tourette’s syndrome), insomnia, loss of appetite, mild tachycardia, hypertension, and death as well as being potentially addicting (Varley et al., 2001). Risk factors for adolescent substance abuse subsequent to treatment utilizing ADHD medication regimes is well documented (Weinberg N.Z., 2001). While stimulants are the matter of choice to treat ADHD pharmacologically, the period of effectiveness of immediate release stimulants is, however, often not satisfying (Sevecke K. et al., 2004).
Ineffectiveness of stimulants in genuine instances of ADHD may be related to causal factors of neurological origin. Recent studies have suggested that ADHD is associated with abnormalities in basal ganglia and prefrontal cortical functioning. However, these studies have primarily relied upon cognitive tasks that reflect impulse control rather than attentional mechanisms (Shafritz et al., 2004). The areas of brain dysfunction in ADHD are identified as being in the right hemisphere, specifically the prefrontal, caudate, and parietal areas (Levy et al., 1998). The frontal lobe is particularly involved when dysfunction interferes with many important purposes such as cognition, executive function, and ability to stay on task, focus, concentration, working memory, volitional movements, and personality (Pedro V. et al., 2003).
It is increasingly apparent that a dire need exists for non-pharmacological interventions and treatment methods for patients with ADHD, or for patients diagnosed with ADHD, or a variation such as ADD (Attention Deficit Disorder without Hyperactivity). It is critical to understand not only what modality of treatment to apply and to which hemisphere, but to know for what duration, at what intensity, and what not to do. For instance, the application of yoga as a treatment modality has been proven effective with boys diagnosed with ADHD, but results can’t be assumed as uniformly beneficial (Jensen et al., 2004).
A distinct advantage of the Cortical Integrative Therapy (CIT) is that it is multimodal. Such an approach can demonstrate documented effectiveness in remediation efforts.