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| ADHD (attention deficit hyperactivity disorder) |
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Written by Dr Helen Likierman and Valerie Muter, chartered clinical psychologists
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What is ADHD?
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| ADHD often prevents children from learning and socialising
well. |
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Attention deficit hyperactivity disorder
(ADHD) and attention deficit disorder (ADD) refer
to a range of problem behaviours associated with poor attention
span.
These may include impulsiveness, restlessness and
hyperactivity, as well as inattentiveness, and often prevent children from
learning and socialising well. ADHD is sometimes referred to as hyperkinetic
disorder.
What are the symptoms of ADHD?
Attention difficulties
A child must have exhibited at least six of the following
symptoms for at least six months to an extent that is unusual for their age and
level of intelligence.
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Fails to pay close attention to detail or makes
careless errors during work or play.
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Fails to finish tasks or sustain attention in play
activities.
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Seems not to listen to what is said to him or
her.
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Fails to follow through instructions or to finish
homework or chores (not because of confrontational behaviour or failure to
understand instructions).
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Disorganised about tasks and activities.
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Avoids tasks like homework that require sustained
mental effort.
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Loses things necessary for certain tasks or
activities, such as pencils, books or toys.
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Easily distracted.
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Forgetful in the course of daily activities.
Hyperactivity
A child must have exhibited at least three of the following
symptoms for at least six months to an extent that is unusual for their age and
level of intelligence.
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Runs around or excessively climbs over things. (In
adolescents or adults only feelings of restlessness may occur.)
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Unduly noisy in playing, or has difficulty in
engaging in quiet leisure activities.
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Leaves seat in classroom or in other situations
where remaining seated is expected.
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Fidgets with hands or feet or squirms on seat.
Impulsivity
At least one of the following symptoms must have persisted at
least for six months to an extent that is unusual for their age and level of
intelligence.
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Blurts out answers before the questions have been
completed.
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Fails to wait in lines or await turns in games or
group situations.
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Interrupts or intrudes on others, e.g. butts into
others conversations or games.
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Talks excessively without appropriate response to
social restraint.
Pervasiveness of attention difficulties and
hyperactivity
For a diagnosis or description of ADHD a child would be
expected to show the above difficulties in more than one setting, eg at school
and at home.
Sometimes problems are not shown 'at home' but are very
evident when a child goes to a hospital department. This can happen when
parents do not realise that their child's behaviour is out of the normal range
(perhaps because they have no other children, or they have other children who
behave similarly).
It may also be because the problems are mild, or because the
family has handled the attention lack at home in such a way that it is not
evident there is a major problem, or because the child is very young. In those
cases it is quite reasonable for parents not to consider that their child has
an attention deficit problem.
Who is affected by ADHD?
About 1.7 per cent of the UK population, mostly children, have
ADD or ADHD. Boys are more likely to be affected.
What else could it be?
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Grand mal or petit mal epileptic seizures can cause a child to
become drowsy, impairing their attention. Epilepsy can also cause unusual
behaviour and lead to abnormal perceptions.
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Hearing problems such as deafness or glue ear can make it hard
for a child to follow instructions and make them appear inattentive.
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Reading problems, making it hard to complete tasks or follow
instructions.
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Obsessive compulsive disorder leads to people following strange
rituals that preoccupy their thoughts and distract their attention.
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Tourette's syndrome involves repetitive, involuntary jerking
movements of the body and sudden outbursts of noise or swearing.
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Autism and Asperger's syndrome often lead to difficulties in
understanding and using language.
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Prolonged periods of insufficient sleep, causing poor
concentration.
NB: Many children may be very active or be easily distracted or
have difficulty concentrating. If these behaviours are relatively mild, they
should not be considered a disorder.
What other difficulties can occur alongside ADHD?
ADHD often occurs alongside other difficulties and is not the
sole cause of problem behaviour. Children may exhibit temper tantrums, sleep
disorders, and be clumsy. Other behavioural problems that occur with ADHD
include:
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confrontational defiant behaviour, which occurs in 60 per cent
of children. The child loses their temper, argues and refuses to comply with
adults and deliberately annoys others.
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conduct disorders occur in at least 25 per cent of children.
The child may be destructive or show deceitful behaviour such as lying,
breaking rules and stealing.
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specific learning difficulties, including dyslexia, occur in
25-30 per cent of children.
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severe clinical depression occurs in 33 per cent of children.
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anxiety disorders occur in 30 per cent of children.
What causes ADHD?
Biological factors
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The child's temperament, as this contributes to their
attitude and personality.
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Studies of twins suggest a genetic link to ADHD. In 80-90 per
cent of identical twins where one has ADHD so does the other. Recent research
also suggests there is a greater chance of inheriting the condition from male
relatives such as grandfathers.
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Brain injuries due to birth trauma or pre-birth problems. The
brain structures believed to be linked to the development of ADHD are
vulnerable to hypoxic damage during birth. The damage is caused by inadequate
oxygen reaching parts of the brain while blood flow is reduced.
Environmental factors
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Family stress.
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Educational difficulties.
How is ADHD diagnosed?
ADHD requires a medical diagnosis by a doctor, usually a child
or adolescent psychiatrist, a paediatrician or paediatric neurologist or a GP.
It will often be appropriate for other professionals such as
psychologists, speech therapists, teachers and health visitors to contribute
their observations to the assessment of a child with possible ADHD. There is no
single diagnostic test for ADHD so different sorts of information needs to be
gathered, such as the following:
History of symptoms
The precise nature of the difficulties, when they were first
noticed, in what situations they occur, factors that exacerbate or relieve
them.
Medical history
Risk factors that could predispose the child to ADHD include
difficulties and risks in pregnancy and during birth, for example if the mother
was in poor health, very young or drank alcohol or smoked or had an extended or
complicated labour.
Several medical conditions are known to be associated with
ADHD. These include fragile-X syndrome, fetal alcohol syndrome, G6PD
deficiency, phenylketonuria and generalised resistance to thyroid hormone.
Accidents, operations and chronic medical conditions such as
epilepsy, asthma and heart, liver and kidney disorders all need to be taken in
to account. Also of possible relevance is any medication the child is taking,
as well as any adverse reactions they have had to medication in the past.
Past psychiatric history
Enquiring about any mental health problems the child has had
can help rule out depression or anxiety being behind the symptoms.
Educational history
This means the level of their ability and what specific
difficulties they have, how they function within their peer group and get on
with teachers, and any behaviour difficulties such as suspensions or
exclusions. A more detailed evaluation of the child's learning by a
psychologist may be necessary.
Evaluation of the child's temperament and
personality
The child's temperament and personality, those of other family
members and the nature of relationships within the family may need to be
assessed. This will include discussion of the methods used by the parents to
manage the child's behaviour and how successful they have been. Although this
seems intrusive, the assessor will remain neutral and parents should not feel
the disorder is 'their fault'.
Family history
The mental and physical health of the child's parents and
other family members can be relevant, particularly regarding the incidence of
ADHD or depression.
Social assessment
The family's social circumstances, such as housing, poverty,
and social support may all have an impact on the child's behaviour.
What treatment is available for ADHD?
Treatment depends on a child's exact diagnosis. It should take
into account any specific difficulties and those strengths that may aid their
improvement.
It is not easy to live or cope with a child with ADHD. Both
parents and teachers can follow general guidelines to manage a child's
problematic behaviour but they may need specialist support and advice, e.g.
from a psychologist.
Management techniques for parents and teachers
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Create a daily routine for the child, eg homework schedules,
bedtime and mealtime routines.
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Be specific in your instructions to the child and make clear
and reasonable requests, eg instead of telling the child to 'behave' suggest
'play quietly with your Lego for 10 minutes'.
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Set clear and easily understood boundaries, eg how much TV
they may watch, and that rudeness is unacceptable.
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Be consistent in the handling and managing of the child.
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Remove disturbing or disruptive elements from their daily
routine. For example, remove siblings from the room when they are doing
homework or turn off the TV.
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Plan structured programmes aimed at gradually lengthening the
child's concentration span and ability to focus on tasks.
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Communicate with the child on a one-to-one basis and avoid
addressing other children at the same time.
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Use rewards (eg stickers, tokens or even money) consistently
and frequently to reinforce appropriate behaviour such as listening to adults
and concentrating.
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Use sanctions (eg loss of privileges, being sent to their
room) for unacceptable behaviour or 'overstepping' of boundaries.
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Discuss your child with their school or nursery and see if
you can work together.
Medication
Behavioural management techniques such as those above are
always important, and for mild attention deficit problems they are the
treatment of choice. US research suggests that medication is the best treatment
for true ADHD. The most common and effective medications are amphetamine-like
stimulants, mainly
methylphenidate (eg
Ritalin) and
dexamfetamine
(Dexedrine). If there are coexisting conditions then these may also
require medication.
Ritalin reduces hyperactivity and impulsiveness and helps to
focus a child's attention. They become less aggressive, seem to comply with
requests, and become less forgetful. Many parents say their child's behaviour
has vastly improved as a result of Ritalin.
However, there is growing concern about the use of Ritalin to
treat ADHD. Like amphetamines, Ritalin is classified as a class A drug. Many
parents and professionals are worried about alleged side effects, including
damage to the cardiovascular and nervous systems. Ritalin's manufacturers
recommend that it is only used to treat children aged six years and over. If
symptoms don't improve after a month's trial it should be discontinued. The
manufacturers also recommend that even if Ritalin is effective it should
discontinued periodically to assess the child's condition. You should discuss
any concerns with your child's doctors, and they may alter the dose prescribed.
Psychological treatments
In addition to the management techniques described, other
forms of psychological treatment might include anxiety management, cognitive
therapy, individual psychotherapy and social skills training.
Educational management
This includes individual, or group, learning support for
coexisting learning difficulties and educational underachievement.
Diet
Research suggests that diet is not a significant factor in
ADHD for most children. Some children have particular food allergies that need
investigation. Dietary changes need to be supervised by a doctor and
nutritionist. In this approach all foods suspected of causing behavioural
problems are removed from the diet then gradually reintroduced while the
child's behaviour is monitored by the psychologist.
What is the likely outcome?
Many children simply outgrow ADHD. About half of those affected
appear to function normally by young adulthood, but a significant number will
have problems that persist into adult life. These may take the form of
depression, irritability, antisocial behaviour and attention
problems.
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Last updated 28.05.2005
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