Attention-Deficit/Hyperactivity Disorder (ADHD)

What is ADHD?

Attention-Deficit /Hyperactivity Disorder (usually referred to as ADHD), is one of the most common childhood disorders. It can, however, continue through adolescence and into adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behaviour, and hyperactivity (over-activity).

ADHD has three subtypes:

1. Attention-Deficit/Hyperactivity Disorder, Combined Type
This diagnosis is made when six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present. Most children and adolescents with ADHD have the Combined Type. It is not known whether the same is true of adults.

2. Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type
This diagnosis is made when the majority of symptoms (six or more) fall into the inattention category, and fewer than six symptoms of hyperactivity-impulsivity are present - although it may still occur to some degree.

Children with this subtype are less likely to act out or have difficulties getting along with other children. Although they may not be paying attention to what they are doing, they may sit quietly and thus parents and teachers may not notice that he or she has ADHD.

3. Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type
This diagnosis is made when most symptoms (six or more) are in the hyperactivity-impulsivity categories.

Fewer than six symptoms of inattention are present – although it may still occur to some degree. It is worth noting that individuals who, at an earlier stage of the disorder, had the Predominantly Inattentive Type or the Predominantly Hyperactive-Impulsive Type, may go on to develop the Combined Type - or vice versa.

Treatments can relieve many of the disorder's symptoms, but there is no cure. With treatment, most people with ADHD can be successful in school or work and lead productive lives. Researchers are developing more effective treatments and interventions, and using new tools such as brain imaging, to better understand ADHD and to find more effective ways to treat and prevent it.

What are the Symptoms of ADHD?

The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.

Some hyperactive-impulsive or inattentive symptoms that cause impairment must have been present before the age of seven, although many individuals are only diagnosed after the symptoms have been present for a number of years.

In order for behaviour to be diagnosed as ADHD, some impairment from the symptoms must be present in at least two settings. This means that the symptoms must create a real handicap in at least two areas of the individual’s life - such as home and at school or work, in the community or in social settings.

If a child seems too active on the playground but not elsewhere, the problem might not be ADHD. It might also not be ADHD if the behaviours occur in the classroom but nowhere else.

There must be clear evidence of interference with developmentally appropriate social, academic or occupational functioning. So a child who shows some symptoms should not be diagnosed with ADHD if his or her schoolwork or friendships are not impaired by the behaviours.

In addition, the disturbance must not be better accounted for by another mental disorder, such as a mood or anxiety disorder.

Inattention may be manifest in academic, occupational, or social situations. Individuals with ADHD may fail to give close attention to details, or may make careless mistakes in schoolwork or other tasks. Work is often messy and performed carelessly and without considered thought.

Individuals often have difficulty sustaining attention in tasks or play activities, and find it hard to carry a task through to its completion. There may be frequent shifts from one uncompleted activity to another. Individuals diagnosed with ADHD may begin a task, move on to another, then turn to yet something else, prior to completing any one task. They often appear as if their mind is elsewhere, or as if they are not listening, or did not hear what has just been said. They often do not follow through on requests or instructions, and fail to complete schoolwork, chores or other duties. However, failure to complete tasks should be considered in making this diagnosis only if it is due to inattention as opposed to other possible reasons, such as a failure to understand instructions.

Individuals with ADHD often have difficulty organising organising tasks and activities. They find tasks that require sustained mental effort unpleasant and markedly aversive. As a result, they typically avoid - or have a strong dislike for - activities that demand sustained self-application and mental effort, or that require organisational demands or close concentration, such as homework or paperwork. (This avoidance must be due to the person’s difficulties with attention and not due to a primary oppositional attitude, although secondary oppositionalism may also occur). Work habits are often disorganised and the materials necessary for doing the task are often scattered, lost, or carelessly handled and damaged.

Individuals with this disorder are easily distracted by irrelevant stimuli and frequently interrupt ongoing tasks to attend to trivial noises or events - such as a car hooting or a background conversation - that are usually and easily ignored by others.  They are also often forgetful in daily activities, such as forgetting appointments or forgetting their lunch at home.

In social situations, inattention may be expressed as frequent shifts in conversation, not listening to others, not keeping one’s mind on conversations, and not following details or rules of games or activities.

Hyperactivity may be manifested by fidgeting or squirming in one’s seat, by not remaining seated when expected to do so, by excessive running or climbing in situations where it is inappropriate (for example during a Sunday church service), by having difficulty playing or engaging quietly in leisure activities, by appearing to be often 'on the go' or as if 'driven by a motor', or by talking excessively.

Hyperactivity may vary with the individual’s age and developmental level, and the diagnosis should be made cautiously in young children. Toddlers and pre-schoolers with this disorder differ from normally active young children by being constantly on the go and into everything: they dart back and forth, are 'out of the door before their coat is on', jump or climb on furniture, run through the house, and have difficulty participating in sedentary group activities in pre-school classes, such as listening to a story.

School age children display similar behaviours, but usually with less frequency or intensity than toddlers and pre-schoolers. They have difficulty remaining seated, get up frequently, and squirm in, or hang on to the edge of, their seat. They fidget with objects, tap their hands and shake their legs or feet excessively. They often get up from the table during meals, while watching television, or while doing homework. They talk excessively and they make excessive noise during quiet activities. In adolescents and adults, symptoms of hyperactivity take the form of feeling restless and experiencing difficulty engaging in quiet, sedentary activities.

Impulsivity manifest itself as impatience, difficulty in delaying responses, blurting out answers before questions have been completed, difficulty awaiting one’s turn and frequently interrupting or intruding on others to the point of causing difficulties in social, academic or occupational settings. Others may complain that they cannot get a word in edgewise. Individuals with this disorder typically make comments out of turn, fail to listen to directions, initiate conversations at inappropriate times, interrupt others excessively, intrude on others, grab objects from others, touch things they are not supposed to touch and clown around.

Impulsivity may lead to accidents (for example, knocking over objects or bumping in to people), and to engagement in potentially dangerous activities without consideration of possible consequences (for example, riding a skateboard over extremely rough terrain).

Behavioural manifestations usually appear in multiple contexts, including home, school, work and social situations. To make the diagnosis of ADHD, some impairment must be present in at least two settings. It is very unusual for an individual to display the same level of dysfunction in all settings or within the same setting at all times. Symptoms typically worsen in situations that require sustained attention or mental effort, or that lack intrinsic appeal or novelty (for example, listening to a teacher in the classroom, doing school tasks, reading or listening to lengthy texts, or working on monotonous, repetitive tasks).

Signs of the disorder may be minimal or absent when the person is under very strict control, is in a novel setting, is engaged in especially interesting activities, is in a one-to-one situation (for example the clinician’s office), or while the person experiences frequent rewards for appropriate behaviour.  The symptoms are more likely not to occur in group situations such as in playgroups. It is important therefore to monitor the individual’s behaviour in a variety of situations within each setting.

Summary of the Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) gives the following diagnostic criteria for ADHD:

A. Either 1. or 2.:

1. Six or more of the following signs of inattention have been present for at least 6 months to a point that is disruptive and inconsistent with developmental level:

Inattention:

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work or other activities.

2. Often has difficulty sustaining attention in tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions).

5. Often has difficulty organizing tasks and activities.

6. Often avoids, dislikes or does not want to do things that require sustained mental effort (such as schoolwork or homework).

7. Often loses things needed for tasks and activities (such as toys, school assignments, pencils, books, or tools).

8. Is often easily distracted by extraneous stimuli

9. Often forgetful in daily activities.

2. Six or more of the following signs of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity:

a. Often fidgets with hands or feet or squirms in seat.

b. Often gets up from seat when remaining in seat is expected.

c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to feeling very restless).

d. Often has difficulty playing or engaging in leisure activities quietly.

e. Is often 'on the go' or often acts as if 'driven by a motor'.

f. Often talks excessively.

Impulsiveness:

g. Often blurts out answers before questions have been finished.

h. Often has trouble waiting one's turn.

i. Often interrupts or intrudes on others (example: butts into conversations or games).

B. Some signs that cause impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (such as at school/work and at home).

D. There must be clear evidence of significant impairment in social, school or work functioning.

E. The signs do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder. The signs are not better accounted for by another mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder or a Personality Disorder). 

Making a Definitive ADHD Diagnosis

In early childhood it may be difficult to distinguish symptoms of Attention-Deficit /Hyperactivity Disorder from age-appropriate behaviours in active children, such as running around or being noisy.

Symptoms of inattention are common in children with low IQ who are placed in academic settings that are inappropriate to their intellectual ability. Inattention in the classroom may also occur when children with high intelligence are placed in academicallyunderstimulating environments.

Teachers and parents who tell a child that they can go and play or do some other fun activity, as “soon as they finish their work”, can also expect the bright child not to pay close attention to detail or make careless mistakes in schoolwork. The child is merely hurrying so that they can go and play. It is important for parents and teachers to set the standard of work too. For example, tell the child they can go and play only when they have finished their work neatly and to the best of their ability.

Attention-Deficit /Hyperactivity Disorder is not diagnosed if the symptoms are better accounted for by another mental disorder, such as a mood or anxiety disorder. A child suffering from an anxiety or mood disorder may well manifest symptoms of inattention and restlessness, but in such disorders the childhood history of school adjustment generally is not characterised by disruptive behaviour or teacher complaints concerning inattentive, hyperactive or impulsive behaviour.

Attention-Deficit /Hyperactivity Disorder is not diagnosed if the symptoms of inattention, hyperactivity or impulsivity are accounted for by a medical condition. Conditions that would need to be ruled out include: 

• anemia;
• child abuse;
• chronic illness;
• hearing or vision impairment;
• hypothyroidism;
• lead poisoning;
• substance abuse;
• medication side-effects;
• sleep impairment.

When it comes to medication, many medications have side effects that manifest as symptoms of ADHD. For example, broncodilators (medications used to open up the small airways of the lungs (bronchi) to make breathing easier), Isoniazid Preventive Therapy (Isoniazid Preventive Therapy has proven to be safe and effective at reducing the risk of active TB in people living with HIV), and akathisia (a movement disorder) from neuroleptics (antipsychotic medications).

As far as sleep is concerned, it is interesting to note that sleep deprivation will manifest itself in a child’s behaviour. Behavioural signs of sleepiness range from the classic ones (yawning, rubbing eyes) to externalising behaviours (impulsivity, hyperactivity, aggressiveness), to mood swings and inattentiveness. Many sleep disorders are important causes of symptoms that may overlap with the key symptoms of ADHD. Children with ADHD should be regularly and systematically assessed for sleep problems.

Read my article on Insomnia to learn the principles of good sleep hygiene and help ensure your child gets enough sleep.

Attention-Deficit/Hyperactivity Disorder must also be distinguished from difficulty in goal-directed behaviour in children living in inadequate, disorganised or chaotic environments. Children need to be taught how to organise themselves and their tasks, possessions etc. Without such learning they will have difficulty organising tasks and activities, and will often lose things.

Reports from a variety of people involved in the child’s life are critical. Baby-sitters, grandparents, teachers and parents of play-mates can all report their experience and observations of the child concerning the child’s inattention, hyperactivity and capacity for developmentally appropriate self-regulation in various settings.

If the mother is the only person complaining that her child never listens, is out of control or impossible to handle, it may be that it is the mother who has the problem rather than the child. The mother may need to learn how to set boundaries and use more appropriate discipline techniques. Sadly, it is only too often that the child’s ‘behavioural problems' stem from an inadequate parenting style.

What Causes ADHD?

Unfortunately, as with most mental disorders, scientists are not sure exactly what causes ADHD.  Like many other mental illnesses, ADHD probably results from a combination of factors.

This fits in with the Diathesis–Stress Model, which is commonly accepted to be the most comprehensive explanation of the cause of mental disorders. 

Read more about the Diathesis–Stress Model in my article Understanding Mental Disorders.

The Diathesis-Stress Model says that predisposing factors and precipitating factors influence each other and result in the disorder, which is then maintained by various other factors.

The possible causes of ADHD include:

1. Long-Term, Predisposing Factors

Heredity (genes)
Results from several international studies of twins show that ADHD often runs in families. Researchers are looking at several genes that may make people more likely to develop the disorder. Knowing the genes involved may one day help researchers prevent the disorder before symptoms develop. Learning about specific genes could also lead to better treatments.

Children with ADHD who carry a particular version of a certain gene have thinner brain tissue in the areas of the brain associated with attention. This NIMH (National Institute of Mental Health) research showed that the difference was not permanent, however, and as children with this gene grew up, the brain developed to a normal level of thickness. Their ADHD symptoms also improved.

2. Biological Factors

Brain injuries
Children who have suffered a brain injury may show some behaviours similar to those of ADHD. Brain injury can be caused by oxygen deprivation at birth or prenatal trauma.

However, only a small percentage of children with ADHD have suffered a traumatic brain injury.

Medical conditions that can cause disorders
Studies suggest a potential link between cigarette smoking and alcohol and /or drug use during pregnancy and ADHD in children.

In addition, preschoolers who are exposed to high levels of lead, which can sometimes be found in plumbing fixtures or paint in old buildings, may have a higher risk of developing ADHD.

Excess copper has also be found in some children with ADHD.

3. Short-Term, Precipitating (Triggering) Factors

Food additives and sugar
See below

4. Maintaining Causes

Food additives
Recent British research indicates a link between consumption of certain food additives like artificial colours, flavours and preservatives, and an increase in activity. Research is under way to confirm the findings and to learn more about how food additives may affect hyperactivity.

Sugar
The idea that refined sugar causes ADHD or makes symptoms worse is popular, but research is conflicting.

How is ADHD Diagnosed?

Unfortunately, there isn’t a single, all-encompassing test for ADHD. A licensed health professional will usually only make the diagnosis after gathering extensive information about the way the child behaves in varying environments from parents, teachers and other relevant individuals.

We must remember that most children – especially small children – get distracted, act impulsively and 'bounce off the walls' from time to time! This is normal, although it is often mistaken for the onset of ADHD.

True ADHD symptoms usually appear in children between the ages of 3 and 6. However, because all children are different, with differing levels of maturity and behaviour, it can be difficult to make a definitive ADHD diagnosis at this age. Often, it’s only once a child goes to into a formal school environment that behavioural abnormalities are picked up on by a teacher. They may complain, for example, that a child has difficulty following rules, or often seems 'out of it' in class or during play.

After noticing 'out of control' behaviour in their child, and having their suspicions validated by a teacher,  many concerned parents will take the next step in the diagnostic chain – consulting with their child’s pediatrician. While some pediatricians are happy to assess the child themselves, many opt to make a referral to a psychologist, who will in turn first try to rule out other possible reasons for the symptoms. Some of these could include:

• Hearing or vision problems (either chronic or acute, such as from an infection);

• Medical problems affecting thinking and behaviour;

• Undetected seizures;

• Learning disabilities;

• Anxiety or depression;

• Sudden and significant change - the death of a family member, divorce, or parent's job loss.

The psychologist will also examine school and medical records to see if there is anything unusually stressful ot disruptive about the child’s home or school environments. S/he will also speak to the child’s parents, teachers, parents of the child’s friends, and other adults such as sports coaches, babysitters etc, who know the child well.  Questions the psychologist may ask include:

• "Is the child’s behaviour extreme, affecting all aspects of their life?"

• "Does this extreme behaviour occur more often in this child compared to their peers?"

• "Is this behaviour long-term, or simply an age-appropriate response to a temporary situation?"

• "Does this behaviour occur in more than one place, or is it only noticed at home OR school OR church?"

The psychologist will closely observe the child’s behaviour in different situations – some very structured, others less so, in groups with other children, and on their own. Most children with ADHD control themselves better in situations where they are getting individual attention, or where they are free to focus on activities they enjoy.

Finally, if, after gathering all this information, if the psychologist feels the child meets all or most of the criteria for ADHD with no mitigating circumstances, they will make a formal ADHD diagnosis.

Treatment for ADHD

There is no cure for ADHD, so all currently available treatments are aimed at managing the disorder – reducing the severity of the symptoms and helping the child function more “normally.” These treatments include various medications, psychotherapy, education and/or training, or a combination of some or all of these.

Medications

It may seem strange, but the most common medications used to treat ADHD are stimulants. Because of the way ADHD works, stimulants actually have a calming effect on children with the disorder. ADHD medications reduce hyperactivity and impulsivity, and improve a child’s ability to focus, work, and learn. Some may also improve physical coordination.

Treatment however, is not an exact science, and what works for one child may not work with another. Trial and error, while not very scientific, is often the best way to find out which treatment will work best for your child in the long-term.

ADHD treatments come in different forms - pill, capsule, liquid or skin patch – and can be short- or long-acting, or extended release. In each case, the active ingredient is the same, but it is released differently in the body.

Even once the correct medication has been found, it may take time to get the dosage correct. Parents and doctors should decide together how much to give the child, and whether s/he needs it only during school hours, or in the evenings, at weekends and during holidays as well.

Here is a list of medications and the approved age for use: 

 *Not all ADHD medications are approved for use in adults.

NOTE: 'extended release' means the medication is released gradually so that a controlled amount enters the body over a period of time. 'Long acting' means the medication stays in the body for a long time.

Psychotherapy

Different types of psychotherapy are used for the treatment of ADHD.

Behavioural Therapy

This may take the form of practical assistance - such as help with organising tasks or completing schoolwork - or working through emotionally difficult events. Behavioural therapy teaches a child how to monitor and regulate their own behaviour. Learning to act in a desired way, such as controlling anger or thinking before acting, and receiving rewards and positive feedback from parents and teachers for getting it right, is also part of the process. Clear rules, chore lists, and other structured routines can also help a child control his or her behaviour.

A Behavioural therapist can help teach ADHD children social skills - such as how to wait their turn, share their toys, ask for help, or respond to teasing. Learning to read facial expressions and tones of voice - and how to respond appropriately – are also all part of this training.

How can I Help my Child With ADHD?

Children with ADHD need guidance and understanding from their parents and teachers. Often, before a child is diagnosed, family members may not have understood why their child is behaving in a seemingly disruptive and uncontrolled manner. Anger and frustration may be festering in such a family, and both parents and children will need specialist help to overcome these feelings.

There are many things you as a parent can do to help your ADHD child:

• Introduce a rewards and consequences system – rewards for appropriate behaviour and attitudes, and consequences (for example, the temporary removal of an enjoyed activity - TV, computer etc) for undesirable behaviour.

• Give immediate, positive feedback for behaviour you want to encourage, and ignore behaviour you want to discourage.

• Share a pleasant or relaxing activity with your child – play a board game, kick a ball around, bake cupcakes etc. Notice and point out what the child does well, and praise the child's strengths and abilities.

• Restrict the number of playmates to one or two at a time, so your child isn’t overstimulated.

• Help your child divide large tasks into smaller, more manageable ones.

• Learn stress-management techniques to help you deal with frustration. In this way, you’ll be able to respond more calmly to your child’s behaviour.

• Sometimes, the whole family may need therapy to find better ways to handle disruptive behaviour and encourage behaviour changes.

• Join a support group to meet other parents with similar problems and concerns.

Tips to Help Your Child Stay Focussed

Keep to the same schedule every day - from waking up to going to bed.
Make time for homework, outdoor play, and indoor activities. Keep the schedule where both you and your child can see it – perhaps on the fridge or on a notice board in the kitchen. Make any changes as far in advance as possible.

Organise everyday items
Have a place for everything, and keep everything in its place.

Use homework and notebook organisers
Help your child understand the importance of writing down assignments and bringing home the necessary books.

Be clear and consistent
Children with ADHD need consistent rules they can understand and follow.

Give praise or rewards when rules are followed
Children with ADHD often receive,  and thus come to expect, criticism. Look for good behaviour and praise it.