The Prevalence of ADHD in Children and Adolescents
Attention deficit hyperactivity disorder (ADHD) is the most misunderstood and neglected mental health condition that mostly affects school-age children and young people in UK. Very few people receive appropriate diagnosis or treatment leading to increase in prevalence of the condition (rota.org.uk 2013). ADHD is a type of mental disorder associated with symptoms of inattention, hyperactivity and impulsivity that persists for a long time and interferes with the development of children. (Tresco, Kessler and Mautone 2017). ADHD is a highly heritable disorder as children have a higher chance of developing the condition if their parents are diagnosed with ADHD. Globally, the prevalence rate of ADHD is 5.29% (Smith 2017). Although genetic factors have been found to cause of ADHD, however, there are many arguments regarding the factors contributing to ADHD and impact of the condition on child development. The disease is also regarded as a socially or culturally constructed condition because of links between social factors and increase in risk of ADHD. Such kind of interpretation influences the process of managing the disorder and seeking services to treat the mental health condition. To gain better idea about the way to manage the condition, the primary purpose of this essay is to critically appraise ADHD prevalence in children and adolescents by discussion on theories of child development and identifying sociological and psychological factors that contribute to the disorder in children. The essay also critiques existing initiatives that have been implemented for supporting children with ADHD and discuss policy or ethical implications to improve child and mental services.
The mental health issues of ADHD prevalence has been specifically chosen as a topic for the essay due to the increase in rate of ADHD diagnosis in children, unequal representation in ethnic group and increase in risk of behavioral issues in later life of children and adolescent. The number of children diagnosed with the condition has increased by 5% per year from 2003 to 2011 (Smith 2017). According to a recent survey done in the US in 2016, the number of children diagnosed with ADHD was 9.4%, and these children also suffered from other issues like behavioural problem, anxiety and autism (cdc.gov 2016). The estimated prevalence rate of the condition in the UK is 3.6% in children between 5-15 years because of DSM-IV criteria. The prevalence of ADHD London’s Black and Minority Ethnic (BAME) community is also increasing because of the prevalence of unfair and prejudicial experience in children (rota.org.uk 2013). They are over-represented among diagnosed or mis-diagnosed cases of ADHD because of stigma around the condition and lack of public knowledge regarding the mental health issue (Rees 2016). Hence, critical understanding links about social and psychological factors that contribute to ADHD is necessary to change perception of people and improve mental health services for recovery of children and adolescent diagnosed with ADHD.
Exploring Links between Developmental Theories and ADHD
As the main aim of the essay is to critical discuss the prevalence of ADHD in children, finding links between development theory and ADHD may help to identify individual at high risk of developing the mental disorder. Mental health is defined as a state of emotional, psychological and social well-being. In contrast, mental illness is a condition that results in negative changes in thinking, emotion and behavior of an individual (Rogers and Pilgrim 2014). The transition from mental health to mental illness is understood from different developmental theories such as social learning theory, humanistic theory, psychoanalytical theory and attachment theory. The nature versus nurture theory is a debate on the role of nature or nurture on mental illness. Nature refers to the role of hereditary factors and genetic factors on one’s personality, whereas nurture is related to all environmental variables that has an impact on development of an individual (Coll, Bearer and Lerner 2014). Hence nature and nurture is linked to explain the cause of mental illness. For example, a pregnant woman with major emotional loss in the early stage of pregnancy is at high risk of schizophrenia. Large genetic influence on the developmental course of ADHD symptom was proved by Pingault et al. (2015) and the developmental interface between nature and nurture was explored by Harold et al. (2013) by investigating about biological and rearing mother influences on child ADHD symptoms. The study proved the role of maternal parenting behavior on course of children’s ADHD symptoms and the role of early disrupted child behavior on children’s later ADHD symptoms. Hence, addressing parenting practices may be crucial to reduce development of ADHD symptom in children with time.
Jean Piaget’s cognitive development theory and Vygotsky’s socio-cultural theories can explain the reasons for negative symptoms like poor concentration and poor focus in n children with ADHD. For example, according to Piaget’s cognitive development theory, children start developing formal and organized thought during the concrete operational stage (7-11 years of age). However, children are diagnosed with ADHD at this stage. Children and youths can use abstract thought and observational skills to understand people’s need. However, it can also lead to social and emotional challenges for youths if they use their cognitive abilities to compare themselves with others. Such thought pattern leads to negative consequences for children. This is the reason for poor learning ability and poor focus in children with ADHD (Yanagisawa 2016). Shoham et al. (2016) argues that children with ADHD may engage in risk taking behavior in the future because of their subjective experience. They find risk taking to be appealing for them. The psychoanalytic theory explains regarding the dynamics of personality development by explaining human behavior in terms of interaction with various components of personality. This theory finds application in the interpretation of inner world of ADHD children. It can shed light about the child’s experiential world and the factors contributing to negative behavioral outcome in them (Salomonsson 2017). Vygotsky’s theory concentrates on the impact of the social system on child development and this theory may be utilized to explain how social factors influence the severity of ADHD (Sawyer 2017).
Addressing Parenting Practices to Reduce Development of ADHD Symptoms
Diagnosis of ADHD in children and adolescent results in many challenges both the child and their parents. For instance, social functioning and academic performance of children is significantly impaired and the stress level of parents increases. Another negative impact of the condition is that ADHD significantly contributes to social challenges for children as the condition worsens social skills and results in inattention from peers and poor parent-child relationship (Keen and Hadjikoumi 2011). Identifying and looking for sociological or psychological links contributing the disorder may help to better manage the condition and reduce risk of diagnosis in children and adults in UK. The etiology of ADHD is understood differently by different people. Some link it to clinical factors whereas others link the development of ADHD with cultural, social and psychological factors of an individual.
As parental beliefs about the etiology of ADHD influence the help-seeking behaviour and service uptake rate, Lawton et al. (2014) focused on evaluating the role of cultural values, traditional gender roles and spirituality to explain parental beliefs about etiology. The research was done with Latino parents and Latino children with ADHD were found to have a higher unmet need (Zimmerman 2005). Research in this area was necessary because their perception influences the response they take and the type of service they visit for the care of their child (Ahmed et al. 2017). From the statistical review of parent’s response, it was found that 69.08% of parents endorsed bio-psychosocial etiological beliefs whereas 32.5% supported spiritual beliefs. Traditional gender role and Anglo orientation was the main reason for parents to consider a child’s friend to be contributing to ADHD (Lawton et al. 2014). These factors were also the reason for parents to report about spiritual factor and nature disharmony as the cause of ADHD. The factors that influenced adherence to ADHD medication in adolescents included negative attitude towards medications, stigma, experience of social withdrawal and issues related to treatment independence (Bhang et al. 2017).
Gender wise differences in self-perception of ADHD have been found among children and adolescents too. Children and adolescent with ADHD are at high risk of emotional and social problems like risk taking behavior, suicide, depression and addiction due to pervasive nature of symptoms. Adolescent girls have lower self-efficacy and poor coping strategies than adolescent boys with ADHD due to more internalizing problems and diminished self-efficacy. Hence, school performance, peer relationship and acceptance to the condition influence self-esteem and self-concept in adolescent. Early intervention is needed to prevent such emotional injuries in adolescents with ADHD (Houck et al., 2011).
Negative Symptoms: Poor Concentration and Poor Focus in Children with ADHD
The explanation by Lawton et al. (2014) shows that cultural values and traditional gender role are strongly associated with parent’s tendency to favor sociological factor as the cause of ADHD. Bussing et al. (2015) argued that racial and social demographic disparities in care exist due to parental social networks, which influence the help-seeking process. Hence reasons for differential help-seeking behaviour in parents to treat ADHD is understood and this provides the clinical implication to target parents to make them aware about etiology of ADHD and suggest mental health services for the child. Engaging parents in care process may also help to provide culturally competent care and improve parent’s satisfaction with mental health care service. In future, health care workers and staffs must focus on increasing knowledge about idea about ethnic group differences in relation to the understanding of the cause of ADHD.
Exploring the knowledge, perception and information sources of parent, adolescent children may also help to establish sociological or psychological risk concerning the disorder. Bussing et al. (2012) used the health belief model to predict health-related behaviour of individuals, and in the study, the participant’s awareness of the health condition was judged to understand the need for psycho-educational intervention for prevention of ADHD. The survey-based research tested predictor variable of ADHD knowledge, level of mental health service use and ADHD knowledge and cues to action. The review of survey result indicates that parents and adolescents had many misconceptions related to the cause of ADHD. For example, there were some groups who regarded sugar as the cause of ADHD and some linked ADHD to medication overuse. Regarding predictors of ADHD knowledge, the racial background was found to be the most common predictor of knowledge for adolescents as Caucasians were found to have higher knowledge related to ADHD compared to African American. However, for parents, their child’s past mental health service used was the standard predictor of knowledge (Bussing et al. 2012).
It is evident that ADHD knowledge of people is influenced by their racial background. In contrast to the research by Lawton et al. (2014), Bussing et al. (2012) emphasized more on predictors of knowledge instead of evaluating the cultural values related to ADHD knowledge. The belief regarding sugar etiology of ADHD also reflects old popular opinion is still high among racial group instead of believing scientific facts about ADHD. The evidence proves that knowledge about ADHD is low among ethnic group and poor pervasive belief is the reason for disparities in ADHD care which is consistent with other research (Siegel et al. 2015). Hence, the discussion give implications for improving health information exchange between care providers and racial group to address disparities in care and improve quality of life of people affected by ADHD. The discussion provides an insight that by evaluating participant’s preference for ADHD information source, the credibility of ADHD information available on the internet can be improved so that misconception of people can be addressed (Rosenblum and Yom-Tov 2017). The most important implication is that low awareness of ADHD points to the need to increase communication between patient and care provider to increase uptake of services in the ethnic group.
The Dynamics of Personality Development in ADHD Children
Racial and cultural factors also influence awareness of about ADHD among adolescent and parent suggest that family engagement is necessary for treatment of children with ADHD. It implies that family-centred care is needed for treatment of sensitive disorders like ADHD and the advantage of such type of care is that it increases adherence to treatment and patient satisfaction with care. Davis et al. (2012) focused on investigating about the perspective of parent’s perception about family-centred care for ADHD. The review of interview transcript revealed that majority of participants did not prefer shared decision making process and they mainly had the perception that parents are responsible for deciding on ADHD treatment. Also, the family perspective regarding the causes of ADHD was evaluated by taking four domain of internal factors and external factors to the child, mix of both and developmental perspective. Internal factors were related to genetic factors and personality of children, and the external factor was related to environmental stressors and family separation factor. In this area, families were found to be confused about the cause of ADHD, and their perspective also changes with time after complex interaction with healthcare providers. Stress level is also a factor that influences treatment choices of parents, and in this area, the majority of people reported experiencing emotion stress (Davis et al. 2012). The evidence highlights the critical components of family-centred care for ADHD and the need to address non-medical needs of patients and families. The research outcome can be utilised by family-centered medical home to identify needs of children and parents while development treatment programs for ADHD (Kuo et al. 2011).
The impact of culture and social factors on parent’s ADHD knowledge and help-seeking behaviour and preferences for mental health services is understood from the discussion so far. However, the uniqueness of the population-based longitudinal study by Galéra et al. (2014) is that it focused on investigating the impact of behavioural and environmental factors on ADHD medication use. Taylor (2014) argued that the effectiveness of ADHD treatment is hampered due to the use and misuse of ADHD treatment. This research was significant to understand the reason behind overuse and underuse of medication. Using longitudinal study design, data were collected by interview with participating families, and the primary outcome measured included ADHD medication use. The review of the statistical analysis of research data revealed that the level of ADHD medication use dependent on core symptoms of ADHD and also using low maternal education, gender and immigrant status. The most robust clinical predictor for ADHD as medication use was hyperactivity-inattention thus indicating that no medication was prescribed for the patient having an anxiety problem. By the analysis of cultural trends in medication use, it was also found that mothering ideology and masculinity stereotypes affected medication use pattern. For example, adolescent boys were more likely to use medication for ADHD compared to girls (Galéra et al. 2014). This study outcome proved the fact that social variables influenced the rate of ADHD medication use instead of psychiatric comorbidity or parenting style. This evidence points out to the factors contributing to disparities in treatment and develop ways to offer same intervention to all groups irrespective of cultural differences.
The Impact of Social Factors on the Severity of ADHD
Galéra et al. (2014) explained the role of genetic and environmental factors contributing to ADHD, social and cultural characteristics influence the diagnostic process and prescription of ADHD medication too. The findings presented by Galéra et al. (2014) exemplify that factors that contribute to biases in medication use. The credibility and validity of the research finding have also been enhanced by taking a large sample group and consideration of other behavioural symptoms of ADHD. However, the limitation found in current research is that the severity of symptoms was not considered which leaves a significant gap in research. It was necessary to review the severity of symptoms as this factor greatly determines the rate of medication use. Secondly, the cultural and environmental factors of the different country may be various. Hence it cannot be generalized to all setting. However, it provided practical implications for clinicians to consider the social context of children with ADHD to improve adherence to therapeutic intervention (Bhang et al. 2017).
The perception related to quality of life is an important parameter that determines a patient’s ability to cope with the disease in life. Sciberras, Efron and Iser (2011) used cross-sectional survey method to compare the self-perception of parent and children with ADHD related to the quality of life (QoL). The strength of the study is that it focused on analyzing the perception of both parents and children and this would help to understand the strength of families in coping with ADHD. Children with ADHD were recruited from an outpatient clinic, and the other necessary variables like family history, education of parents and gender were considered. Validated tools were also used for collecting data on quality of life in subjects. The statistical analysis of differences between self and parent-reported child QoL revealed that differences in perception as parents reported their child’s QoL as lower compared to their child. The evidence depicted discrepancy between parents and child reported QoL. This research evidence indicates that children were more optimistic regarding their future and QoL compared to parents. The research is consistent with previous work discordance between parents and child’s view on symptoms always occurs (Coker et al. 2016). However, the limitation of the work is that the study failed to uncover the factors that lead to such perception in parents. Harpin et al. (2016) argued that self-esteem attributes and community attitudes also influence adolescents and their parent’s ability to cope with ADHD. Hence, to promote efficiency in treatment, it is necessary that clinicians communicate effectively to know about the experience of ADHD from families. It would help to understand coping abilities and stress level of parents, and it would support clinicians to deliver effective therapy both for the child and the family.
Challenges of Diagnosing ADHD and Looking for Sociological or Psychological Links Contributing to the Disorder
By the review of the research work by Sciberras, Efron and Iser (2011), it was found that parents, children and adolescent coping behavior and perception related to QoL was influenced by their experiences in the community after the diagnosis of ADHD. In this context, getting an idea about the role of stigma on ADHD perception and challenges for children is also essential. dos Reis et al. (2010) examined the experience of parents whose child received an initial diagnosis of ADHD. By interviewing parents about their experiences leading ADHD diagnosis and treatment, it was found that about 77% of participants reported about the experience of stigmatization due to ADHD. Due to experience of stigma, parents were concerned about their children and experienced self-isolation and rejection in society. The research study is critical to understand and address stigma as research has shown that stigmatization also affects parent’s decision to seek treatment (Mikami et al. 2014). Mueller et al. (2012) also showed that stigma results in maladaptive cognitive behavior in adolescents and influences emotional well-being of adolescents who are at high risk for ADHD. Hence, one important implication of this evidence is that it highlights the need for improved community outreach programs too so that parents and children with ADHD do not suffer additional burden and do not associate ADHD with shame and guilt.
The role of social divisions on ADHD knowledge and uptake of mental health service is understood from above critical review of research literature. Social division in society implies the difference in treatment of an individual’s by race, class and ethnicity. As the cultural values and social beliefs of families from different racial background or ethnicity are different, this factor has an impact on decision making and care for children with ADHD. A study done in two racial group explained that racial background resulted in differences in belief about ADHD. For instance, African subjects have been found to have a lower level of ADHD knowledge compared to Caucasian thus indicating racial/ethnic variations in ADHD knowledge Bussing et al. (2012). From this explanation, it is understood that misconception and lack of awareness about causes of ADHD are highly prevalent due to social divisions of society. Hence, there is a need to provide culturally competent care along with the integration of appropriate health care model so that all population group irrespective of racial or class difference received the same treatment and attention from mental health services. The family-centered approach is also a necessity to address the deficit of knowledge and poor attitude towards seeking help in the parent (Davis et al. 2012). Such steps can contribute to strengthening parenting skills and improving health outcome of children with ADHD (Zajicek-Farber et al. 2015).
Parental Beliefs about the Etiology of ADHD and Their Influence on Service Uptake Rate
Many psychosocial factors increase the risk of severity and psychiatric comorbidity in children with ADHD. For example, experiences of stigma and exclusion increase the psychological risk for ADHD children. Stigma perception or experience of stigma results in adverse mental outcome such as poor self-esteem, social stigma. Such individual is at risk of psychiatric disorders along with ADHD (Mueller et al. 2012). For instance, depression and low-esteem are common in children with ADHD. It implies that changing the attitude of parents is not enough; there is a need to address adverse psychological risk factors for ADHD. Psychoeducation and referral to an appropriate support group are essential to minimize psychiatric outcomes (Kellison et al. 2010). Interagency collaboration should also be considered to promote inequity in mental health care service provision and address the negative impact of stigma on the mental health outcome of children with ADHD and their parents (Cooper, Evans and Pybis 2016).
As ADHD is a disorder that influences social life and academic achievement of children, different policies in the area of education, social rights and emotional welfare can protect and improve the well-being of children with ADHD. School-related policies can enhance social and emotional wellbeing in children by preventing discrimination in the classroom. For example, an Individual education plan (EIP) is necessary for children with special learning needs according to Children with Disabilities Education Act (IDEA). In accordance with this policy, development of IEP is necessary for children with ADHD after assessment of special learning needs in such children. This policy gives the implication regarding increasing collaborative meeting among parents, counselor, teachers and child psychologist to effectively develop education plan for children (Wilmshurst and Brue 2018). Secondly, emotional welfare policies can strengthen resource needed by children and parents to cope with ADHD symptoms and improve their quality of life. Bullying has been an important UK national health and education policy agenda, however government statistics on the problem is scarce. There is a need to increase the scope of anti-bullying policies in UK so that flags up the importance of recording and reporting incidents of bullying. Initiative should also be implemented in educational institute to provide guidance regarding the ways to tackle bullying of children with ADHD (Singh 2011). Hence, policies can influence the rate of diagnosis as well the rate of adverse symptoms reported in children with ADHD.
In addition, as stigma related to ADHD is one factor that increases the likelihood of differential treatment for ADHD patients, there is a need to implement ethical standards in different organization to prevent stigmatization of people. Mueller et al. (2012) gave the evidence that children with ADHD are at high risk of being confronted with stigma. It showed that children with ADHD has stigmatizing prejudices related to ADHD medication. They failed to adhere to medication regimen because of beliefs regarding negative side effects of the drug. Some also reported personality changes after taking medication. Such stigmatizing beliefs affect long term care for patient. The Beauchamp and Childress model can be used to develop ethical values in school and education staffs and to help them support children and adolescent with ADHD. The four principles of Beauchamp and Childress model is related to autonomy, beneficence, non-maleficence and justice. Utilization of these four principles can largely influence ethical values of key stakeholders. It is an appropriate model for routine ethical practice and increasing safety of children with ADHD. It can help staffs to overcome common dilemma while coming in contact with children and adolescents with ADHD (Foreman 2006). However, one limitation of the model is that it can work well to solve everyday ethical problems, however difficult cases may require careful individual scrutiny too. Most difficult issues may require tailor made approach to promote safety of children and adolescents with ADHD.
Conclusion
Currently, many social support organization and interagency collaboration have been initiated to manage people with ADHD. Self-help approaches such as DVD or video material on ADHD are now available, and tiered models of care are available to ensure that integrated care pathway is created and all professionals, parents and social groups are involved in the care of children with ADHD. One important initiative that has been implemented in the UK is the ‘YOUNG MINDS’ that looks at supporting and empowering children and adolescent with mental problem. It provides 360 degree schools to promote well-being and resilience among learners. It uses strategic communication and collaborative advocacy to empower youths in the community (youngminds.org.uk 2017). The strength of this initiative is that it has changes the way conversation is done with young adults living with mental illness and played a vital role in reducing stigma. Hence, more number of such empowering initiatives is needed to improve lives of children and families with ADHD.
From the essay related to critical appraisal of ADHD prevalence in children and adolescent, the complexity of the disorder in terms of diagnosis, etiology and understanding among common people is understood. It can be concluded that social factors, cultural values and racial differences has significant impact on ADHD knowledge and help seeking behaviour of people. ADHD prevalence is increasing, however the community is not progressing in terms of diagnosis, management and appropriate support for children and youth affected by ADHD. The experience of stigma and lack of knowledge related to the disorder increases the challenges for parents. To make improvements in management of the condition, there is a need to take a culturally competent approach to the treatment of children with ADHD so that cultural and psychological barriers to care are addressed. From the critical discussion provided in the essay, it can be concluded that biological and genetic factors cause ADHD, however social and cultural factors of parents and children have an impact on the severity of the condition, the psychological outcome of families, help-seeking behaviour and coping ability. For example, experience of stigma related to ADHD affects emotional well-being and coping ability of affected individuals. Due to Anglo-orientation and traditional gender roles, parents perceived nature disharmony as the cause of the mental disorder. Gender wise difference in perception resulted in poor coping abilities of girls compared to body. From this evidence, it is understood that parent engagement and improving communication between health care provider and the patient is also necessary to reduce the burden of ADHD and increased knowledge of target group related to treatment choices and coping with the disease. There is also need to incorporate relevant mental health theories and models to ensure that outpatient services and community outreach programs are successful in eliminating misconceptions and stigma associated with the diagnosis of ADHD (Sciutto 2015).
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