Attention-Deficit/Hyperactivity Disorder In Children

Introduction to Attention-Deficit/Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (AD/HD) is the most commonly diagnosed behavioral disorder of childhood and is estimated to effect 3 to 5 % of school-aged children and 2-4% of adults. In addition, boys are approximately 6 times as likely to be diagnosed with AD/HD as girls. The core symptoms of the disorder include developmentally inappropriate and problematic levels of impulsivity, inattention, and hyperactivity. Formal diagnosis of the disorder is made using criteria established in the Diagnostic and Statistical Manual – 4th edition of the American Psychiatric Association (DSM-IV), which delineates three different subtypes of the disorder (AD/HD-inattentive type; AD/HD-hyperactive type; AD/HD-combined type). The particular subtype identified is dependant upon the level of severity and the particular combination of the various symptoms.

Symptoms of Attention-Deficit/Hyperactivity Disorder

The type of behavior experienced within the inattentive realm includes:

• Failure to give close attention to details or making careless mistakes;
• Having difficulty sustaining attention
• Not appearing to listen
• Struggling to follow through on instructions
• Difficulty with organization;
• Avoiding or disliking tasks that require sustained mental effort
• Is easily distracted
• Is forgetful in daily activities.

Within the hyperactivity/impulsivity realm problematic behaviors that characterize the disorder are:

• Fidgeting with hands or feet or squirming in one's chair
• Having difficulty remaining seated
• Running about or climbing excessively
• Difficulty engaging in activities quietly
• Talking excessively
• Blurting out answers before questions have been completed
• Difficulty waiting or taking turns
• Interrupting or intruding upon others

When symptoms from both categories are experienced at a sufficient level and in sufficient number, a child is considered as having AD/HD-combined type. While the behaviors described above may appear common to many children, in children with AD/HD these behaviors are found to be at a level of severity and number that exceeds what would usually be expected for a child at particular stages of development. In addition, with children with AD/HD the symptoms will have been an ongoing problem for at least 6 months and will have begun before the child is 7 years of age. Finally, these behaviors generally impact the child's well being in more than one setting (home, school, socially with peers). Children with AD/HD may experience significant problems associated with the symptoms of the disorder such as school problems, academic underachievement, disrupted relationships with family members and peers, and low self-esteem.

Etiology of Attention-Deficit/Hyperactivity Disorder

AD/HD is a neurobehavioral disorder in which the specific cause remains unknown. However, current research suggests that neurological and genetic factors are the chief contributors to the disorder. Such research has shown AD/HD to have a familial or hereditary transmission pattern. Other factors, such as neurological impairment (prenatal injury, brain damage) and environmental toxins (side effects of sedatives, prenatal exposure to alcohol and tobacco) may account for the disorder in some children, yet in much smaller numbers of those diagnosed as AD/HD. It is important to note that there is not evidence to suggest that AD/HD is caused by chronic stress, poor child management strategies by parents, nor by family dysfunction. These types of phenomena may worsen the symptoms of a child that has AD/HD, but are not viewed as causing the disorder. In understanding AD/HD, parent bashing is as irresponsible a response to the disorder as blaming the child for having developed a neurological/genetic condition.

Assessment of Attention-Deficit/Hyperactivity Disorder

There is no single definitive test for AD/HD and as a result a degree of arbitrariness is a part of the process of diagnosis. It is important therefore that diagnosis should be made using a comprehensive, multimodal method of assessment. In such an assessment, information should be gathered from a number of sources including the child's parents, the school, and the child. What the clinician looks for is clinically significant impairment due to the symptoms or combination of symptoms of hyperactivity/impulsivity and/or inattention in two or more settings.

An AD/HD assessment should include an extensive clinical interview with the parents of the child. The parents should also be asked to complete behavior-rating scales both to assess for the specific symptoms of AD/HD as defined by the DSM-IV and to help identify other difficulties that may be of concern along with AD/HD. As many as one-third of the children with AD/HD have one or more coexisting conditions. Among the disorders most commonly found to be present with children with AD/HD are those involving highly disruptive behavior (Oppositional Defiant Disorder, Conduct Disorder), mood disorders (depression and anxiety), and learning disabilities and to a lesser extent with tics, Tourette's syndrome, and Obsessive Compulsive Disorder. Clinicians may include screening measures for coexisting conditions as part of the comprehensive assessment for AD/HD. It is also valuable to secure information about the child's medical history to understand the possible contribution of medical conditions to his/her symptoms. Finally, it is vital that the individual or group of individuals assessing the child for AD/HD be familiar with other types of childhood disorders.

A second source of information in a multimodal assessment should be the child's teacher or other school personnel. Since children spend a substantial portion of their day in school, information about their behavior in that setting is of particular value. In addition, it is often in school where behavior associated with AD/HD is first identified as problematic. It is in school that children are required to sit quietly for periods of time, maintain focus as they work independently, inhibit impulsive responding (blurting out answers), organize their school materials and assignments, and smoothly switch from task to task. These are examples of expectations that children with AD/HD find most difficult to fulfill. Information gathered from school may be provided through behavior rating scales, verbal narratives if contact with the teacher is made directly, written narratives, and/or questionnaires. It is also valuable to gather information as to the types of situations encountered in school where the child's behavior is most problematic to help in the diagnosis.

Finally, a third source of information is the child him/herself. Time should be spent directly with the child being assessed. The nature of the interview will vary depending on the child's age, intellectual level and language abilities. While younger children (below age 9 years) are not particularly reliable in making reports about their own disruptive behavior, their report of symptoms associated with coexisting conditions such as depression or anxiety problems can be informative and help in making the most accurate diagnosis. In addition, IQ and achievement data about the child is valuable in determining cognitive factors that may contribute to the child's attention difficulties or underlie his/her academic problems. Should that data not be available, a brief screening for IQ and achievement status may be done as a part of the assessment. Finally, another source of information regarding the child may include an assessment of their attention, impulsivity, and distractibility using a computerized continuous performance test. The use of such testing should never be the sole source of the diagnosis of AD/HD, but can be used to confirm the diagnosis based on other information and/or provide additional information as to the level of severity of the symptoms. After gathering information from the sources identified above a diagnosis of AD/HD can be made if there is sufficient evidence of severe, pervasive, and debilitating impulsiveness/hyperactivity that began early in the child's life.

The thorough and comprehensive nature of the assessment of AD/HD is in keeping with the seriousness of the disorder and potential ramifications such a diagnosis has for the child and his/her family. Among those ramifications is the fact that children do not outgrow AD/HD and are likely to be involved in attempts to manage the disorder throughout their life. Over 70% of children diagnosed with AD/HD will continue to display the clinical syndrome into adolescence and between 15 and 50% will do so into adulthood. The particular presentation of symptoms may change somewhat as the child develops into adolescence in that there may be a decline in the levels of hyperactivity and an improvement in attention span and impulse control, however it is common for children with AD/HD to continue to display symptoms that exceed what would be expected at particular stages of development. Symptoms in adolescence may include poor follow through on instructions, difficulty with organization and planning, frequent daydreaming, restlessness rather than more overt hyperactivity, and engaging in risky activities. Left untreated or in situations where treatment is terminated prematurely the potential risk for depression, academic failure, substance abuse, and other difficulties is high. This is particularly so given the increasing demands placed on the adolescent and young adult for independent, responsible conduct, requiring him/her to manage their time effectively and for them to be organized.

Treatment of Attention-Deficit/Hyperactivity Disorder

Because the symptoms of AD/HD impact the child's family, social, and academic life, proper treatment of AD/HD is viewed as requiring a multi-modal or multi-treatment approach. Depending on the child's age and stage of development the specific nature of the treatment plan will vary. However, during any point in childhood and adolescence effective treatment of AD/HD should include various core components that are adjusted to meet developmental needs. These components include: (1) Education, (2) Medication, (3) Parent training, and (4) School involvement.

In managing a problem like AD/HD that cannot be cured requires a thorough understanding of the nature of the disorder. Education is a key component of treatment as parents, teachers, and other caretakers are assisted in learning as much as possible about the disorder. Clinicians with expertise in treating AD/HD can provide help in this area. Parent support groups such as Children and Adults with Attention-Deficit/Hyperactivity Disorder (C.H.A.D.D.) are a great resource for information and support. In addition, there is a wonderful array of other resources both in print and on video to help in learning about AD/HD.

The data on treatment of AD/HD has provided evidence that at the center of a multi-modal model for properly diagnosed AD/HD is medication management. Stimulant medication treatment far exceeds other types of interventions in terms of behavioral improvement. The reasoned and discriminating use of medication is an essential treatment component for most children with AD/HD. Pediatricians, psychiatrists, and other medical doctors not only are responsible for prescribing the various medications used to manage the symptoms of AD/HD, but should be viewed as a valuable resource and ally in the ongoing process of addressing the impact of AD/HD.

Counseling and training parents to manage their child's behavior more effectively is a vital component of treatment. It is important that parents develop appropriate expectations for children with AD/HD, use effective behavioral techniques for child behaviors, and modify the home environment to increase the potential for greater compliance, productivity, and more rewarding social relationships.

Because of the frequent negative impact of AD/HD symptoms in the school setting, educational planning and programming for the student with AD/HD is a critical part of their multi-modal treatment plan. It is important that a strong working alliance be developed with the child's school. A great deal of information has been generated regarding educational strategies to enhance performance of children with AD/HD. Such strategies may include implementing classroom management programs to address disruptive behavior as well as more formal educational planning that considers both the strengths and needs of the child. A strong relationship with the school is also of importance due to the incidence of learning disabilities in a number of children with AD/HD. The particular level of accommodations within the classroom is dependant on the severity of the symptoms of AD/HD, the presence of coexisting conditions, and the child's response to other treatment interventions. Such accommodations may vary from enhancing the regular classroom environment to increase the potential for greater attention and productivity, to securing special services for the child through the protections of the Individuals with Disabilities Education Act (IDEA) or Section 504 of the Rehabilitation Act of 1973.

Attention Deficit/Hyperactivity Disorder Hope for the Future

Finally, while the symptoms of AD/HD in a child can have an enormous impact on their life and of the lives of those around them, there is hope and reason for optimism. If adequately treated, most individuals with AD/HD live productive lives despite the challenges posed by the disorder. For this reason, it is vital to establish a good working relationship with professionals that families are likely to encounter such as pediatricians and other medical doctors, psychiatrists, clinical psychologists, school psychologists, social workers, and nurse practitioners. It is important that the clinician you choose to assist you in the assessment and treatment process not only be willing to act as a consultant and provide guidance, support, and assistance, but be willing to communicate and advocate for the needs of the child to other professionals instrumental in your child's care.