STRATEGIC WAYS TO IMPROVE THE LONG TERM MEMORY IN ADOLESCENTS WITH ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) IN RELATIONSHIP TO THEIR MEDICATION REGIMEN.
INTRODUCTION
A present issue faced in the classroom and in the clinic is the care of the student diagnosed with ADHD. Teachers are faced with the challenge of how to engage the student with ADHD, assist with organizational skills, and create a positive learning environment. The school nurse is faced with the challenge of how to assist the student with ADHD to comply with his/her medication regimen. Statistics show that more males than females are diagnosed with ADHD, and the age range of students who take medication related to their respective grade levels are early elementary to high school. The adolescent student with ADHD is a difficult challenge for two reasons, one being there is a stigma attached to taking the medicine as viewed by the student and his/her peers, and the other being the simple task of remembering to go to the clinic to take the medication at a specific time daily. As a school nurse, it is my responsibility to see that the student is in compliance with their daily medication through administration and dispension. To ensure compliance, it is imperative to develop a relationship with the student that is based on trust by listening to the student and providing a "safe, nonjudgemental, discretionary" environment to take the medication. Additionally, the student needs to be educated on the importance of adhering to the daily medication regimen. Adherence to the medication regimen can be aided by the development of memory strategies that will improve the long term memory of the student directly corresponding with the appropriate time for medication dispension, which will ensure compliancy.
Literature Review
Adolescents with ADHD
Attention-deficit/hyperactivity disorder (ADHD), previously known as attention deficit disorder (ADD), is a neurobehavioral disorder characterized by pervasive inattention and hyperactivity-impulsivity that often results in substantial functional impairment. Prevalence estimates of ADHD in school-aged children have ranged from 2% to 18% in community samples. (Visser; Lesesne, 2005) Research shows the incidence of ADHD is 2.3 times more common in boys than girls.( Bauermeister, 2007) . ADHD usually becomes evident in preschool or early elementary years. The National Institute for Mental Health (NIMH) states that the median age of onset of ADHD is seven years, although the disorder can persist into adolescence and occasionally into adulthood. The DSM-IV provides criteria for the diagnosis of ADHD, based on three subtypes: hyperactivity-impulsivity, inattention, and combination. The three main characteristics of ADHD are hyperactivity, impulsivity, and inattention. (DSM-IV) Although diagnosis criterion is available, the diagnosis of ADHD can be complicated with the presence of comorbities. These include oppositional defiant disorder (ODD) and conduct disorder (CD), as well as affective, anxiety, and tic disorders. (Pliszka, 2003) Management of attention deficit hyperactivity disorder (ADHD) encompasses two general domains: pharmacologic therapies and nonpharmacologic therapies, including educational, cognitive-behavioral, and other psychological and psychiatric approaches. (Shaywitz; Fletcher; Shaywitz, 2001)
Pharmacological treatments include the use of psychostimulant drugs, which are most widely used and studied treatment for ADHD. The primary treatment for attention-deficit/hyperactivity disorder (ADHD) has been psychostimulants. (Quintana; Cherlin; Duesenberg; Bangs; Ramsey; Feldman; Allen; Kelsey, 2007) Common psychostimulant medications used in the treatment of ADHD include methylphenidate (Ritalin, Concerta), mixed salts of a single-entity amphetamine product and dextroamphetamine. Atomoxetine (Strattera), is the only nonstimulant medication approved for the treatment of ADHD, is a norepinephrine reuptake inhibitor. Antidepressants are also, at times prescribed for the ADHD. Non-pharmacological treatments include behavioral intervention therapy, behavioral modification therapy, the multimodal approach, which consists of a combination of both pharmacological and non-pharmacological treatments. Treatments are effective in improving cognitive and behavioral functioning.
Working Memory and Long-Term Memory (in Adolescents)
Working memory is defined as the brief, immediate memory for material that you are currently processing; a portion of working memory, also coordinates your ongoing mental activities. (Matlin, 2005)
Long-Term memory is defined as, having a large capacity and contains our memory experiences and information that has accumulated over a lifetime. (Matlin, 2005).
How do working memory and long-term memory interact to enable cognitive processes to occur? The theory behind this question can be answered, by using the Alan Baddeley’s (2000b) Model of Working Memory. The working-memory approach suggests that the immediate memory is a multipart system that temporarily holds and manipulates information as we perform cognitive tasks. (Matlin, 2005) Simply stated: working memory acts as an "interface", where new information obtained and old information retrieved from storage (long-term memory) is being exchanged, combined, and transferred. There are four components which make up the working memory model. These components are known as the central executive, visuospatial sketchpad, phonological loop, the episodic buffer. The episodic buffer was added to the model later and is defined as the interface between the sub-systems of working memory and long-term memory (LTM). (Baddeley, 2003) The phonological loop is a temporary storehouse for a limited number of sounds for a short period of time. The visuospatial sketchpad has a duel function: the first being a storehouse for visual and spatial information, and two for encoding verbal stimuli. The episodic buffer is a temporary storehouse where information is gathered and combined from other areas. Also manipulates information to interpret earlier experiences and solve new problems. The central executive is the "supervisor" over all the storehouses that integrates the information from all the areas and plays a major role in attention, planning, strategies, and coordinating behavior. (Matlin, 2005) If the information that is in working memory is to be stored in long-term memory then it must be encoded. The theory that explains this transference of information is known as the levels of processing approach. This approach states that in order to have information processed for permanent retention, the information must be deep and meaningful, not shallow. (Matlin, 2005) To help process information for long term memory may also be done with the self-reference effect. Basically, this means trying to relate the information to yourself. (Matlin, 2005) Once the information is encoded into long-term memory, there must also be a way to retrieve it. To utilize the retrieval process, one could use an explicit or implicit memory task. Explicit memory tasks are designed for recall of information given or remembering the information given, and implicit memory tasks request information to complete a cognitive task that is not directly related to the information or material given.
Where do these processes occur in the brain?
Phonological loop is primarily localized in the left temporoparietal region of the brain. (Baddeley, 2003)
Visuospatial working memory is primarily localized in the right hemisphere of the brain. Other areas that were broadly analogous to the left hemisphere activation of verbal working memory, namely right inferior parietal cortex, right premotor cortex, and right inferior frontal cortex, were also involved, although there was also activation in the anterior extrastriate occipital cortex (associated with visual imagery). (Baddeley, 2003)
Central Executive is primarily localized in the frontal lobes. (Baddeley, 2003)
Long-term memory (related to the self-reference effect) localized in the front portion of the frontal lobe: prefrontal cortex. (Matlin, 2005)
See Fig. 6 notes (pg. 836)Adolescent Brain
Some studies have researched the development of the adolescent brain. One such researcher, Dr. Jay Giedd along with other colleagues looked at the brains of 145 normal children by scanning them at two-year intervals. Giedd and his colleagues found that in an area of the brain called the prefrontal cortex, appeared to be growing again just before puberty. The prefrontal cortex sits just behind the forehead. It is particularly interesting to scientists because it acts as the CEO of the brain, controlling planning, working memory, organization, and modulating mood. As the prefrontal cortex matures, teenagers can reason better, develop more control over impulses and make judgments better. In fact, this part of the brain has been dubbed "the area of sober second thought." Giedd hypothesizes that the growth in gray matter followed by the pruning of connections is a particularly important stage of brain development in which teens do or do not do can affect them for the rest of their lives. He calls this the "use it or lose it principle."
Notable differences in the brain of an adolescent with ADHD are abnormal volumes in both the frontal lobes and basal ganglia. (Shafritz; Marchione; Gore; Ganz;and Shaywitz, 2004) Research findings suggest that children with ADHD (1) do not have generalized impairments in working memory, (2) rehearse verbal and spatial information in the same manner as healthy children, (3) may have an impairment in the central executive. (Karatekin, 2004) For partail compensation of this deficit pharmacological and non-pharmacological management may be utilized to improve memory, as mentioned above. Research has shown pharmacological management, such as stimulant medication is associated with better executive function performance. (Kempton; Vance; Luk; Costin; and Pantelis, 1999)
A non-pharmacological management technique to improve working memory would consist of training, which research has shown training improved performance on tasks related to prefrontal functioning and had also a significant effect on motor activity in children with ADHD. (Klingberg; Forssberg; Westerberg, 2002)
Memory Strategies
Memory strategies are defined, as performing mental activities that are designed to improve encoding and retrieval. (Matlin, 2005) Memory strategies allow for a deeper level of processing which allows information to be encoded into long-term memory. Memory strategies are utilized to enhance prospective memory. Prospective memory is remembering to do things in the future. A prospective memory task has two components: first, establishing a particular task at a future time, and secondly, fulfulling that intention. (Matlin, 2005)
One type of memory strategy is association. An association strategy is taking new information and associating it to something else. The association occurs because the new information is linked to a piece of familiar information. There are several types of association strategies. One type of association strategy, known as the comparison strategy, involves finding points of similarity, between two items that must be associated or remembered.
Example: First letter Association to relate taking medication before lunch, using the phrase “Before I get the Munchies, I need take my Medicine
A second type of memory strategy is journaling. Journaling allows for organization and time management. It is an example of an external memory aid.
Example: Agendas: planned activity written in a specific time slot.
Assisting the student who is diagnosed with ADHD, to comply with his/her medication regimen will demand a multimodal approach to achieve this goal. By a multimodal approach, I am speaking of pharmacological and nonpharmacological approach. Pharamacological treatment is the medication the student is prescribed (as mentioned above). The student needs to remember to take the ,medication, which will require a nonpharmacological approach. A nonpharmacological treatment would be the use of memory strategies to enhance the student's long-term memory. By utilizing explicit memory tasks of association and the use of an agenda, will assist the student to relate the cognitive task to themselves (the self-reference effect). Thus, the utilization of these explicit memory strategies will aide in improving the long-term memory of the adolescent with ADHD and at the same time provide assistance in the compliance of their medication regimen of their prospective diagnosis.
REFERENCES:
Matlin, M.W. (2005) Cognition (6th Ed.). Hoboken, NJ: Wiley.
SN Visser, MS, CA Lesesne, PhD (2005). Mental Health in the United States: Prevalence of Diagnosis and Medication Treatment for Attention-Deficit/Hyperactivity Disorder --- United States, 2003 (842-847)
Bauermeister (2007) Journal of Child Psychology and Psychiatry and Allied Disciplines, Volume 48, Number 8, August 2007 , pp. 831-839(9)
Pliszka (2003) Psychiatric Comorbidities in Children with Attention Deficit Hyperactivity Disorder: Implications for Management. Therapy In Practice Pediatric Drugs. 5(11):741-750
Shaywitz; Fletcher; Shaywitz, (2001) Current Treatment Options in Neurology 2001, 3:229-236Current Medicine Group LLC ISSN 1092-8480
Quintana ; Cherlin; Duesenberg; Bangs; Ramsey; Feldman; Allen; Kelsey, (2007). Clinical Therapy. 2007 June 29(6):1168-77. PMID
A Baddeley - Current Opinion in Neurobiology, 1998 - biologie.kappa.ro... Page 2. Recent developments in working memory [12 • ]AD: Working memory. ...
A Baddeley (2003) Working Memory: Looking Back and Looking Forward; Nature Reviews: Neuroscience Vol. 4 (p. 829-839)
Shafritz; Marchione; Gore; Ganz;and Shaywitz, (2004) The Effects of Methylphenidate on Neural Systems of Attention in Attention Deficit Hyperactivity Disorder; Am J Psychiatry 161:1990-1997, November 2004 © 2004 American Psychiatric Association
Canan Karatekin (2004) A test of the integrity of the components of Baddeley's model of working memory in attention-deficit/hyperactivity disorder (ADHD) Journal of Child Psychology and Psychiatry 45 (5)
S. Kempton, A.Vance, P. Meruff, E. Luk, J. Costin, and C. Pantelis; Executive function and attention deficit hyperactivity disorder: stimulant medication and better executive function performance in children; Psychological Medicine (1999), 29: 527-538 Cambridge University Press
Klingberg; Forssberg; Westerburg, (2002) Training of working memory in children with ADHD. Journal of Clinical Experience Neuropsychology. 2002 Sep; 24(6): 781-91.
RESEARCH QUESTION/HYPOTHESIS:
Can the long term memory of adolescents be improved to enhance compliance with medication regimen? My hypothesis would be that adolescents with ADHD who are taught specific memory strategies with the scope of improving their long term memory concerning their medication regimen, would present improved compliance with the medication regimen.
RESEARH DESIGN AND METHOD
The research design will consist of subjects (adolescents diagnosed with ADHD using pharmacological intervention) divided into three sub-groups of subjects. The sub-groups will be labeled as follows: Group A-control; Group B memory strategy #1; Group C memory strategy #2. Group A will receive no strategy, whereas, Group B will receive a memory strategy(#1) of journaling in their agenda the time to take their medication and Group C will receive the memory strategy( #2) that will consist of association ie. lunch=medication time. The research will be documented over a six week time frame with comparison of all three groups. To measure outcomes, a tally system will be utlilized to count the number of times the students come for medication during the designated time daily. Personal interviews be conducted at the end of the study to see if the students used the memory strategy given to help remember when to take their medication.
EXPECTED OUTCOMES
The expected outcomes will show from the results that memory strategies are effective in the long term memory of adolescents with ADHD. I believe the results will favor the memory strategy of association over the memory strategy of journaling. The reason for my proposed hypothesis is due to the fact that an external aide is only useful, when utilized. Most adolescents "forget" to bring agendas, they may misplace their agendas, or leave them at home. This is especially true for the student with ADHD.
VI. Educational Implications-
Children diagnosed with ADHD should be viewed as those with a learning disability, not a medical diagnosis requiring medication. A multimodal approach is the best way to treat a student with ADHD. Sometimes, medication is necessary, but nonpharmacological approaches can be utilized in the clinic as well as in the classroom. Teachers can utilize memory strategies in classrooms, which positively assist students with ADHD.
LIMITATIONS and WEAKNESSES:
A limitation that I identified is finding a sample size adequate to research for reliable results to base conclusions on. Most students take their medication at home before school; therefore, depending on the school year, I may or may not have enough students to participate.
A weakness I have identified is the time to conduct the experiment will take away valuable classroom instruction.
FUTURE STEPS:
Researching the need of medication with students with ADHD. Perhaps researching students diagnosed with ADHD on pharmacological treatment and students diagnosed with ADHD who do not have pharmacological intervention.
