AD/HD is a disorder characterised by problems with attention, hyperactivity/impulsiveness, or, as is usually the case, both attention and hyperactivity/impulsiveness. The diagnostic criteria are given in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV 1994) published by the American Psychiatric Association.
AD/HD is almost certainly a genetic disorder with a bio-neurological basis. However, AD/HD can be exacerbated by social, psychological and environmental factors. It can be useful to think of AD/HD as a threshold which can be reached by a combination of factors – some of which can be avoided and some of which cannot.
These problems have been recognised and treated for many years, in many parts of the world, including the UK. In the past, European health professionals have often recognised Hyperkinetic Disorder, a similar though more stringent set of criteria (published by the World Health Organisation in the International Classification of Diseases – ICD 10), rather than AD/HD. Increasingly, Hyperkinetic Disorder is used to describe children who are severely hyperactive, while AD/HD is seen as a more inclusive category allowing for a broader range of problems and causes.
It is important to remember that all children have to learn how to control their attention, mood and naturally lively behaviour, but children with AD/HD have considerably more difficulty acquiring self-management skills than others. One of the most misleading aspects of AD/HD is that the children experience distinctly good and bad days, and this can lead adults to believe they can behave well when they want to. Children with AD/HD also tend to behave well when they are being assessed, as they enjoy attention and new situations.
AD/HD is not an ‘all or nothing’ condition, like a broken bone, so much as a continuum along which we all lie. It can be seen as a mismatch between the characteristics of an individual and the demands made upon him/her in certain situations. In our society – particularly in school – it is very important to be able to sit still, listen and work hard even when you would rather be doing other things. We expect children to follow rules, be organised and adhere to a strict timetable. Some children fit naturally into this pattern while others have more problems. For many children with AD/HD, the demands of school conflict so much with their natural behaviour that they simply cannot cope – unless we adapt this environment to meet their needs.
Children with AD/HD often have co-occurring, or co-morbid, problems in other areas, most frequently: speech/language difficulties, dyspraxia, dyslexia, social, emotional and behavioural disorders. AD/HD is unrelated to intelligence and affects children from all cultures and social groups. Estimates of prevalence vary between 2 and 5%, with many more boys than girls being affected.
The Core Deficits
- Attention: Children with AD/HD find it easy to concentrate when they are enjoying themselves – for example with a computer game – but difficult or boring tasks quickly result in problems with getting started and staying ‘on-task’, and it is then they become easily distracted. It can also be hard for these children to change from one task to another, or to tear themselves away from an activity they find interesting or fun. It is important to remember that children with AD/HD do not have a problem with attention per se, but a problem in controlling attention. Problems with attention usually continue into adulthood.
- Hyperactivity: Children with AD/HD – particularly when they are young – are always ‘on the go’, and often remain restless and fidgety into adulthood
- Impulsiveness: Children with AD/HD find it difficult to await their turn in queues, conversations and games, or to work for long term rewards. Professor Edmund Sonuga Barke, (University of Southampton, England) argues that ‘delay aversion’ is the core difficulty underlying AD/HD. The children often act without considering the consequences, saying and doing things which they later regret. Impulsiveness results in social, learning and behavioural difficulties – and a high accident rate!
AD/HD can be difficult to diagnose and manage, and for this reason it is generally considered good practice for children to be assessed by a Child and Adolescent Psychiatrist or Paediatrician, together with a Clinical or Educational Psychologist and any other relevant professionals – for example a Speech and Language or Occupational Therapist. There are several reasons why this multi-professional approach is required:
There are many factors which can cause a child to look as though s/he is AD/HD when this is not in fact the case, for example: the existence of another developmental disorder, emotional difficulties or a sensory impairment such as hearing loss. At the same time, we must remember that around half of children with AD/HD will have other problem areas.
Differential diagnosis refers to the process of untangling which of a child’s behaviours are primary symptoms of AD/HD; which behaviours are secondary symptoms (for example low self-esteem) and which behaviours are due to another disorder.
AD/HD is a continuum rather than a categorical disorder, which means that all children are active, impulsive and inattentive at times. It is often difficult to decide if a child’s problems are at the difficult end of the normal range, or severe enough to warrant a psychiatric diagnosis.
There is no test or tests for AD/HD, which is diagnosed by its symptoms. Professionals use many diagnostic aids – questionnaires, rating scales and computerised tests of attention and impulsiveness, but diagnosis ultimately depends upon taking a detailed developmental history from parents, making careful observations at home and at school and talking with teachers. The professionals involved then make a clinical judgement based on the information they have gathered.
Every child with AD/HD is an individual who will require his/her own management plan. The following tips are useful for many children:
Think about the future rather than the past and solutions rather than problems.
Involve the child in problem-solving and facilitate this process. Remember: children cannot be confrontational while they are problem solving; they are learning a useful skill; they are learning to take responsibility for their own behaviour and thus improving self-esteem. Also, we all like our own ideas to work.
Isolate only one or two problems, and make sure targets are clearly stated, attainable and positively worded.
Reward success immediately and generously. Rewarding good behaviour is more effective than punishing bad behaviour, but try not to use material rewards such as sweets (candy) and money.
Response cost is very effective: e.g. the child earns a marble for each 10 minutes s/he does not swear, and loses one when he does swear. At the end of the day the marbles are exchanged for time on the computer.
Try to make tasks short, participatory and multisensory. Alternate hard tasks with more interesting or easy ones. If you can make a task the most interesting thing in the environment you have won! Make good use of computers which have all of these qualities and also provide immediate feedback – remember, AD/HD children cannot tolerate delay. If a task is too easy or too difficult the child with AD/HD will give up, but software enables a child to work at exactly his/her own level without involving the teacher in extra work.
AD/HD children have memory and organisational problems: use visual cues, write instructions down, check the child knows what to do and teach organisational skills.
Be prepared for difficult times of the day: playtime (have an experienced teacher outside), lunchtime, changes of lesson, outings, parties, supply teachers.
Parents and school should liaise closely, using a home-school diary.
Never resort to sarcasm, anger or pleading. Be assertive and let the child know that you always like him/her even when you dislike a behaviour.
Remember that the most valuable reward is attention. Ignore minor irritations while never forgetting to notice good behaviour.
Children with AD/HD are often unpopular. Teachers can help this by treating the child in a positive way – peers will copy this behaviour.
Between 60-90% of hyperactive children respond positively to stimulant medication, and important new research has shown that it is more effective than behavioural interventions in controlling the core symptoms of AD/HD (Multimodal Treatment Study of Children with AD/HD). Howevr, the study showed that other interventions play an important part in improving behaviours related to AD/HD, and can also make a real difference for children whose parents do not want their child to take medication. The efficacy of medication is vastly increased when the treatment is carefully planned and monitored, and combinations of medication are then rarely necessary.
Stimulant medication controls the symptoms of AD/HD and creates a ‘window of opportunity’ for the child to learn positive behaviours, but it does not cure the disorder. Medication takes effect within 30 minutes, peaks after approximately 2 hours and wears off after approximately 4 hours.
No-one is certain how medication works, but it is thought to stimulate activity within the executive, or self-control, areas of the brain, and improve neural networking. Some children fear they are being tranquillised so as to control their behaviour: this is not the case, children should feel alert and focused.
The positive effects of medication can be dramatic, showing a marked improvement in the child’s ability to control his behaviour, mood and attention. The brain works more efficiently and quickly, and for some children handwriting and motor control is improved. However, some children experience appetite loss, wakefulness, tearful/withdrawn behaviour. These side-effects are usually transitory, or easily controllable by adjusting the timing and/or dosage and/or type of medication.
Although stimulants have been used to treat AD/HD for 40 years there is no long term research showing the effects of taking the medication over time. What evidence exists suggests that for the vast majority of individuals medication does not have adverse long term effects. All children with AD/HD are at increased risk for later substance abuse, but this is not increased by taking medication. Children with Tourette’s syndrome, or a personal or family history of tics, need careful consideration, as stimulant medication can reveal or exacerbate the symptoms.
The most commonly used medications for treating AD/HD are described as follows*:
STIMULANTS: Methylphenidate, (brand names Ritalin and Equasym), Dexamphetamine (brand name Dexedrine) and Pemoline (only available in the UK on a named patient basis following the Committee of the Safety of Medicine’s concern of the incidence of liver toxicity. It should only be prescribed in specialist units.
ANTIDEPRESSANTS: Imipramine and Nortriptyline
ANTIHYPERTENSIVES: Clonodine and Carbamazepine
Only Methylphenidate (Ritalin or Equasym) or Dexamphetamine (Dexedrine) should be used in most generic mental health and paediatric services; the other drugs are unlicensed for this indication and should be reserved for specialist centres.
*See p.7 of the FOCUS report ‘The Use of Stimulants in Children with ADHD – Primary Evidence-Base Briefing’, published by the Royal College of Psychiatrists’ Research Unit, London, 1999. (available from IPS).
A second important resource on Methylphenidate is the recently published National Institute for Clinical Excellence (NICE) report, available on the Internet.
A number of professional tools are available to help in assessing AD/HD and attention problems, and are available from IPS. Further information on the Conners’ Continuous Performance Test and the Gordon Diagnostic System is available on this website.
Courses for Professionals
IPS runs regular courses for professionals interested in AD/HD, in Europe, both at an introductory level and advanced level. For up-to-date details of IPS courses on developmental disorders click here.
The following books are available from IPS Publications; prices are shown in £ sterling; an approximate exchange rate for US$ is £1 = US$1-50. Postage is £1 per book for UK domestic orders, and £2 per book for overseas surface postage. A publication ordering system is now available on this website, see IPS OnLine Store. If you have any queries, please contact us at: firstname.lastname@example.org
AD/HD – A Clinical Workbook (2nd edition) – Barkley £20
AD/HD – A Practical Guide for Teachers – Cooper and Ideus £13
AD/HD and the Nature of Self-Control – Barkley £29
AD/HD: Education, Medical and Cultural Issues (New edition) – Cooper & Ideus £10
AD/HD Information and Guidelines for Schools – Hampshire LEA £7
ADD in the Workplace – Nadeau £21
AD/HD: Research, Practice and Opinion – Cooper and Bilton £19-50
AD/HD Handbook for Diagnosis and Treatment (2nd edition)- Barkley £40
Attention Zone (The) – A Parent’s Guide £19
Comprehensive Guide to ADD in Adults – Nadeau £37
Diagnostic and Statistical Manual of Mental Disorders – DSM-IV (4th edition) £35
Hyperactivity – Why Won’t my Child Pay Attention? – Goldstein £14
Managing ADHD in Children, Guide for Practitioners (2nd edition) – Goldstein and Goldstein £51-50
Managing Attention and Learning Disorders – Goldstein £55
Overcoming Underachieving – Goldstein £15
Taking Charge of AD/HD – Barkley £11
Taming the Dragon – Eastman £13
Understanding AD/HD (2nd edition) – Green and Chee £10
Understanding Your Hyperactive Child – Taylor £8-00
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Further information on Childhood Developmental Disorders is available on this website – please click here. If you have arrived on this page from a Search Engine, we recommend visiting the IPS Home Page for an introduction to this website.