Learning about ADHD

Background Information on ADHD Attention deficit hyperactivity disorder is a condition, which affects those parts of the brain which control attention, impulses and concentration (a neurobiological condition). It is thought to affect 3 to 7% of school age children.^{1 2 3} There is some evidence that boys are three times more likely to suffer from ADHD than girls.⁴ Until recent years it was thought that children outgrew ADHD in adolescence. However, it is now known that in approximately one third to one half of children with ADHD, the symptoms continue into adulthood.⁵

The best description for ADHD is that a child who suffers from this condition shows disruptive behaviours, which cannot be explained by any other psychiatric condition and are not in keeping with those of the same-aged people with similar intelligence and development. These behaviours are usually first noticed in early childhood, and they are more extreme than simple “misbehaving”. Children with ADHD have difficulty focussing their attention to complete a specific task. Additionally they can be hyperactive and impulsive and can suffer from mood swings and “social clumsiness”.

Although people with ADHD can be very successful in life, without identification and proper treatment, ADHD may have serious consequences, which can include⁴: –

Under-performance at school
Depression
Problems with relationships
Problems finding and keeping a job
Criminal behaviour

Early identification by a healthcare professional is therefore very important to ensure that the child can fulfil his/her full potential.

Children with ADHD tend to display the following behaviours: –

Hyperactivity
Impulsive behaviour
Inattention
Social clumsiness
Poor coordination
Disorganisation
Mood swings
Specific learning disabilities such as dyslexia, language problems, difficulties with handwriting/written work

In people with ADHD, behavioural problems are seen in several places i.e. not just at school. Some children with ADHD have significant problems with concentration and attention but are not necessarily overactive or impulsive.

Symptoms and Diagnosis

Typically the symptoms of ADHD develop in early childhood. Healthcare professionals use a list of symptoms to officially diagnose ADHD (known as the diagnostic criteria of the American Psychiatry Association DSM-IV or the World Health Organisation ICD10). Although the diagnostic guidelines state that symptoms must start before the age of 7, leading researchers in ADHD argue that the criteria should be broadened to include a child developing ADHD anytime during childhood.²

Diagnosis can be quite challenging because: –

There is no physical test for ADHD (such as a blood test)
All children may have some problems with self-control
Other problems can result in behaviour similar to ADHD
e.g. language or hearing difficulties, dyslexia or major life disruptions
ADHD exists in conjunction with many other conditions whose symptoms can overlap and mask those of ADHD
e.g. Asperger’s syndrome, language disorder, dyspraxia and obsessive compulsive disorder

Children with ADHD are restless and cannot sit still or do any one thing for very long. They are easily distracted and, because they find it so hard to pay attention, they may often be criticised for being careless and making too many mistakes at school. They appear not to listen when someone is talking to them, they find it hard to wait their turn and they can be disruptive in play.

Diagnostic Criteria for ADHD

The official list of symptoms which healthcare professionals use to diagnose ADHD (diagnostic criteria DSM-IV1 or ICD-10)state that: –

The child must display either inattention or hyperactivity-impulsivity (or both) and symptoms must have been present for at least 6 months.

Inattention. Usually at least 6 symptoms are seen.
- Fails to pay close attention to details or makes careless errors in schoolwork, work or other activities
- Has trouble keeping attention on tasks or play
- Doesn’t appear to listen when being told something
- Neither follows through on instructions nor completes chores, schoolwork, or jobs (not due to failure to understand or a deliberate attempt to disobey)
- Has trouble organising activities and tasks
- Dislikes or avoids tasks that involve sustained mental effort (homework, schoolwork)
- Loses materials needed for activities (assignments, books, pencils, tools, toys)
- Easily distracted by irrelevant information
- Forgetful
Hyperactivity-Impulsivity. Usually at least 6 symptoms are seen.Hyperactivity
- Squirms in seat or fidgets
- Inappropriately leaves seat
- Inappropriately runs or climbs (in adolescents or adults, there may be only a subjective feeling of restlessness)
- Has trouble quietly playing or engaging in leisure activity
- Appears driven or “on the go”
- Talks excessively
  Impulsivity
- Answers questions before they have been completely asked
- Has trouble waiting his/her turn
- Interrupts others
Symptoms begin before age 7
Symptoms must be present in at least 2 places, such as school, work or home
The disorder negatively affects school, social or occupational functioning
The symptoms do not occur solely due to a psychotic disorder (such as schizophrenia)
The symptoms are not better explained by an alternative disorder (such as a mood, anxiety or personality disorder)

Process for ADHD Diagnosis

Only healthcare professionals can officially diagnose ADHD. One (or more) of the following types of healthcare professional could be involved in the process: –

Child psychiatrist
Child psychologist
Paediatrician
Psychiatric social worker
Educational psychologist
GP

There are four main steps which a child psychiatrist or paediatrician will use for diagnosing ADHD and which you can consider if you think your child may have ADHD.⁴

The healthcare professional will look for alarm signals: –
- The child who significantly under-performs at school, despite having a normal intellect and no major specific learning disabilities
- The child who has ADHD behaviour problems which are considerably worse than would be expected
They will exclude ADHD look-alikes, such as: –
- The normal active pre-school child
- Intellectual disability
- Hearing impairment
- Autism
- Epilepsy
- Depression
They may also use some objective pointers towards diagnosis: –
- Questionnaires by parents and teachers e.g.
  - Conners Teacher and Parent Rating Scales
  - Achenbach Child Behaviour Checklists
  - Edelbrock Child Attention Problems Rating Scale
  - Barley and DuPaul ADHD Rating Scale
- DSM-IV or ICD-10 criteria
- Tests which measure the length and type of mental process (psychometric tests and profiles)
- Tests of attention and persistence e.g.
  - The Paired Association Learning Test
  - Continuous Performance Test
Healthcare professionals have been trained to look at a detailed history of someone with suspected ADHD in order that they may recognise the smallest signs and symptoms. It is therefore important that they are consulted to ensure an accurate diagnosis.

ADHD can be exhibited in mild, moderate and severe forms. The mild and moderate forms may be responsive to psycho-social interventions (i.e. those not requiring medication)

Treatment

Most experts agree that the most effective way to treat ADHD is with a variety of different approaches. Depending on the needs of the individual child, a combination of medical, teaching and behavioural support can help the child to reach his/her full potential and live as normal a life as possible, having meaningful relationships and reducing family stress. Some treatment options are outlined below: –

Psychiatry/psychology
- Psychiatrists and psychologists have a major role in diagnosing ADHD, implementing behavioural programmes, prescribing medication (psychiatrists) and supporting parents
Behavioural Therapies
- Behavioural interventions can include:
  - Family therapy focusing on management strategies
  - Individual therapy focusing on changing behaviours
Medications
- Parents, in consultation with doctors, should decide if they would like their child to try medication
- Where medications are prescribed to treat ADHD these are mainly psychostimulants. There are some concerns with these current treatments and you must speak to your healthcare professional if you have any worries. Psychostimulants work by changing the levels of natural chemicals in the brain, which appear to be incorrectly balanced in ADHD children. These treatments help the ‘controlling’ and ‘inhibiting’ part of the brain to work in a more normal way and the child is able, to concentrate better and behave in a calmer way.
- Tricyclic antidepressants are also used
School-based Interventions and Preventive Measures
- School-based intervention can include:
  - Help with reading, spelling, maths and organisation
  - Speech therapy
  - Physical education therapy
  - Counselling
Social Skills Training
- Many children with ADHD have difficulty socialising. Because they don’t recognise the more subtle rules of communication, they frequently make mistakes and are teased by other children. In social skills training, children are taught in groups to think how their words and behaviour affect those around them
Coordination Training
- Since many children with ADHD have coordination problems, there are a few therapies that specifically help develop coordination (known as sensory-motor integration). Some children receive this therapy in schools
Diet
- Some parents see an improvement in their child’s behaviour when the following foods are removed from the child’s diet: –
  - Caffeine – found in chocolate, coffee and some fizzy drinks
  - Some cordials
  - Artificial colourings
Parenting support
- Support for parents is a vital component in the combination of therapies advised to tackle the disorder. It is particularly important as services to diagnose and treat ADHD are seriously underfunded and overloaded
- Although children with ADHD have unique problems, many of the principles of parenting still apply. They particularly need consistent discipline and a structured lifestyle
- Parents can attend parenting classes, as well as join associations and self-help groups to ensure their concerns and opinions are heard

Attention Deficit Hyperactivity Disorder (ADHD) is a complex condition in which the child can have several of a group of symptoms. Due to the range of potential symptoms, and the fact that some of these symptoms can be present due to other conditions or problems, the diagnosis of ADHD can be quite challenging. However, early identification so that treatment (whether behavioural, psychological or medication) can be started is very important, so that the child is able to achieve his/her full potential.

References
¹ American Psychiatric Association DSM IV diagnostic criteria
² Barkley RA et al. ADHD: a handbook for diagnosis and treatment. New York 1998. Guilford Press Barkley RA
³ Wolraich ML et al. Comparison of diagnostic criteria for ADHD in a countrywide sample. Journal of the America Academy of Child and Adolescent Psychiatry 1996;35:319-324
⁴ Green C and Chee K. Understanding ADHD – A Parent’s Guide to Attention Deficit Hyperactivity Disorder in Children. Vermillion Publishing 1997. ISBN 0 009 181700 5
⁵ Murphy KR and Barkley RA. The prevalence of DSM-IV symptoms in adult licensed drivers. Implications for clinical diagnosis. Comprehensive Psychiatry 1996;37:393-401

Essential Reading
Green C and Chee K. Understanding ADHD – A Parent’s Guide to Attention Deficit Hyperactivity Disorder in Children.
Dr Geoffrey Kewley, ADHD Recognition Reality and Resolution A full list of titles is available from our bookstore.

Frequently Asked Questions

What is ADHD?

Attention deficit hyperactivity disorder is a genetically determined condition that affects those parts of the brain that control attention, impulses and concentration. It is thought to affect 3 to 7% of school age children.^{1 2} The best description for ADHD is that a child who suffers from this condition shows disruptive behaviours which cannot be explained by any other psychiatric condition and are not in keeping with those of the same-aged people with similar intelligence and development. These behaviours are usually first noticed in early childhood, and they are more extreme than simple “misbehaving”. Children with ADHD have difficulty focussing their attention to complete a specific task. Additionally they can be hyperactive and impulsive and can suffer from mood swings and “social clumsiness”.

When does ADHD develop?

ADHD develops in childhood and is most commonly noticed at the age of 5.¹ Research suggests that 80% of children diagnosed with ADHD continue to experience symptoms during adolescence and 67% continue to have symptoms into adulthood.¹

Does every person with ADHD have the same symptoms?

The symptoms of ADHD (impulsivity, hyperactivity and inattention) are not seen to the same degree in all people diagnosed with this condition. As a result, clinicians recognise three types of people with ADHD²: –

The mostly (predominantly) hyperactive-impulsive type
The mostly (predominantly) inattentive type
The combined type (which make up the majority of ADHD cases)

There is also a fourth type, which does not fit into any of the three categories and which healthcare professionals classify as ADHD not otherwise specified.²

What causes ADHD?

ADHD has multiple causes. However the evidence so far shows that it is not caused by poor parenting, rather, it is caused by a complicated combination of factors. These factors include changes in those parts of the brain which control impulses and concentration (neurobiological factors) and genetic, inherited and environmental factors.

Is ADHD genetic?

ADHD has a significant genetic component: most differences in severity of symptoms are due to genetic factors. For example, if a family has one ADHD child, there is a 30-40% chance that another brother/sister will also have the condition and a 45% chance (or greater) that at least one parent has the condition1. If the child with ADHD has an identical twin, the likelihood that the twin will also have the disorder is about 90%.¹

Other research has suggested that in a small percentage of cases, ADHD can be due to injury (during development) to specific regions of the brain. For example, use of alcohol or tobacco during pregnancy, premature delivery with associated minor brain bleeding or accidental head injury after birth, could all cause ADHD-like symptoms. ADHD is not associated with purely social factors such as poor parenting (child management), family stress, divorce, excessive TV viewing or video game playing, or diet, although some of these factors can exacerbate a pre-existing condition.

What treatments are typically recommended for ADHD?

There are typically four steps in the management of ADHD: –

Proper diagnostic evaluation by an experienced psychiatrist or paediatrician
Information provided for parents and teachers
Discussions between healthcare professional and parents and teachers on behavioural therapy and educational support (such as special educational services)
Medication

Most experts agree that the most effective way to treat ADHD is with several complimentary approaches. An effective treatment plan will involve a combination of treatments such as psychiatry, psychology, appropriate educational interventions, behavioural therapy and medication. Depending on the needs of the individual child, a combination of medical, teaching and behavioural support can help the child to reach his/her full potential and live as normal a life as possible, having meaningful relationships and reducing family stress.

What shall I do if I think my child or somebody I know has ADHD?

There is no specific test for ADHD but it is important that a psychiatrist or paediatrician makes a diagnostic evaluation. If you suspect that your child or a child you know has ADHD you may wish to alert their parent or teacher, so that s/he can be referred early and so that the condition can be identified. This will enable treatment (whether behavioural, psychological or medication) to be started, to help the child to achieve their full potential.

Who can diagnose ADHD?

ADHD is diagnosed by a healthcare professional, usually a child psychiatrist or paediatrician. However a team of people may be involved in the steps to diagnosis and decisions regarding therapy. These people can include: –

Child psychiatrist
Neuropsychologist
Child psychologist
Paediatrician
Paediatric neurologist
Psychiatric social worker
Educational psychologist
Specialists in speech and language, auditory processing, occupational therapy etc
Teacher
GP

References:
¹ Green C and Chee K. Understanding ADHD – A Parent’s Guide to Attention Deficit Hyperactivity Disorder in Children. Vermillion Publishing 1997. ISBN 0 009 181700 5
² American Psychiatric Association DSM IV diagnostic criteria