Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder (ADHD) has many faces and remains one of the most talked-about and controversial subjects in education. Hanging in the balance of heated debates over medication, diagnostic methods, and treatment options are children, adolescents, and adults who must manage the condition and lead productive lives on a daily basis
What is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is a neurological condition that involves problems with inattention and hyperactivity-impulsivity that are developmentally inconsistent with the age of the child.
It is a function of developmental failure in the brain circuitry that monitors inhibition and self-control. This loss of self-regulation impairs other important brain functions crucial for maintaining attention, including the ability to defer immediate rewards for later gain.
Behavior of children with ADHD can also include excessive motor activity. The high energy level and subsequent behavior are often misperceived as purposeful noncompliance when, in fact, they may be a manifestation of the disorder and require specific interventions. Children with ADHD exhibit a range of symptoms and levels of severity. In addition, many children with ADHD often are of at least average intelligence and have a range of personality characteristics and individual strengths.
Children with ADHD typically exhibit behavior that is classified into two main categories:
- poor sustained attention and
As a result, three subtypes of the disorder have been proposed and they are : predominantly inattentive, predominantly hyperactive-impulsive, and combined types
A child expressing hyperactivity commonly will appear fidgety, have difficulty staying seated or playing quietly, and act as if driven by a motor. Children displaying impulsivity often have difficulty participating in tasks that require taking turns. Other common behaviors may include blurting out answers to questions instead of waiting to be called and flitting from one task to another without finishing. The inattention component of ADHD affects the educational experience of these children because ADHD causes them to have difficulty in attending to detail in directions, sustaining attention for the duration of the task, and misplacing needed items. These children often fail to give close attention to details, make careless mistakes, and avoid or dislike tasks requiring sustained mental effort.
Current literature indicates that approximately 40–60 percent of children with ADHD have at least one coexisting disability. Although any disability can coexist with ADHD, certain disabilities seem to be more common than others. These include disruptive behavior disorders, mood disorders, anxiety disorders, tics and Tourette’s Syndrome, and learning disabilities. In addition, ADHD affects children differently at different ages. In some cases, children initially identified as having hyperactive-impulsive subtype are subsequently identified as having the combined subtype as their attention problems surface.
These characteristics affect not only the academic lives of students with ADHD, they may affect their social lives as well. Children with ADHD of the predominantly hyperactive-impulsive type may show aggressive behaviors, while children of the predominantly inattentive type may be more withdrawn. Also, because they are less disruptive than children with ADHD who are hyperactive or impulsive, many children who have the inattentive type of ADHD go unrecognized and unassisted. Both types of children with ADHD may be less cooperative with others and less willing to wait their turn or play by the rules .
What Causes ADHD?
ADHD has traditionally been viewed as a problem related to attention, stemming from an inability of the brain to filter competing sensory inputs such as sight and sound. Recent research, however, has shown that children with ADHD do not have difficulty in that area. Instead, researchers now believe that children with ADHD are unable to inhibit their impulsive motor responses to such input.
It is still unclear what the direct and immediate causes of ADHD are, although scientific and technological advances in the field of neurological imaging techniques and genetics promise to clarify this issue in the near future. Most researchers suspect that the cause of ADHD is genetic or biological, although they acknowledge that the child’s environment helps determine specific behaviors.
Imaging studies conducted during the past decade have indicated which brain regions may malfunction in patients with ADHD, and thus account for symptoms of the condition. It is found that the right prefrontal cortex (part of the cerebellum) and at least two of the clusters of nerve cells known collectively as the basal ganglia are significantly smaller in children with ADHD. It appears that these areas of the brain relate to the regulation of attention. Why these areas of the brain are smaller for some children is yet unknown, but re searchers have suggested mutations in several genes that are active in the prefrontal cortex and basal ganglia may play a significant role. In addition, some nongenetic factors have been linked to ADHD including premature birth, maternal alcohol and tobacco use, high levels of exposure to lead, and prenatal neurological damage. Although some people claim that food additives, sugar, yeast, or poor child rearing methods lead to ADHD, there is no conclusive evidence to support these beliefs.
How Do We Identify ADHD?
Although toddlers and preschoolers, on occasion, may show characteristics of ADHD, some of these behaviors may be normal for their age or developmental stage. These behaviors must be exhibited to an abnormal degree to warrant identification as ADHD. Even with older children, other factors (including environmental influences) can produce behaviors resembling ADHD.
A person must exhibit several characteristics to be clinically diagnosed as having ADHD:
. The behavior in question must occur more frequently in the child than in other children at the same developmental stage.
. At least some of the symptoms must have been present prior to age 7.
. The symptoms must also have been present for at least 6 months prior to the evaluation.
. The symptoms must have a negative impact on the child’s academic or social life.
. The symptoms must be present in multiple settings.
A person with Attention Deficit/Hyperactivity Disorder must have either (1) or (2):
(1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fails to give close attention to details or makes careless mistakes in school work, work, or other activities
(b) often has difficulty sustaining attention in tasks or play activities
(c) often does not seem to listen when spoken to directly
(d) often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
(e) often has difficulty organizing tasks and activities
(f) often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) is often easily distracted by extraneous stimuli
(i) is often forgetful in daily activities
(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
(a) often fidgets with hands or feet or squirms in seat
(b) often leaves seat in classroom or in other situations in which remaining seated is expected
(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings or restlessness)
(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
(g) often blurts out answers before questions have been completed
(h) often has difficulty awaiting turn
(i) often interrupts or intrudes on others (e.g., butts into conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Disassociative Disorder, or a Personality Disorder).
Components of a Comprehensive Evaluation
A diagnosis of ADHD is multifaceted and includes behavioral, medical, and educational data gathering. One component of the diagnosis includes an examination of the child’s history through comprehensive interviews with parents, teachers, and health care professionals. Interviewing these individuals determines the child’s specific behavior characteristics, when the behavior began, duration of symptoms, whether the child displays the behavior in various settings, and coexisting conditions.
Specific questionnaires and rating scales are used to review and quantify the behavioral characteristics of ADHD. The AAP has developed clinical practice guidelines for the diagnosis and evaluation of children with ADHD, and finds that such behavioral rating scales accurately distinguish between children with and without ADHD (AAP, 2000). Conversely, AAP recommends not using broadband rating scales or teacher global questionnaires in the diagnosis of children with ADHD.
Collecting information about the child’s ADHD symptoms from several different sources helps ensure that the information is accurate. Appropriate sources of information include the child’s parents, teachers, other diagnosticians such as psychologists, occupational therapists, speech therapists, social workers, and physicians. It is also important to review both the child’s previous medical history as well as his or her school records.
An educational evaluation assesses the extent to which a child’s symptoms of ADHD impair his or her academic performance at school. The evaluation involves direct observations of the child in the classroom as well as a review of his or her academic productivity.
Behaviors targeted for classroom observation may include:
Problems of inattention, such as becoming easily distracted, making careless mistakes, or failing to finish assignments on time;
Problems of hyperactivity, such as fidgeting, getting out of an assigned seat, running around the classroom excessively or striking out at a peer;
Problems of impulsivity, such as blurting out answers to the teacher’s questions or interrupting the teacher or other students in the class; and
More challenging behaviors, such as severe aggressive or disruptive behavior
Classroom observations are used to record how often the child exhibits various ADHD symptoms in the classroom. The frequency with which the child with ADHD exhibits these and other target behaviors are compared to norms for other children of the same age and gender. It is also important to compare the behavior of the child with ADHD to the behaviors of other children in his or her classroom.
It is best to collect this information during two or three different observations across several days. Each observation typically lasts about 20 to 30 minutes
In order to receive special education and related services under Part B of IDEA, a child must be evaluated to determine (1) whether he or she has a disability and (2) whether he or she, because of the disability, needs special education and related services. The initial evaluation must be a full and individual evaluation that assesses the child in all areas related to the suspected disability and uses a variety of assessment tools and strategies. As discussed in the section on Legal Requirements (above), a child who has ADHD may be eligible for special education and related services because he or she also meets the criteria for at least one of the disability categories, such as specific learning disability or emotional disturbance. It is important to note that the assessment instruments and procedures used by educational personnel to evaluate other disabilities—such as learning disabilities—may not be appropriate for the evaluation of ADHD. A variety of assessment tools and strategies must be used to gather relevant functional and developmental information about the child.
An educational evaluation also includes an assessment of the child’s productivity in completing classwork and other academic assignments. It is important to collect information about both the percentage of work completed as well as the accuracy of the work. The productivity of the child with ADHD can be compared to the productivity of other children in the class.
A medical evaluation assesses whether the child is manifesting symptoms of ADHD, based on the following three objectives:
To assess problems of inattention, impulsivity, and hyperactivity that the child is currently experiencing;
To assess the severity of these problems; and
To gather information about other disabilities that may be contributing to the child’s ADHD symptoms.
The recommendations are designed to provide a framework for diagnostic decision making and include the following:
Medical evaluation for ADHD should be initiated by the primary care clinician. Questioning parents regarding school and behavioral issues, either directly or through a pre-visit questionnaire, may help alert physicians to possible ADHD
In diagnosing ADHD, physicians should use DSM-IV criteria.
The assessment of ADHD should include information obtained directly from parents or caregivers, as well as a classroom teacher or other school professional, regarding the core symptoms of ADHD in various settings, the age of onset, duration of symptoms, and degree of functional impairment.
Evaluation of a child with ADHD should also include assessment of co-existing conditions such as learning and language problems, aggression, disruptive behavior, depression, or anxiety.
What Are the Treatment Options?
Although at present no cure for ADHD exists, there are a number of treatment options that have proven to be effective for some children. Effective strategies include behavioral, pharmacological, and multimodal methods.
Behavioral approaches represent a broad set of specific interventions that have the common goal of modifying the physical and social environment to alter or change behavior. They are used in the treatment of ADHD to provide structure for the child and to reinforce appropriate behavior. Those who typically implement behavioral approaches include parents as well as a wide range of professionals, such as psychologists, school personnel, community mental health therapists, and primary care physicians. Types of behavioral approaches include behavioral training for parents and teachers (in which the parent and/or teacher is taught child management skills), a systematic program of contingency management (e.g. positive reinforcement, “time outs,” response cost, and token economy), clinical behavioral therapy (training in problem-solving and social skills), and cognitive-behavioral treatment (e.g., self-monitoring, verbal self-instruction, development of problem-solving strategies, self-reinforcement). In general, these approaches are designed to use direct teaching and reinforcement strategies for positive behaviors and direct consequences for inappropriate behavior. Of these options, systematic programs of intensive contingency management conducted in specialized classrooms and summer camps with the setting controlled by highly trained individuals have been found to be highly effective. A later study conducted indicates that two approaches—parent training in behavior therapy and classroom behavior interventions—also are successful in changing the behavior of children with ADHD. In addition, home-school interactions that support a consistent approach are important to the success of behavioral approaches.
The use of behavioral strategies holds promise but also presents some limitations. Behavioral strategies may be appealing to parents and professionals for the following reasons:
Behavioral strategies are used most commonly when parents do not want to give their child medication;
Behavioral strategies also can be used in conjunction with medicine (see multimodal methods);
Behavioral techniques can be applied in a variety of settings including school, home, and the community; and
Behavioral strategies may be the only options if the child has an adverse reaction to medication.
Behavior therapy has been found to be effective only when it is implemented and maintained. Indeed, behavioral strategies can be difficult to implement consistently across all of the settings necessary for it to be maximally effective. Although behavioral management programs have been shown to enhance the academic performance and behavior of children with ADHD, followup and maintenance of the treatment is often lacking.
In fact, some research has shown that behavioral techniques may fail to reduce ADHD’s core characteristics of hyperactivity, impulsivity, and inattention. Conversely, one must consider that the problems of children with ADHD are seldom limited to the core symptoms themselves. Children frequently demonstrate other types of psychosocial difficulties, such as aggression, oppositional defiant behavior, academic underachievement, and depression. Because many of these other difficulties cannot be managed through psycho stimulants, behavioral interventions may be useful in addressing ADHD and other problems a child may be exhibiting.
Pharmacological treatment remains one of the most common, yet most controversial, forms of ADHD treatment. It is important to note that the decision to prescribe any medicine is the responsibility of medical—not educational—professionals, after consultation with the family and agreement on the most appropriate treatment plan. Pharmacological treatment includes the use of psycho stimulants, antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers. Other types of medication (antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers) are used primarily for those who do not respond to stimulants, or those who have coexisting disorders.
Although the positive effects of the stimulant medication are immediate, all medications have side effects. Adjusting the dosage of the medicine can diminish some of these side effects. Some of the more common side effects include insomnia, nervousness, headaches, and weight loss. In fewer cases, subjects have reported slowed growth, tic disorders, and problems with thinking or with social interaction. Medication also can be expensive, depending upon the medicine prescribed, the frequency of administration, and the subsequent frequency of refills. Stimulant medicines do not “normalize” the entire range of behavior problems, and children under treatment may still manifest higher levels of behavioral problems than their peers. Nonetheless, at least 80 percent of children will respond to one of the stimulants if they are administered in a systematic way. Under medical care, children who fail to show positive effects or who experience intolerable side effects on one type of medication may find another medication helpful. The AAP reports that children who do not respond to one medication may have a positive response to an alternative medication, and concludes that stimulants may be a safe and effective way to treat ADHD in children.
Research indicates that for many children the best way to mitigate symptoms of ADHD is the use of a combined approach. A recent study by the NIMH—the Multimodal Treatment Study of Children with ADHD (MTA)—is the longest and most thorough study of the effects of ADHD interventions. The researchers compared the effects of four interventions: medication provided by the researchers, behavioral intervention, a combination of medication and behavioral intervention, and no-intervention community care (i.e., typical medical care provided in the community).
Multimodal intervention improves:
and reduces . . .
Of the four interventions investigated, the researchers found that the combined medication/behavior treatment and the medication treatment work significantly better than behavioral therapy alone or community care alone at reducing the symptoms of ADHD. Multimodal treatments were especially effective in improving social skills for students coming from high-stress environments and children with ADHD in combination with symptoms of anxiety or depression. The study revealed that a lower medication dosage is effective in multimodal treatments, whereas higher doses were needed to achieve similar results in the medication-only treatment
Researchers found improvement in the following areas after using a multimodal intervention: child anxiety, academic performance, oppositional behavior, and parent-child interaction. Positive results also were found in school-related behavior when multimodal treatment is coupled with improved parenting skills, including more effective disciplinary responses, and appropriate reinforcements. These findings were replicated across all six research sites, despite substantial differences among sites in their samples’ socio demographic characteristics. The study’s overall results appear to apply to a wide range of children and families identified as in need of treatment services for ADHD (NIMH, 2000). Other studies demonstrate that multimodal treatments hold value for those children for whom treatment with medication alone is not sufficient.
How Does ADHD Affect School Performance?
The school experience can be challenging for students with ADHD. Students usually are identified only after consistently demonstrating a failure to understand or follow rules or to complete required tasks. Other common reasons for referral include frequent classroom disruptions and poor academic performance.
Studies found that students with ADHD, compared to students without ADHD, had persistent academic difficulties that resulted in the following: lower average marks, more failed grades, more expulsions, increased dropout rates, and a lower rate of college undergraduate completion. The disruptive behavior sometimes associated with the disorder may make students with ADHD more susceptible to suspensions and expulsions.
ADHD’s core symptoms—inattention, hyperactivity, and impulsivity—make meeting the daily rigors of school challenging. Difficulty sustaining attention to a task may contribute to missing important details in assignments, daydreaming during lectures and other activities, and difficulty organizing assignments. Hyperactivity may be expressed in either verbal or physical disruptions in class. Impulsivity may lead to careless errors, responding to questions without fully formulating the best answers, and only attending to activities that are entertaining or novel. Overall, students with ADHD may experience more problems with school performance than their non disabled peers.
Tips for Home
Caring for children with ADHD may be challenging, but it is important to remember that these children can learn successfully. It is critical that parents remember that some of their child’s disruptive behavior is a manifestation of the disability and that the challenge is finding ways to help their child change the inappropriate behavior. Key to this is remembering to focus on the need for structure and routine for your child’s daily schedule and thereby reinforcing the importance of learning self-control and self-regulation. The following are suggestions for parents:
Focus on discrete rewards and consequences for appropriate and inappropriate behavior:
- Tangible rewards and treats;
- Movie night for a good week at school;
- Removal of privileges; and
- Time-out from reinforcing activities: the child is essentially removed from situations that foster inappropriate behavior.
Set a daily routine and stick to it. Bedtime and preparation for school are much easier if there is a structure already in place.
Have tangible reminders:
- A big clock in the bedroom;
- Charts for chores;
- Assignment pad to record homework and a specific folder to put work in upon completion; and
- Gain the child’s attention before speaking to him or her. Have the child repeat back directions for things that are really important.
Avoid the following:
- Repeating patterns of inappropriate behavior followed by ineffective punishment;
- Administering consequences without prior warning or without the child understanding why he or she is receiving them; and
- Responding inconsistently to inappropriate behaviors.