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Attention-Deficit/Hyperactivity school-age children in the United States,

Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic neurobehavioral disorder characterized by over-activity and impulsiveness beyond what is considered typical development. ADHD affects 3% to 10% of school-age children in the United States, with males being three to five times more likely to have an ADHD diagnosis compared with females (DuPaul, 2007). It is estimated that every teacher in the United States has at least one child with ADHD in their classroom, and four million school-age children are affected with the disorder (Dang, Warrington, Tung, Baker, & Pan, 2007).   There are three subtypes of ADHD described by the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V; American Psychiatric Press, 2013): ADHD, Combined Type (ADHD/COM) characterized by high levels of hyperactive/impulsive and attention problem symptoms; ADHD, Predominantly Inattentive Type (ADHD/I) refers to individuals with significant attention problem symptoms in the absence of clinically significant hyperactivity/impulsivity; and ADHD, Predominantly Hyperactive/Impulsive Type (ADHD/HI) refers to individuals with substantial hyperactive/impulsive symptoms without attention symptoms and it is the least common subtype.   The symptoms of ADHD can affect all aspects of a child’s life, especially school performance, interactions with other family members, and peer relationships (Barkley, 2006; DuPaul & Stoner, 2003). Early recognition, assessment, diagnosis, and treatment of ADHD are important to minimize the impact of ADHD on the individual’s social development, including school performance, interactions, and self-esteem.   Treatment in ADHD  While there is no prevention or cure for ADHD, there are several treatment options that can alleviate the symptoms and help the individual function as normally as possible in everyday life.  In reviewing the literature on ADHD, it is clear that clinicians generally feel that treatment with stimulant medication, usually methylphenidate, is by far the most efficacious treatment (Johnson, 1988), and historically, it has been the primary intervention for this population (Dupaul, Barkley, & McMurray, 1991). However, Volkmar, Hoder, and Cohen (1985) discuss how the lack of careful and comprehensive assessment, the poor monitoring of patient response to medication, and the lack of careful consideration of the risks associated with stimulant medications can lead to the inappropriate use of stimulant therapy. Additionally, improved academic performance and long-term behavioral change have not been convincingly demonstrated in follow-up studies (Barkley & Cunningham, 1978; Johnson, 1988). This suggests that medication treatment is not the single or ultimate answer for treating children with ADHD.   Behavioral therapy interventions have been largely ineffective with the ADHD population (Abikoff, 1985) and the multimodal treatment for ADHD (MTA) was more effective than behavioral therapy alone, but also found as not significantly more effective than stimulant treatment alone (MTA Cooperative Group, 1997).   A notable lack of literature is to be found on other forms of treatment for ADHD. Some studies have addressed the relatedness of nutritional concerns (Haslam, Dalby, & Rademaker, 1984; Wender & Solanto, 1991). Art therapy has also addressed ADHD in terms of effectiveness of medication treatment (Epperson & Valum, 1992), encourage creative growth (Smitheman-Brown & Church, 1996), and as part of a multimodal approach to address interpersonal-social problems associated with ADHD (Henley, 1998). More recently, Neuro-therapeutics, the use of specific tones embedded in white noise to modulate brainwave function, has been espoused as a hopeful new treatment (Abarbanel, 1995; Plude, 1995; Swingle, 1995).   ADHD and external stimulation  Clinicians generally find that parents of children with ADHD describe how their children prefer the use of external stimulation, such as the TV or stereo, while completing homework tasks, and those parents concern that the use of external stimulation hinders the academic performance of their children (Abikoff, Courtney, Szeibel, & Koplewicz, 1996).   A landmark study by Zentall (1975) discussed the Optimal Stimulation Theory with regard to ADHD, claiming that the distractibility of those with ADHD is a functional attempt to control under-arousal from low levels of stimulation, by seeking increased levels of stimulation. Using this theory, Zentall found that children with ADHD demonstrated high levels of activity when they encounter a task or situation of low arousal or stimulation. Additionally, Zentall described how certain situations require more environmental stimulation than others in order to support effective performance. However, children with ADHD have an even higher threshold for such environmental stimulation, Therefore, they typically display hyperactive behavior when levels of stimulation are low, and this leads to low task performance (Wu, Anderson, & Castiello, 2002; Zentall, 1993). Another study was conducted with boys in elementary school, with and without ADHD, to determine the effects of auditory stimulation on their arithmetic performance. The rationale was that stimulation would help children with ADHD stay on task. The participants worked on an arithmetic task during three different auditory conditions: a high stimulation condition in which music was presented, a low stimulation condition of speech, and a no stimulation condition of silence. While those without ADHD performed similarly on all three of the auditory conditions, children with ADHD did moderately better during the high stimulation condition in which music was present compared with the other two conditions (Abikoff et al., 1996).  Auditory stimulation, specifically in the form of music, can possibly act as a means of an appealing external stimulation for children with ADHD, which in turn, increases arousal effects, thus improving attention span of individuals with ADHD, which in turn will increase task performance.   Music Therapy and Music Interventions for ADHD  While music therapy, much like music interventions, can be used to help individuals improve their intellectual functioning, music therapy is implemented by a trained professional who has undergone an evidence-based music therapy program. The definition of music therapy often includes the term “intervention”, although the two concepts are not the same. According to the American Music Therapy Association (2013), music therapy is the “clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.” In contrast, teachers and other professionals without any type of formal music therapy training can implement music interventions. Jackson’s (2003) definition of music intervention refers to “music as a means of increasing an individual’s cognitive, academic, or task performance”, meaning formal training is possible but not necessary to implement music interventions.  A few studies have focused on the effects of external stimulation, specifically music, and its impact on task performance for children with ADHD; however, the current research on this topic is limited. Greenop and Kann, (2007) replicated previous studies of Zentall (1993), comparing children with and without ADHD on an academic task, mathematics problems, during two counterbalanced conditions of stimulation- with or without music. The accuracy score on the task increased significantly during the music condition. A study conducted by Pratt et al. (1995) used background music during neuro-feedback training sessions and examined EEG patterns to determine the impact of background music on the focus, concentration, and impulsivity of children with ADHD. The results of the study showed children with attention deficit disorder (ADD) exposed to the background music during the training sessions showed more improvement in focus.   The use of music to assist in learning has also received some attention in the literature. Shehan (1981) examined four mediation strategies in the retention of a paired-associate learning task for children with learning disabilities. Word pairs were presented in music, verbal, music/visual, and verbal/visual formats. Results indicated that the use of a combination of music/visual or verbal/visual teaching strategies best facilitated the retention of paired associates. Roskam (1979) investigated the effectiveness of a planned series of music activities designed to expand auditory perception and improve language skills in learning disabled children. The children were divided into three groups and treated for reading difficulties using prescriptive music therapy, language development activities, and a combination condition. the music therapy group showed the highest mean difference in the pretest and posttest scores.  Discussion  This literature review sought to examine the knowledge regarding music and its associations with ADHD.   As mentioned above, studies found that external stimulation can have a positive impact on academic performance for children with ADHD (Abikoff et al., 1996; Zentall, 1975; Zentall, 1993). More recent studies support this notion trough the MBA model for ADHD. Environmental noise is introduced into the neural system of individuals through the perceptual system, which allows for reduced neural background activity and a hypo-functional dopamine system in children with ADHD, thus, increasing their memory performance (Söderlund et al., 2007; Solanto, 2002). One study, looked specifically at how ADHD and controls respond to different encoding conditions, providing different levels of environmental stimulation. The results indicated that noise had a positive impact on the cognitive performance of children with ADHD, but a negative impact on the cognitive performance of children without ADHD (Söderlund et al., 2007). This enforces the idea that auditory stimuli is of unique value for children dealing with ADHD.  In accordance, background music has been shown to significantly improve task performance for children with ADHD (Abikoff et al., 1996; Greenop and Kann, 2007; Pratt et al., 1995). A more recent support was found by Pelham et al., (2011), who carried out two experiments that used music as external stimulation for boys with and without ADHD. The results showed that boys with ADHD were more disruptive, less productive, and more distracted than the boys without ADHD, especially when a video distractor was present. However, boys with ADHD were not significantly distracted by music, which was also found to be less distracting than video in general. Such findings highlight the importance of the type of stimulation. Music interventions and therapy methods will probably have better outcomes for treating ADHD, compared with methods basing on visual or other sensory stimulation.   On top of the ability to increase attention span, music interventions were also associated with assistance and improvement of learning, in including the use of music paired with visual cues to increase information retention, and the use of music to improve auditory perception and language skills in learning disabled children (Shehan, 1981; Roskam, 1979). Also of interest in this context, are studies of the effect of music and sound on neurological functioning. Furman (1978), studied the effect of music on alpha brain wave production in children, and Morton, Kershner, and Siegel (1990) demonstrated that music enhances the effect of dichotic listening, which may result in increased short-term memory, decreased distractibility and an enhancement of information processing.   Despite the presented evidence on contributions of background music to attention and the associations of music interventions with improved task performance and enhanced cognitive abilities, the literature on the use of music therapy to treat ADHD is sparse at best. Results a survey by Jackson (2003) indicated that music therapists often utilize a number of music therapy methods in the treatment of children with ADHD. They often address multiple types of goals, and treatment outcome is generally perceived to be favorable according to their treatment outcomes. Gfeller’s (1984) exploration of three theories of learning disability and the different music therapy approaches that best fit these theories has numerous implications for treatment of children with ADHD, since learning disabilities seem to be either part of, or co-morbid with the disorder. In comparing the prominent music therapy methods and the elements just mentioned, one can see that at least some of these elements are part of each of the methods. Music and movement, instrumental improvisation, musical play, and group singing all involve some sort of physical movement, and all except group singing are likely to often involve movement on both sides of the body and across midline (dual activation of both hemispheres in the brain). Musical play and group singing are likely to involve the pairing of music and information, while music and movement may pair music with an increased awareness of emotion or increased spatial awareness (auditory perception and memory). And, of course, all involve the use of sound and tones (potential brainwave modulation). Clearly, further investigation is needed in each of these areas to better understand how music can be effective for these children,  When examining the existing literature, it is clear there is a need for more current research, since most of the studies are 10-15 year old. Changes in research, technology, teaching style, and information regarding this population have progressed drastically and more contemporary studies would reflect this change. Another crucial problem in most of the existing knowledge is that results may have been affected by the fact that the children were allowed to remain on medication throughout the studies and that effect wasn’t always reported to be controlled. Secondly, the age range of participants is very wide, and lastly, many of the participants had co-morbid disorders. As mentioned, the DSM currently differentiates between three subtypes of ADHD and also determined different criteria for children and adolescents, but no studies relating to the specifications were found. Another problem arises from the fact that most studies were conducted solely on boys. Not only is the diagnosis different for each individual, ADHD presents itself differently across genders as well. Today It is established that girls are under-diagnosed with ADHD due to the fact that they usually manifest symptoms related to the attentional and not the hyper-activity aspect, which is more easily detected by parents, teachers etc. (Soffer, Mautone & Power, 2007). Therefore, it is of great importance to include more female subjects, consider and examine gender effects. Such research is essential in this under-studied population, to develop a more thorough understanding of the nature of the disorder in females, and trough that, accurate and differentiate assessment and intervention efforts to adequate the specific characteristics presented by girls with ADHD.   Overall, Considering the potential of music interventions to impact brain function, attention, activity level, social behavior, and learning, and combining it with generally positive outcomes in cases music therapy methods were implemented, there appears to be good reason to support further investigation into the ways that music therapy and interventions might be used to effectively treat children with ADHD, with the purpose of incorporating them into the therapeutic protocol for ADHD interventions in the most optimal manner.  


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