ADHD: What Parents and Teachers Should Know about ADHD

Attention-Deficit-Hyperactivity Disorder (ADHD) is defined as patterns of behaviour in which a child shows developmentally inappropriate levels of inattention, impulsivity, or hyperactivity which are usually apparent before the age of 7. It is the most common mental health problem of childhood, affecting 3% to 5% of the population, and is considerably more common in boys than in girls. The behaviour of children with ADHD often results in serious disturbances in their relationships with parents, teachers, peers, and siblings, as well as academic problems. The symptoms and criteria for a diagnosis of ADHD from the Diagnostic and Statistical Manual of The American Psychiatric Association are described below. A child must show symptoms that cause problems and are present to a greater degree than other same age children.

Symptoms of Inattention:

fails to give close attention to details or makes careless mistakes
has difficulty sustaining attention in tasks or play activities
does not seem to listen when spoken to directly
does not follow through on instructions and fails to finish tasks (not due to oppositional behaviour or failure to understand instructions)
has difficulties organizing tasks and activities
avoids or dislikes tasks that require sustained mental effort (such as schoolwork or homework)
loses things necessary for tasks or activities (e.g., toys, books)
is easily distracted
is forgetful in daily activities

Symptoms of Hyperactivity:

fidgets with hands or feet or squirms in seat
leaves seat in classroom or in other situations in which remaining seated is expected
runs or climbs excessively when it is inappropriate (in adolescents, may be feelings of restlessness)
has difficulty playing or engaging in leisure activities quietly
is always "on the go" or acts as if "driven by a motor"
often talks excessively

Symptoms of Impulsivity:

blurts out answers before questions have been completed
has difficulty awaiting turn
interrupts or intrudes on others (e.g., butts into conversations or games)

To receive a diagnosis of ADD or ADHD, a person must:

Have six or more symptoms of either inattention (listed above on the left) or hyperactivity/impulsivity (listed above on the right)
Symptoms must have persisted for at least six months and must be present to a degree that creates problems and is inconsistent with developmental level
At least some symptoms that caused impairment (that is, problems at home or school) were present before the age of seven
Some symptoms be present in at least two different settings (e.g., home, school), and there must be clinically significant impairment in social or academic functioning at home or school

There are three different subtypes of ADHD, these are:

1. Predominantly Inattentive: 6 symptoms present that are listed above on the left
2. Predominantly Hyperactive-Impulsive: 6 symptoms present that are listed above on the right
3. Combined Type: 6 symptoms present from each of the lists (left and right) above

Children do not have to have all of these symptoms, nor do they have to show symptoms in all settings for a diagnosis to be made. For example, most children with ADHD can pay attention in situations in which they are very interested (e.g., a favourite television show), or in a one-to-one setting such as a testing session with a psychologist or when visiting the doctor. Since all children sometimes show some of these behaviours some of the time, it is important that the behaviours be present to an extreme degree compared to other children of the same age, and that they be causing significant disruption to the child, his or her family, peers, or classroom in at least two different settings before the child is diagnosed as having ADD or ADHD. Diagnosis is a complex process that cannot be based on a single visit to the doctor. Instead, information must be gathered from parents and teachers, and from observations of the child in natural settings. When information from parents and teachers conflicts, more weight is usually given to teachers because they are usually more familiar with normal behaviour for an age group.

In addition to the defining characteristics listed above, children with ADHD often exhibit other problems including defiant and noncompliant behaviour toward adults, verbal and physical aggression towards peers and siblings, low self esteem (particularly in adolescents), and learning disabilities. Also, family problems often accompany ADHD, including marital problems, alcohol problems (especially in fathers) and stress and depression (especially in mothers). Therefore, these parental problems need to be assessed and treated along with the children's problems.

The following additional facts about ADHD are important for parents to know:

There is no test for ADHD. To make a diagnosis, information regarding the behaviours listed above must be gathered from parents and teachers. Standardized rating scales and interviews should be used.
Diagnosis is not as important as a good assessment of the problems that a child is having in daily life functioning and what can be done to improve the problems.
The causes of ADHD are unknown. Most professionals believe that the cause is based in the brain, but the exact nature of the cause is unclear, lt is known that diet is not a cause of ADHD. Artificial substances in foods or sugar do not cause ADHD, and putting a child with ADHD on a special diet will not solve his or her problem.
Most children do not outgrow ADHD. It is a chronic, long-term impairment that requires long-term lifestyle changes in order to cope with it. More than two-thirds of children with ADHD continue to display serious problems in adolescence and adulthood, and often their problems worsen. ADHD adolescents are at increased risk for school failure and dropout, possible substance or alcohol abuse, and delinquency. ADHD adults often have difficulties in job performance, coping with stress, relationships with other people, substance and alcohol abuse, and criminal behaviour. Parents should be wary of advice to wait and see if their child outgrows the problem; waiting rarely helps.
Effective evaluation and treatment of ADHD involves the cooperation of the child's parents, physician, school personnel, and mental health professionals such as psychologists and psychiatrists.
Appropriate, early, intensive, and long-term treatment is needed to deal effectively with ADHD. They are chronic problems and it need long-term interventions.
Many treatments, although widely used, have not been proven to be effective with ADHD. Traditional, one-to-one therapy, play therapy, or counselling done in a therapist's office does not work for children with ADHD. Neither chiropractics, biofeedback, allergy treatments, diets or dietary supplements, perceptual or motor training, sensory integration training, nor treatments for balance have been shown by systematic research studies to help children with ADHD.

So What Can Help?

For most children with ADHD, the combination of behaviour management and medication is the most effective treatment.

1. Behaviour Management

Behaviour management should be used at home, at school, and with peers. If these treatments are not enough, medication should then be evaluated to determine whether it adds to the effectiveness of the other treatments. One big advantage of combining medication with behaviour management is that a child's medication dose can usually be reduced. Behaviour management, in which parents and teachers are taught how to work with their children, is the most widely recommended and effective, nonmedical, short-term treatment for ADHD.

Behaviour management includes:

Establishing specific daily goals for the child
Establishing and consistently enforcing clear rules
Giving clear and appropriate commands
Using rewards (for example, points and praise) to encourage good behaviours
Using appropriate, nonphysical punishments (for example, time out) to discourage bad behaviours
Using a Daily Report Card to motivate the child and facilitate communication between school and home

It usually takes 8 to 12 clinical or inservice sessions for parents and teachers to learn these techniques. Treatment for peer difficulties involves working directly with the child, should be conducted in a natural setting such as a school or summer camp/summer treatment program, and requires intensive and long-term involvement.

2. Medication

Medication with a psychostimulant drug can be an effective short-term treatment for ADHD, especially when combined with behaviour therapy. Medication alone is not an effective long-term treatment; that is, it will often reduce the symptoms of ADHD, but will not cure the condition. Therefore, medication should never be relied upon as the only treatment for a child with ADHD.

If medication is used with a child who had ADHD it should be given only after other appropriate behaviour management programs have been established at home and at school. Because not all children with ADHD respond to stimulant treatment, it is important to evaluate carefully whether the medication is helping the child. A comprehensive, double-blind, school-based medication trial should be conducted prior to a long-term medication regimen to insure that a child is showing a good response to medication. This requires a process involving detailed questionnaires completed daily by parents and teachers. Ongoing monitoring should be conducted to be sure that medication continues to work for the child. Teachers must play a major role in this evaluation and monitoring.

^{Source: Pelham, William E., 1999. Attention Deficit Hyperactivity Disorder: Diagnosis, Nature, Etiology, and Treatment. State University of New York at Buffalo, NY 14260}