What is ADHD?
|ADHD often prevents children from learning and socialising well.|
Attention deficit hyperactivity disorder (ADHD) and attention deficit disorder (ADD) refer to a range of problem behaviours associated with poor attention span.
These may include impulsiveness, restlessness and hyperactivity, as well as inattentiveness, and often prevent children from learning and socialising well. ADHD is sometimes referred to as hyperkinetic disorder.
What are the symptoms of ADHD?
A child must have exhibited at least six of the following symptoms for at least six months to an extent that is unusual for their age and level of intelligence.
- Fails to pay close attention to detail or makes careless errors during work or play.
- Fails to finish tasks or sustain attention in play activities.
- Seems not to listen to what is said to him or her.
- Fails to follow through instructions or to finish homework or chores (not because of confrontational behaviour or failure to understand instructions).
- Disorganised about tasks and activities.
- Avoids tasks like homework that require sustained mental effort.
- Loses things necessary for certain tasks or activities, such as pencils, books or toys.
- Easily distracted.
- Forgetful in the course of daily activities.
A child must have exhibited at least three of the following symptoms for at least six months to an extent that is unusual for their age and level of intelligence.
- Runs around or excessively climbs over things. (In adolescents or adults only feelings of restlessness may occur.)
- Unduly noisy in playing, or has difficulty in engaging in quiet leisure activities.
- Leaves seat in classroom or in other situations where remaining seated is expected.
- Fidgets with hands or feet or squirms on seat.
At least one of the following symptoms must have persisted at least for six months to an extent that is unusual for their age and level of intelligence.
- Blurts out answers before the questions have been completed.
- Fails to wait in lines or await turns in games or group situations.
- Interrupts or intrudes on others, e.g. butts into others conversations or games.
- Talks excessively without appropriate response to social restraint.
Pervasiveness of attention difficulties and hyperactivity
For a diagnosis or description of ADHD a child would be expected to show the above difficulties in more than one setting, eg at school and at home.
Sometimes problems are not shown ‘at home’ but are very evident when a child goes to a hospital department. This can happen when parents do not realise that their child’s behaviour is out of the normal range (perhaps because they have no other children, or they have other children who behave similarly).
It may also be because the problems are mild, or because the family has handled the attention lack at home in such a way that it is not evident there is a major problem, or because the child is very young. In those cases it is quite reasonable for parents not to consider that their child has an attention deficit problem.
Who is affected by ADHD?
About 1.7 per cent of the UK population, mostly children, have ADD or ADHD. Boys are more likely to be affected.
What else could it be?
- Grand mal or petit mal epileptic seizures can cause a child to become drowsy, impairing their attention. Epilepsy can also cause unusual behaviour and lead to abnormal perceptions.
- Hearing problems such as deafness or glue ear can make it hard for a child to follow instructions and make them appear inattentive.
- Reading problems, making it hard to complete tasks or follow instructions.
- Obsessive compulsive disorder leads to people following strange rituals that preoccupy their thoughts and distract their attention.
- Tourette’s syndrome involves repetitive, involuntary jerking movements of the body and sudden outbursts of noise or swearing.
- Autism and Asperger’s syndrome often lead to difficulties in understanding and using language.
- Prolonged periods of insufficient sleep, causing poor concentration.
NB: Many children may be very active or be easily distracted or have difficulty concentrating. If these behaviours are relatively mild, they should not be considered a disorder.
What other difficulties can occur alongside ADHD?
ADHD often occurs alongside other difficulties and is not the sole cause of problem behaviour. Children may exhibit temper tantrums, sleep disorders, and be clumsy. Other behavioural problems that occur with ADHD include:
- confrontational defiant behaviour, which occurs in 60 per cent of children. The child loses their temper, argues and refuses to comply with adults and deliberately annoys others.
- conduct disorders occur in at least 25 per cent of children. The child may be destructive or show deceitful behaviour such as lying, breaking rules and stealing.
- specific learning difficulties, including dyslexia, occur in 25-30 per cent of children.
- severe clinical depression occurs in 33 per cent of children.
- anxiety disorders occur in 30 per cent of children.
What causes ADHD?
- The child’s temperament, as this contributes to their attitude and personality.
- Studies of twins suggest a genetic link to ADHD. In 80-90 per cent of identical twins where one has ADHD so does the other. Recent research also suggests there is a greater chance of inheriting the condition from male relatives such as grandfathers.
- Brain injuries due to birth trauma or pre-birth problems. The brain structures believed to be linked to the development of ADHD are vulnerable to hypoxic damage during birth. The damage is caused by inadequate oxygen reaching parts of the brain while blood flow is reduced.
- Family stress.
- Educational difficulties.
How is ADHD diagnosed?
ADHD requires a medical diagnosis by a doctor, usually a child or adolescent psychiatrist, a paediatrician or paediatric neurologist or a GP.
It will often be appropriate for other professionals such as psychologists, speech therapists, teachers and health visitors to contribute their observations to the assessment of a child with possible ADHD. There is no single diagnostic test for ADHD so different sorts of information needs to be gathered, such as the following:
History of symptoms
The precise nature of the difficulties, when they were first noticed, in what situations they occur, factors that exacerbate or relieve them.
Risk factors that could predispose the child to ADHD include difficulties and risks in pregnancy and during birth, for example if the mother was in poor health, very young or drank alcohol or smoked or had an extended or complicated labour.
Several medical conditions are known to be associated with ADHD. These include fragile-X syndrome, fetal alcohol syndrome, G6PD deficiency, phenylketonuria and generalised resistance to thyroid hormone.
Accidents, operations and chronic medical conditions such as epilepsy, asthma and heart, liver and kidney disorders all need to be taken in to account. Also of possible relevance is any medication the child is taking, as well as any adverse reactions they have had to medication in the past.
Past psychiatric history
Enquiring about any mental health problems the child has had can help rule out depression or anxiety being behind the symptoms.
This means the level of their ability and what specific difficulties they have, how they function within their peer group and get on with teachers, and any behaviour difficulties such as suspensions or exclusions. A more detailed evaluation of the child’s learning by a psychologist may be necessary.
Evaluation of the child’s temperament and personality
The child’s temperament and personality, those of other family members and the nature of relationships within the family may need to be assessed. This will include discussion of the methods used by the parents to manage the child’s behaviour and how successful they have been. Although this seems intrusive, the assessor will remain neutral and parents should not feel the disorder is ‘their fault’.
The mental and physical health of the child’s parents and other family members can be relevant, particularly regarding the incidence of ADHD or depression.
The family’s social circumstances, such as housing, poverty, and social support may all have an impact on the child’s behaviour.
What treatment is available for ADHD?
Treatment depends on a child’s exact diagnosis. It should take into account any specific difficulties and those strengths that may aid their improvement.
It is not easy to live or cope with a child with ADHD. Both parents and teachers can follow general guidelines to manage a child’s problematic behaviour but they may need specialist support and advice, e.g. from a psychologist.
Management techniques for parents and teachers
- Create a daily routine for the child, eg homework schedules, bedtime and mealtime routines.
- Be specific in your instructions to the child and make clear and reasonable requests, eg instead of telling the child to ‘behave’ suggest ‘play quietly with your Lego for 10 minutes’.
- Set clear and easily understood boundaries, eg how much TV they may watch, and that rudeness is unacceptable.
- Be consistent in the handling and managing of the child.
- Remove disturbing or disruptive elements from their daily routine. For example, remove siblings from the room when they are doing homework or turn off the TV.
- Plan structured programmes aimed at gradually lengthening the child’s concentration span and ability to focus on tasks.
- Communicate with the child on a one-to-one basis and avoid addressing other children at the same time.
- Use rewards (eg stickers, tokens or even money) consistently and frequently to reinforce appropriate behaviour such as listening to adults and concentrating.
- Use sanctions (eg loss of privileges, being sent to their room) for unacceptable behaviour or ‘overstepping’ of boundaries.
- Discuss your child with their school or nursery and see if you can work together.
Behavioural management techniques such as those above are always important, and for mild attention deficit problems they are the treatment of choice. US research suggests that medication is the best treatment for true ADHD. The most common and effective medications are amphetamine-like stimulants, mainly methylphenidate (eg Ritalin) and dexamfetamine (Dexedrine). If there are coexisting conditions then these may also require medication.
Ritalin reduces hyperactivity and impulsiveness and helps to focus a child’s attention. They become less aggressive, seem to comply with requests, and become less forgetful. Many parents say their child’s behaviour has vastly improved as a result of Ritalin.
However, there is growing concern about the use of Ritalin to treat ADHD. Like amphetamines, Ritalin is classified as a class A drug. Many parents and professionals are worried about alleged side effects, including damage to the cardiovascular and nervous systems. Ritalin’s manufacturers recommend that it is only used to treat children aged six years and over. If symptoms don’t improve after a month’s trial it should be discontinued. The manufacturers also recommend that even if Ritalin is effective it should discontinued periodically to assess the child’s condition. You should discuss any concerns with your child’s doctors, and they may alter the dose prescribed.
In addition to the management techniques described, other forms of psychological treatment might include anxiety management, cognitive therapy, individual psychotherapy and social skills training.
This includes individual, or group, learning support for coexisting learning difficulties and educational underachievement.
Research suggests that diet is not a significant factor in ADHD for most children. Some children have particular food allergies that need investigation. Dietary changes need to be supervised by a doctor and nutritionist. In this approach all foods suspected of causing behavioural problems are removed from the diet then gradually reintroduced while the child’s behaviour is monitored by the psychologist.
What is the likely outcome?
Many children simply outgrow ADHD. About half of those affected appear to function normally by young adulthood, but a significant number will have problems that persist into adult life. These may take the form of depression, irritability, antisocial behaviour and attention problems.