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ADHD

Coping with Attention Deficit/Hyperactivity Disorder 

A child’s ability to concentrate and pay attention, like all other skills, develops over time and at an individual rate.  As a child matures and gets a chance to practice, the level of skill increases.

Unfortunately for some children, the ability to inhibit or curb behaviour and pay attention is inconsistent with their development level.  Some of these children have Attention Deficit/Hyperactivity Disorder (ADHD) and are neurobiologically different from other children.  Because of this difference, ADHD is classed as a neurological disorder.

This neurobiological difference interferes with their ability to inhibit, control and direct behavior in response to the environment and situation. It is characterized by inappropriate levels of three behaviours: inattention, impulsiveness and sometimes hyperactivity.  Many children and adults experience these symptoms, but for someone with ADHD they are pervasive and debilitating.

ADHD is characterised by inappropriate levels of three behaviours: inattention, impulsiveness and sometimes hyperactivity.  Many children and adults experience these symptoms, but for someone with ADHD they are pervasive and debilitating.

What causes ADHD?

Research indicates that ADHD is likely to be caused by biological factors that influence neurotransmitter activity (or chemicals that transmit messages) in certain parts of the brain.

Slight imbalances in the brain’s neurotransmitters affect the parts of the brain that control reflective thought and our ability to control poor or ill-considered behaviour.

Evidence also suggests ADHD is hereditary, indicating a strong genetic basis. ADHD ranks as the most common neurobiological disorder in children, affecting about five percent of school children.  ADHD can persist in adulthood with two and a half percent of adults affected by ADHD.  There is a gender bias found in children and adults, with twice as many boys diagnosed with ADHD than girls, a similar bias persists in adults (1.6:1, men to women).

How is ADHD diagnosed?

There is currently no single definitive medical or psychological test for ADHD.

Diagnosing ADHD requires a comprehensive assessment conducted by a paediatrician, psychiatrist or clinical psychologist.  The professional conducting the assessment uses multiple methods and instruments to gather the information needed.  The traditional diagnosis depends on observing and assessing behaviour, the by-product of brain function, while the more recent diagnosis combines this with observing neurological differences.

The most common assessment includes:

  1. interviews with a child’s carers and the child if appropriate to determine the nature and scope of a child’s difficulties and rule out other causes such as medical, emotional or family problems;
  2. direct observation of a child in various settings (for a diagnosis of ADHD to be confirmed the symptoms need to be present across various settings such as the home and school);
  3. achievement and psychometric tests; and
  4. feedback from parents, teachers, carers and others about a child’s behaviour in various situations (several behavioural rating scales have been developed specifically for the identification of ADHD).

After collecting information from all sources, a professional analyses the results to determine if a child’s behaviour meets the diagnostic criteria for ADHD outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

To meet these criteria, behaviour must be problematic and inconsistent with a child’s developmental level in two areas: (a) Inattention and/or (b) Hyperactivity and Impulsivity.  The problematic behaviours must have appeared before twelve years of age, remained persistent for at least six months, been present in two or more settings, and not better explained by another disorder.  Children and adolescents require a minimum of six symptoms in either the Inattention and/or Hyperactivity domains before a diagnosis can be made.

Because the formula for diagnosis is based upon subjective information, its validity has been questioned and there have also been claims of over-diagnosis. In an effort to produce a more objective measure of ADHD, some researchers and practitioners are incorporating new techniques into their assessments.

Some researchers have observed neurobiological differences in individuals with ADHD. They use electro physical indices of brain functions (such as EEG and ERP assessment) to assist diagnosis, while others use continuous performance tests (such as TOVA computerised assessment).

Early diagnosis is essential.  Early identification and intervention can help children with ADHD avoid negative outcomes such as school failure, inappropriate social skills and deflated confidence.

How does ADHD affect children?

ADHD can cause mild to severe disruptions in a child’s life depending upon the severity of the behaviours and the effectiveness of intervention.

It is generally agreed that ADHD does not have a significant effect on an individual’s intelligence.  Despite natural ability, a child’s inattentiveness, impulsivity and hyperactivity unfortunately often result in failing grades.

The behaviours associated with ADHD can fluctuate from hour to hour and day to day, causing an inconsistency in performance that is often mistaken for lack of effort.  ADHD symptoms become more obvious with tasks requiring sustained effort, inhibition, organisation and self-regulation.

An inability to control behaviour increases the risk of school failure for any child.

The structure of most schools requires that children sit still, remain on task, work independently, organise and keep track of materials, monitor their time and performance, and follow rules and directions.  A child’s ability to meet these demands in part determines school success.

ADHD is not a learning disability but may co-exist with one and approximately 30% of individuals with ADHD have some type of learning disability. A student diagnosed with ADHD is highly likely to experience learning difficulties due to the influence of attention problems, their impulsivity and hyperactivity.

Untreated, ADHD can lead to poor self-esteem and social adjustment. Children with ADHD commonly experience interpersonal difficulties, peer rejection and difficult relations with family members.

ADHD does not disappear and usually continues into adult like, sometimes with a slight variation or reduction in symptoms. Some children mature in ways that cause their ADHD symptoms to diminish or disappear. For others, hyperactivity may abate the problems but with impulsivity, inattention and organisation remain.

Treatment

ADHD cannot be cured but education and treatment can help children cope and succeed at home and school.

Most experts believe that ADHD is best treated through a multi-modal approach that involves parents, teachers, and medical and mental health professionals.

This approach involves educating parents, teachers and the child about ADHD, training parents and teachers to use appropriate behavioural and academic interventions at school and at home, accommodating the child in the classroom and possibly providing medication, counselling and social skills training.

There is currently an array of medications available for the treatment of ADHD.

The prescribed drugs act by normalising the imbalance in the brain’s neurotransmitter chemicals.  Stimulants such as ritalin and dexamphetamine are the most common forms of medical treatment.

Medication does not cure the disorder but can help to control the symptoms.  In most children, it can provide a short-term decrease in the characteristic behaviours of inattention, impulsivity and hyperactivity, but does not increase knowledge, improve academic skill or social adjustment.

Medication combined with educational and/or psychological intervention such as organisational and skills development, time management and behaviour modification appear to produce improvements in behaviours and associated issues related to ADHD.

How can parents best support children with ADHD?

Children with ADHD experience difficulties in many aspects of their lives – at home, school, in peer relationships and social activities. The difficulties often result in low self-esteem, anxiety, depression, and behavioural problems.

While parenting any child is hard work and an ongoing learning process, parents whose children have ADHD often feel frustrated, guilty and angry as they struggle with children who do not learn quickly from their experiences and who are often impulsive, moody and don’t adapt well to changes. Some of the following principles can be applied to help families:

Recognise that the child’s difficulties are not your fault – they are not due to what parents have or have not done.  Parents need to develop strategies that will be effective with difficult temperaments and unacceptable behaviours.  They need to be firm, consistent and set clear, explicit limits and guidelines for their children.  At the same time they need to remain calm when dealing with their children so as not to escalate an issue and the child’s behavior.

Have realistic expectations of a child’s behavior that is based on both the child’s age and developmental stage. At the same time, parents need to find strategies to increase their tolerances of what is often a normal chaos and noise level in families with children. It is important not to fight battles that do not need to be fought.

Set limits for a child to set clear expectations for their behavior and enable a child to develop competence, self-control, autonomy and an ability to relate effectively with those in his/her environment.

As much as possible institute a routine in a child’s day, allowing them to learn the sequence of day-to-day activities and predict what is happening in his or her environment.

Maintain eye contact and use your child’s name when speaking with them.

Use “I” messages” – this invites the child to participate in problem solving.

Maintain detachment – don’t get involved in a child’s chaos. Be firm but respond in terms of a child’s behaviour rather than your feelings – this is particularly important if a child is continuing to be defiant. Maintaining control is important to maintaining a positive relationship with a child. It is especially important not to enter into arguments or negotiations.

Punish less but more effectively. Have fewer power struggles and say “no” less often. Parents should target the most important behaviours that enable the child to improve their self-esteem and social relationships.

Focus on behavious rather than a child as the problem. This allows a parent to join with their child to find a solution to problem behavior and increases the chances that a child will change and eventually learn to set his or her own boundaries.

Differentiate between behaviours that result from the child’s difficult temperament and those which are manipulative or within the child’s control. Parents can often intervene to prevent unacceptable behavior that would require punishment by identifying instances where the child’s difficult temperament contributes to the situation and developing a strategy to diffuse the situation earlier.  For example, “I know you like playing outside and it’s hard for you to change, but right now we need to …”

Build children’s self-esteem and competence by encouraging them to develop skills in areas they enjoy and do tings for themselves. Don’t expect perfection, but rather praise for having a go.

Above all parents need to look after themselves. They need to have time to recharge their batteries and to nurture their own adult relationships. Parenting programs are excellent, not only for developing effective parenting strategies but also for developing mutual support and sharing of experiences. Understanding that a child’s problems result from a disorder rather than a purposeful non-compliance is important and allows the parent to join the child in learning new solutions to their difficulties.

How can professionals best support children with ADHD and their families?

Each child is different and each needs a specifically designed program. There is no one program or set accommodations for children with ADHD. However, the following general principles can typically be applied.

Adopt a supportive non-judgemental approach to both the children with ADHD and their families. Establish yourself as an ally and portray your understanding that ADHD is a real condition.

Embrace teamwork. Work in a collaborative way with the family and other involved professionals.

Actively work towards the inclusion of the child with ADHD along side their peers.

Provide routines and structure, and communicate these using visual aides.

Rather than trying to dampen hyperactivity, provide the child with acceptable ways to channel this need for activity.

Keep instructions simple, short and clear.

Always get the child’s attention first before giving an instruction.

Be consistent with expectations and rules. Provide visuals to display the expected behaviours and the consequences if these are not followed.

Minimise visual distractions and noise.

Shorten the task, or break one task into smaller parts to be completed at different times.

Provide closer supervision and support (e.g. use hand signals to remind the child that he or she is distracted and needs to refocus; place the child in close physical proximity to a teacher or peer model).

Document History:  Original article authored by Dr Danielle Tracey and Sandra Samuel.

Recent edits provided by Dr Samantha Hornery and Michelle Button.