ATTENTION DEFICIT HYPERACTIVITY DISORDER

Identifying ADHD

The primary tool for identifying the symptoms of ADHD is the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. This diagnostic manual specifies three groups of behaviors that are characteristic of ADHD. Children need only demonstrate behaviors in any one group to be diagnosed with ADHD. Children in the first group show signs of being consistently inattentive. Children in the second group will show hyperactive and impulsive behaviors. The third group of children exhibit a combination of behaviors from both groups (inattention, hyperactivity, and impulsiveness).

According to the diagnostic manual, an inattentive type of ADHD child is identified when six or more of the following symptoms have persisted for at least six months to a degree that significant impairments in a child's daily activities are noted. These symptoms must be seen in two or more environments, such as at home, at school, or in social settings. Symptoms include:

• failure to pay close attention to details or make careless mistakes in schoolwork;
• difficulty sustaining attention to tasks or play activities;
• failure to listen when spoken to directly;
• failure to follow through on instructions or complete schoolwork, chores, or duties;
• difficulty organizing tasks and activities;
• avoidance, dislike, or reluctance to engage in tasks that require sustained mental effort;
• frequent loss of things necessary for tasks or activities;
• easy distraction by outside stimuli; and
• forgetfulness in daily activities.

The diagnostic manual identifies the hyperactive/impulsive ADHD child when six or more of the following symptoms have persisted for at least six months to a degree that significant impairment in a child's daily activities are noted. These symptoms must also be seen in two or more environments, such as at home, at school, or in social settings. Symptoms include:

• fidgeting with hands or feet or squirming in seat;
• leaving seat in classroom or in other situations where remaining in seat is expected;
• running about or climbing excessively;
• having difficulty playing or engaging in leisure activities quietly;
• often "on the go" or acting as if "driven by a motor";
• talking excessively;
• blurting out answers;
• having difficulty waiting turn; and
• interrupting or intruding on others.

Possible Causes of ADHD

ADHD has been extensively researched, but its exact cause is unknown. According to the organization Children and Adults with Attention Deficit Hyperactivity Disorder (CHADD), current research suggests a neurobiological basis for this disorder. This means that there may be an imbalance of neuro-transmitters or a lack of the chemical dopamine, which is used by the brain to control behavior. When individuals concentrate, the brain releases neurotransmitters that enable them to focus on one thing and block out others. People with ADHD seem to have decreased amounts of these neurotransmitters. Some research suggests that abnormal glucose metabolism in the central nervous system may be a possible cause. Research indicates that the areas of the brain that control attention use less glucose, suggesting that these areas are less active for those with ADHD. Other studies suggest that prenatal drug and alcohol exposure may have an effect. Some doctors believe that environmental toxins and chemical additives in food may be the cause. There is no definite agreement on the neurobiological cause of ADHD. There is, however, widespread agreement among researchers that ADHD tends to run in families.

How Is ADHD Diagnosed?

There is currently no single test that can be given to diagnose ADHD. Since some biological and psychological disorders can appear similar to ADHD, these should be considered and ruled out before a diagnosis of ADHD is made. Conditions such as stress-related anxiety, depression, oppositional defiant disorder, the effects of child abuse or neglect, or obsessive compulsive disorder may look like ADHD but require different treatments.

A comprehensive evaluation is necessary to determine a diagnosis of ADHD. This includes information and observations from parents, teachers, school psychologists, and pediatricians. Parents see their children at home and in small social groups. Classroom teachers can be of assistance since they see how well children perform school work and how children interact with their peers. School psychologists can make behavioral observations in multiple settings and interview the child. Pediatricians provide needed medical information.

Completion of behavioral checklists are part of a comprehensive evaluation. The checklists rate the severity of ADHD symptoms and are completed by primary caregivers such as parents or guardians and classroom teachers. Items on the checklist include behaviors such as having no sense of fair play, temper outbursts, unpredictable behavior, and excessive demands for attention. In addition to this information, a thorough evaluation is needed of the child's current level of academic, social, and emotional functioning. This assessment is used to determine significant impairment in social relationships and academic performance. Careful consideration and review of all the information gathered is needed before the evaluation is complete.

Recommended Treatment for ADHD

Although there is no cure for ADHD, there is a recommended treatment plan that requires parents, educators, and members of the medical profession to work cooperatively. This plan includes parent training in managing behavior, counseling, educational supports, and medication when needed.

The parent training component recognizes how important it is for parents to provide clear expectations for behavior, establish consistent rules, provide positive reinforcement when rules are followed, and provide immediate consequences when rules are broken.

The counseling portion of the treatment plan may include both individual and family counseling. Family counseling may be useful in planning and evaluating workable strategies, such as conflict resolution, and providing needed emotional support. Individual counseling for the ADHD child can provide training in social skills, anger control, and relaxation techniques.

A supportive educational program with regular home-school communication is also needed. An ADHD child benefits when teachers provide structure by clearly communicating expectations, rules, and consequences. The educational program may also include modifications and accommodations such as shortening assignments, allowing more time for work completion or tests, and limiting homework.

The most controversial part of the treatment plan is the decision regarding medication of children with ADHD. When medication is prescribed, it is intended to improve the symptoms of ADHD. The benefits of medication can include a decrease in impulsiveness, aggressiveness, hyperactivity, and inappropriate social interaction. There can also be an increase in the child's ability to concentrate, shut out distractions, and complete schoolwork and jobs at home. The use of medication is controversial, though. Many people believe that schools advocate the use of medication as a way to control unruly behavior in children who do not necessarily have ADHD. The primary reason, however, that parents oppose the use of medication is because of possible side effects. Some children experience weight loss, lose their appetite, or have difficulty falling asleep. Together, parents and doctors should consider the benefits and concerns when making a decision about medication.

The Impact of ADHD on Families

Children with ADHD may have significant impairments that can have a profound impact on their families. Children often forget what they have been told or defiantly oppose what is requested of them. They tend to be demanding, unpredictable, restless, quick tempered, forgetful, inconsistent in their school work, and socially immature. These experiences lead to increased levels of parental frustration. Many parents struggle with deciding on the best methods for disciplining their child. They may question if they are being too strict or too permissive. Parents may feel guilty and at fault for their child's problems. Fair and consistent disciplinary practices can help change behavior in a positive way. When the condition is identified early and adequate treatment plans are implemented, children with ADHD can have successful school experiences and can develop positive relationships with peers and adults.

See also: ACTIVITY LEVEL; MENTAL DISORDERS

Bibliography

Barkley, Russell. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 2nd edition. New York: Guilford Press, 1998.

Children and Adults with Attention Deficit Hyperactivity Disorder(CHADD). Available from http://www.chadd.org; INTERNET

Rief, Sandra. How to Reach and Teach ADD/ADHD Children. West Nyack, NY: Center for Applied Research in Education, 1993.

Sandra J. White