Attention Deficit / Hyperactivity Disorder – excerpt from www.mentalhealth.org.nz
Children with attention deficit /hyperactivity disorder (ADHD) are constantly distractible, impulsive and unusually active. They may also have other serious behavioural, emotional and learning problems which can get them into an awful lot of trouble if ADHD is not recognised and treated.
Children with ADHD often have poor self-esteem as a result of being constantly criticised by families, whanau and teachers who have not recognised their behaviour as a health problem. It is heartbreaking to hear such children refer to themselves as dumb, stupid or naughty.
Since the 1940s, ADHD has been given several names, including Minimal Brain Damage. Researchers knew that these were otherwise normal children whose brains received and processed information differently from others and resulted in the behaviour associated with ADHD.
By 1980 they agreed on the name Attention Deficit Disorder (ADD). This emphasised that attention was the major problem. A few years later the name was again changed to include hyperactivity – recognising that as an equally significant problem.
Nowadays most people talk about attention deficit hyperactivity disorder or ADHD (although you will also hear it being called ADD). This can still be confusing, because some children with extreme attention problems, may not be hyperactive. They are the more dreamy types who seem often to be away with the fairies. In a classroom these children are in danger of being overlooked because the children who have the ‘H’ in ADHD cannot fail to get noticed!
There is no absolute test for ADHD. The diagnosis needs to be made by expert doctors or specialists, such as child psychiatrists or paediatricians (doctors who specialise in child health) who have experience in treating ADHD. A medical check-up should be part of any assessment for ADHD.
There has been a huge increase in interest in ADHD recently and a lot of conflicting information being reported. It is therefore important that you get advice from your GP or specialist child and family service if you are concerned that your child may have ADHD.
Parents and teachers may be asked to fill out separate questionnaires on the child’s behaviour to see if there is overall agreement on the symptoms. Sometimes it may be suggested that the child do some psychological tests to find out if there are any specific problems with learning. There are two main errors in diagnosing ADHD: making the diagnosis too often, and missing it.
Signs of attention deficit / hyperactivity disorder
Children with ADHD have a characteristic pattern of development right from the time they are toddlers – this is one of the key indicators of the problem. Another clear sign of ADHD is that the child’s behaviour patterns are similar at home, school (or pre-school) and in all other situations. In addition, the signs of ADHD must be severe enough to cause major problems for the child in all of these places.
A child with ADHD will have several or all of the following difficulties.
• As babies they may be colicky, restless, hard to cuddle or hold
and poor sleepers.
• They may have crawled or walked earlier than other children.
• They talk a lot, interrupt others and can’t seem to wait their
turn.
• They have lots of energy and are constantly on the go. They
seem unable to sit still even if they are enjoying doing something.
• They have a short attention span and often don’t follow through
what they set out to do.
• They may tune out or appear to be daydreaming, especially
when being given instructions.
• At school they have trouble with the work and often give the
impression they have not heard the teacher’s instructions.
• They may frequently call out in class or a group and may be
known as the class clown.
• They do dangerous and impulsive things, like jumping from
heights or running out onto the road without looking out for
traffic.
• They act before they think.
• They are often easily upset.
• They get angry and ‘explode’ quite easily.
• They find it hard to make and keep friends, usually because of
their exuberance and bossiness rather than any nastiness.
These symptoms must have been present for at least the last six months, for a diagnosis of ADHD.
Children who are affected by ADHD
ADHD affects between three and five percent of school-aged children (one percent are affected quite severely). Some will have milder symptoms than others (about one in 20). ADHD is more common in boys than girls. Sometimes it is not diagnosed until the teenage years.
There is no cure for ADHD although there is a belief that many children seem to grow out of it before adolescence. Recently there has been an increasing awareness that ADHD can progress into adulthood. It is really important that children with ADHD get help early in life so that they can learn to manage their problems and develop the skills and confidence they will need to lead a successful adult life.
Myths
NOT TRUE Children with ADHD are deliberately naughty or bad children.
NOT TRUE ADHD is just youthful high spirits.
NOT TRUE Every child who displays some symptoms of ADHD has it. There may be other reasons for children having symptoms which mimic ADHD. For example, children who are anxious because they have been abused either sexually or physically, or whose parents have recently separated, maydisplay some of the above behaviour. That’s why it is extremely important for the assessment and diagnosis to be thorough and done by qualified professionals who, as much as possible, try to rule out any other causes for a child’s symptoms
NOT TRUE Children with ADHD are incapable of concentrating at all. Most children with ADHD are often able to concentrate for quite long periods of time on specific activities or hobbies – for example, watching videos they enjoy. In some, this ability to hyperfocus is extraordinary and has led some experts to comment that attention deficit might more accurately be called attention inconsistency.
NOT TRUE Everything that is wrong with the child is ADHD (e.g., all learning and behaviour problems are part of the ADHD).
NOT TRUE If you have ADHD you are not responsible for your behaviour and therefore can be excused for it (i.e., don’t have to face the consequences).
Causes of ADHD
Even though a lot of research into ADHD has gone on around the world, its exact cause is still unknown. It is likely that there are not one, but several causes, which, when they occur together, become ADHD.
Studies of computerised tomography or CT brain scans show that children with ADHD seem to have brain circuits which are wired a little differently from other people’s. This results in the brain having trouble processing the messages it receives – a little bit like a telephone exchange which gets overloaded with calls. This may happen to the infant’s brain in pregnancy, in babyhood, or it may just be an individual variation which has received more notice in the last 40 years. It does not seem to be caused just by a poor diet, yeast infections, allergies or food colourings as some people have thought, although these may be factors in the overall ADHD picture. It is also not caused by bad parenting although often a child’s behaviour will have earned plenty of negative attention in and outside of the family or whanau by the time ADHD is recognised.
Risks factors for developing ADHD
There is thought to be a genetic element to most ADHD, that is, it runs in families. Studies have shown that brothers or sisters of children with ADHD have two to three times the risk of having it as well.
ADHD often occurs with other child mental health problems. These may exist alongside or develop as a result of ADHD. For example, some children with ADHD will have Oppositional Defiant Disorder, Conduct Disorder or experience anxiety or depression. Learning difficulties which are unrecognised also present a risk for serious mental health problems, as they affect progress at school and self-esteem.
ADHD and its associated problems are serious if untreated because they can put young people at risk for accidents, drug or alcohol abuse problems, or suicide. Smoking during pregnancy and prematurity are all risk factors for ADHD.
Living with Attention Deficit / Hyperactivity Disorder
The most important thing to remember about having a child with ADHD is that, like all children, they need love, affection, nurturing and clear rules. Sometimes this is hard to remember when whole days of nagging seem to be the rule rather than the exception at home and everywhere else.
A child with ADHD may have chalked up quite a lot of frustrations and failures before his/her problem is recognised. Some parents worry about the label ADHD and wonder if they have caused it to happen, or failed their child in some way. They may feel anger that this has happened to their family or whanau, or upset that other family or whanau members have dismissed the child’s behaviour as being normal. Others will be relieved that the problem they’ve lived with over a number of years finally has a name.
For the child, knowing he/she has ADHD can be a relief. Often though, children feel there is something really wrong with them. ADHD needs to be carefully explained to them in a way that they can understand and learn to handle. Brothers, sisters and friends, too, may need an explanation that can help them to stop teasing or provoking the child with ADHD.
Some children who have to take medicine to help their symptoms say it is like admitting that something scary is wrong with them and worry that they are retarded or crazy – labels they’ve probably heard before.
In two-parent homes it is important for parents to support each other with managing their child’s behaviour. Consistency is essential. Often one parent will say that the child is “perfectly all right when he is with me.” This can be infuriating for the other parent. For single parents, having a child with ADHD is even more difficult. Have at least one supportive friend outside the family or whanau that you can confide in.
Treatment of Attention Deficit / Hyperactivity Disorder
Summary of treatment options
There is no magic pill to make ADHD disappear, and medication should not be used as a substitute for other appropriate interventions, including educational and psychosocial. It is a complicated condition generally best managed by a mixed treatment programme which may include the following components.
Medication
The main kind of medication are used in the treatment of ADHD are stimulants; antidepressants are only very occasionally prescribed. The same medications are used for both children and adults. It is important that the progress of a child on medication for ADHD is checked and the treatment reviewed regularly with regular weight and height checks if stimulants are taken. You are entitled to know the names of any medicines prescribed; what symptoms they are supposed to treat; how long it will be before they take effect; how long they will have to be taken for and what their side effects (short and long-term) are.
Psychosocial treatments
Psychosocial treatments are non-medical treatments which look at the child or young person’s thinking, behaviour, relationships and environment, including their culture. The main psychosocial treatments for ADHD include behaviour management and social skills training to ensure encouragement and support for the child at home and at school. Other psychosocial treatments may include individual psychological therapy or family therapy to help young people and their families and whanau understand the condition and to make positive changes in their lives and relationships.
All types of therapy/counselling should be provided to children, adolescents and their families and whanau in a manner which is respectful of them, and with which they feel comfortable and free to ask questions. It should be consistent with and incorporate their cultural beliefs and practices.
Complementary therapies
Complementary therapies that enhance the young person’s life may be used in addition to psychosocial treatments and prescription medicines.
Tips for paying attention
Having acknowledged that many children struggle with inattention (for many different reasons) there are a range of ways in which parents and teachers can help inattentive children stay on task long enough to learn better and accomplish the tasks they need to. Remember that it’s the boring, mundane activities that cause problems with inattention – fun, new, interesting activities don’t usually pose such a problem. The everyday routines like getting ready for school or other outings, after-school activities, homework and the usual evening activities are where problems tend to occur. Bear in mind that school is a tiring business and that inattention is likely to be worse in the late afternoon and early evening.
In this article we will match the common difficulties with strategies to assist with them. These strategies can usefully be employed with all children – not just those who struggle with inattention.
First, inattentive children have trouble holding onto a lot of information or instructions at one time. Thus, they forget a series of instructions, possibly only remembering one; they lose track of the sequence of tasks, and may skip out important parts of a routine; and they can’t hold information in mind long enough to think about it and work it out. Therefore, these strategies are helpful: Give one instruction at a time – wait until the child has completed the task before giving the next one; when there is a routine to be followed, for example, going to bed, make a “comic strip” of pictures depicting the steps in the routine – this way the child can return to the strip to check out what needs to be done, and in what order; tell the child what to do – not what NOT to do – because it may be too hard to think about an undesirable behavior and turn it into a desirable behavior, it will be easier for the child to think directly about what you want them to do.
Second, concepts of time are especially hard for children with attentional problems, and they find it difficult to judge or allow for the time available within which to complete a task. Therefore, it’s very helpful to make time “visible” for them – use timers wherever you can to keep them aware of the passing of time. Inexpensive “wind-up” timers work well because you can hear and see them winding down, and they give a buzz when the time is up. For younger children or those with more severe difficulties, you can break time into smaller chunks when a complex task is demanded. So, you may give a set amount of time for each subtask, for example, brushing teeth gets three minutes, then getting into pyjamas gets three minutes and so on. Re-set the timer after each subtask is completed. Timers are also great for Timeout – when a child is sent to timeout for a fixed period, the timer keeps them (and you) aware of the passing of time.
Third, rewards for success do not seem to be successful with children who struggle with inattention. The fact is that rewards and consequences do work with these children, but have to be implemented differently. The structures of the brain that are sensitive to positive and negative consequences do not operate as efficiently as they do in children without attentional problems. Consequently, it is harder for them to learn to associate particular behaviors with rewards or negative consequences. Children with attentional problems need rewards and consequences often, close in time to the behaviors they are intended for, and of strong significance for the child. Rewards need to be obvious and quickly available – for example, verbal praise or soft touches. Parents need to be on the lookout for positive behaviors so that they can use praise often and quickly. Praise can also be connected to a reward system that has a payoff in some material reward in the future. This helps children learn to wait for rewards by providing quick, frequent smaller rewards along the way to the bigger one.
Fourth, these children have trouble paying attention to speeches or explanations. Therefore, keep explanations to a minimum and, as has been advocated by the experts in the area – “act, don’t yak”! The more you talk, try to explain why a behavior is desirable, or “yak”, the further away the rewards or consequences will be from the target behavior. It’s not that the child doesn’t understand you, it’s that the child finds it difficult to comply because her attention wanders so easily.
Fifth, inattention also means that a child finds it difficult to remember what will happen from one experience to the next. It can be hard to generalise knowledge from one situation to another. So, for example, a child may have been difficult to control at a friends’ party with the consequence that he was removed from the party and had the party treats confiscated as a consequence. Unfortunately, there is no guarantee that this lesson will be remembered when visiting the grandparents’ house, or attending the next party. This can be particularly frustrating because it feels as though you have to go through the drama all over again when the same thing happened recently. Parents come to know what settings or places are going to be problematic, so can anticipate problems and prepare accordingly. Here is a five-step plan that helps. One, shortly before the event, review one or two rules that apply to the situation with the child (be concise!) and have the child repeat them back to you. For example, one rule for visiting other people may be that the child is not to touch the party food before permission is given by the hosts, and another may be that the child greet others appropriately. Two, set up a small immediate reward for being successful and a small immediate consequence for failure. For example, polite greetings earn public praise, and waiting for treat foods earn an extra treat. Three, as you enter the situation, begin giving praise for success before any difficulties arise. For example, comment repeatedly on the fact that the child has not taken any party food. Four, deliver rewards and consequences immediately after the target behaviors. For example, lack of greetings result in the child having to stay beside the parent (when he would rather be off playing with other children) for five minutes. Five, remember not to engage in conversations about what is happening – the child knows what the deal is, and conversations simply drag out the situation and dilute the strength of the rewards or consequences.
Sixth, keep stimulation levels down when you can as the child’s nervous system has trouble trying to screen out extra sensory information that is interfering with paying attention. Keep your voice down when giving instructions, and don’t try to compete with the TV or other noise. When you’re speaking, make sure you have the child’s full attention, with a minimum of interfering noise, light, or movement around her. Shouting can be overwhelming for these children and they won’t even get the first part of what you say if you yell. You’re far better off to whisper – this will make her lean in towards you and concentrate harder.
So, with these pointers, your child will be better able to grasp what is being asked of him, and better able to keep his attention going long enough to get things done.
