Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) refers to a condition in children who experience difficulty in concentrating and behave in an overactive and impulsive way.  Studies have shown that up to one in one hundred children of primary school age have ADHD.  ADHD is not linked to a lack of intelligence. Children who have ADHD can have difficulties at school, with their friends and in their family relationships.  Many more boys than girls have ADHD (about 90% of ADHD cases are boys) and it is thought to have a genetic component.  This is why parents are sometimes asked about their own childhood and behaviour.

It is normal for children to be overactive at times. When parents are exhausted or stressed, even normal behaviour in children can feel tiring and relentless.  However, ADHD is a diagnosis that applies to children who have persistent over-activity and difficulty in concentration in more than one setting.  When professionals assess for ADHD they conduct a thorough health and social history of the child. They will consider:

The child's development since being born.

Discuss how parents deal with the child's behaviour.

Ask about any relevant family events such as divorce and bereavement.

May observe children in the clinic, home and school.

Will check with school to get an overall picture of the child. They will ask about your child's intelligence, academic achievements and relationship skills with staff and children.

They aim to get a picture of the child in different environments.  It is very important to get a proper assessment before assuming a child has ADHD.

Diagnosis is not usually made in children under the age of five.  Below this age, it is difficult to properly assess children's behaviour.  The best person to approach if you have a worry is your doctor.  They will be able to refer you to a specialist ADHD clinic or to a child and adolescent mental health team.  In many areas of the country there are specialist health teams who assess and diagnose for ADHD, ask your GP about this.

Some professionals have concerns about the frequency of ADHD diagnosis.  They feel that true instances of ADHD are rarer than many other professionals claim.  They worry that children are unnecessarily being prescribed medication. They are concerned that many of the difficulties parents complain about in their children, reflect inadequate parenting skills, psychological difficulties in the child, or poor socio-economic conditions.

Children with ADHD may have spells of more controlled behaviour. When they come to the clinic for their assessment they may behave much better than they do normally.  This is why a thorough assessment looks at the child's behaviour over time and in different settings.  ADHD will not be diagnosed if the child's behaviour is specific to one area of their lives and not another. For instance, if a child behaves well at school but not at home, it is unlikely a diagnosis of ADHD will be made. This is because a child with ADHD would find it very difficult to confine their impulsive behaviour, overactivity and lack of concentration to some places and not others.

You may find that some doctors in your area will not prescribe medication for your child even when another doctor or psychiatrist has made a diagnosis.  If this is the case, you may have to go to another doctor or ask the person who made the diagnosis to prescribe medication. This happens much less often than it used to.

What should you look for?

Distractibility and a general inability to finish tasks off, such as completing a jigsaw or not being able to watch a TV programme all the way through.  Children might be attracted to another task before finishing the first.  They may appear to day-dream a lot.  The can cause difficulties in completing school work that appears to teachers to be careless and due to laziness.

Restless and overactive behaviour.  Children with ADHD can be very fidgety and not able to stay in one place or complete an activity.  They can find it very difficult waiting their turn in a queue.  They find keeping to rules difficult and become agitated if they are made to wait for anything.  They can talk too much in class and appear disruptive and difficult to control.  They find waiting to answer questions difficult, often blurting out answers or interrupting other people.

Difficulty in concentrating for a normal amount of time.  Children with ADHD don't appear to think things through like other children of a similar age.  They often under-perform at school because of this.  They become labelled as "difficult children" by school authorities and by their fellow pupils.  This leads to low self-esteem, difficulty in making and keeping friends and a loss of motivation.  This become a vicious circle for the child.

Impulsivity.  Children with ADHD can do dangerous things such as running across a road without looking.  They appear to act before they think. They can act in a way that seems out of proportion to a stimulus, for instance, getting over-excited in games or getting quickly upset and angry.  They find it difficult to tolerate having to wait or deal with a situation that is frustrating. They have poor self control.

As children with ADHD get older, they often develop better self control, but they may still have some difficulties with restlessness.

ADD  is a similar disorder which includes children who lack the impulsivity and hyperactivity of ADHD but who exhibit the difficulties in concentration and attention.

Many of the above behaviours are seen in children, and in small bursts, are normal.  Sometimes such behaviour can arise when there are periods of stress in a family or for a child at school.  It is the intensity and persistence of these behaviours over time, and in different environments, that will indicate ADHD.

What are the consequences for children, families and schools

Children with ADHD may have difficulty in making and sustaining friendships.  They may become known as troublesome at school.  They may fall behind in their work.  They can feel stupid and bad about themselves.  At home their parents can become exhausted with them.  Brothers and sisters may resent their apparent attention seeking.  Sometimes parents fall out with each other because of the persistent and exhausting nature of the problem.

Treatment

This begins with a thorough assessment as mentioned above. You may be given a questionnaire to fill in about your child.  A similar form may be sent to the school.  Sometimes professionals meet with school staff or arrange that a child is observed in the classroom.  It is important that teaching staff are educated in the management of children with ADHD and that they are made aware of the difficulties your child may face in a school situation.  The school may need additional special support teachers to help in the management and development of children with ADHD. It may take some time to do a proper assessment and to get all the relevant information in from your school.  The school SENCO (special educational needs co-ordinator) will be able to offer advice and support. School doctors and nurses are also good sources of help and advice.

Initially, a behavioural management programme may be set up.  You may be anxious to get your child started on medication, but a behavioural management programme will help in the assessment of ADHD. If your child is eventually diagnosed with ADHD, this behavioural management programme will form an important component in how you learn to deal with ADHD behaviour in your child. These programmes can help children develop better self control and social awareness. Think of parenting and behaviour management training as a way of giving you some tools to deal with your child's behaviour. For some children, the most useful aspect of medication may be to create a space in which to carry out other treatments.

The behavioural management programme should offer you some strategies for handling children's behaviour and provide insight into the difficulties your child may experience. It may include individual work with your child.  Sometimes group work for children can be offered too. The individual work focuses on helping your child develop social and self-awareness and better control of their feelings.  Such a programme may be set up at school. It can be useful for children to have tasks broken down into smaller, more easily remembered and achievable parts.  They will benefit from gentle reminders about what needs to be done. A timetable, or checklist can be helpful. If your child is 14 or above ask the Connexions service if they run any programmes for children with ADHD.

If a diagnosis is made and medication is recommended, it is up to you as a parent (and up to children as well above a certain age) to decide on whether or not you want to use it.  This can be a difficult decision for parents and children. You should be provided with information on the side effects and benefits of taking medication. Take your time considering this. If you want to ask more questions of your doctor, it may be useful to write them down before you go.   Be aware, that not all children are prescribed medication and that a few children who do have medication have to be taken off it because of side effects.  The most common medication is Ritalin (Methylphenidate).  Other drugs are also used such as Concerta. Your doctor will describe the different types of medication.

The side effects of Ritalin can include a loss of appetite, sleeplessness, stomach aches and nervousness.  Where there are side effects, these usually wear off after about a week or so. It may take some time to find the most effective dosage. Ritalin and Concerta are not addictive.

Because the effect of Ritalin are short-term (2-4 hours), tablets are normally taken in the morning and during the day.  Because they can produce sleeplessness, they are not normally taken at night. Newer drugs can be taken less frequently (such as Concerta) and may have fewer side-effects. Your doctor will advise you about these.

What to expect after medication commences

The common drug treatment is Ritalin, but there are other, similar drugs prescribed.  It does not actually cure the ADHD, but reduces the symptoms.  The results of medication are often good, with children becoming less irritable and restless.  Their concentration and co-ordination often improve.  This makes them easier to get along with and so their social relationships often improve.  This can lead to a rise in self-confidence and academic performance.

Children who are medicated should receive regular medical check-ups after the medication starts. These check-ups will identify any side effects and assess the level of medication required.  As the dosage is properly regulated, these check-ups will be less frequent.  From time to time, children may be given a period of time off medication to check if it is still required.  These are called 'drug holidays'. Your doctor will advise you about this.  Often, when medication stops all the symptoms return.  Some children are very resistant to taking drugs on a regular basis, especially over a long period of time.  This is more of a problem with teenagers. Discuss any such difficulties with your doctor.

As children mature, their hyperactivity often reduces by their late teens.  However, some people require medication and help for many years.  Many adults continue to show signs of restlessness and other aspects of ADHD.

You may find there are ADHD support groups in your area.  Read the article on this site called "Getting Extra Help" to find other sources of information.  You will also find many sites on the internet about ADHD and it's management.  Be sure to visit reputable sites that belong to major hospitals and universities or are run by professionals or recognised self-help groups.  You will find many support organisations and sites run by parents as well.  Some of these sites will be excellent, others will not be so good. Local support groups or ADHD clinics will point you to good sites. In some countries the diagnosis of ADHD is more widespread and the criteria for diagnosis may be looser than it is in the UK.

Book:

Dr. Christopher Green "Understanding Attention Deficit Disorder"

Web Sites:

ADD Net

http://www.adders.org/

ADDISS Suport Group

http://www.addiss.co.uk/

Dennis Neill

Family Therapist

Family Therapy UK

21st October 2008