Excerpts from Your Child on Attention Deficit/ Hyperactivity Disorder(ADHD)
From time to time, in the normal course of their explorations and interactions in the world, most children bubble over with restlessness. On their feet, they dash from here to there. In a chair, they squirm, twist, churn, wriggle, and jiggle. With so much to do and so much going on around them, there's neither time nor reason to sit still.
While such activity is normal during early childhood, some children continue to operate as though they live within a high speed kaleidoscopic world. For children who have attention deficit/hyperactivity disorder, images, sounds, and thoughts churn constantly, distracting them, making it impossible for them to stay fixed on any one task or activity. These children often start running almost as soon as they learn to walk.
Sometimes when people speak, hyperactive children are so distracted or so inattentive that they don't even notice. Such children have great difficulty sitting still, planning ahead, or attending to what's going on around them. They often find it impossible to consider and conform to expectations and requirements of the world around them. As a result, their difficulties often cause disruption, annoyance, and disappointment to others in their environment. In addition, these children are more accident prone and difficult to manage.
Once called hyperkinesis or minimal brain dysfunction, attention deficit/hyperactivity disorder (ADHD) occurs in between 3 and 5 percent of all children, perhaps as many as two million American youngsters. Many more boys than girls are affected, though the disorder is being identified increasingly in girls. On the average, at least one child in every classroom in the United States needs help for the disorder.
Characteristic behaviors are inattention, hyperactivity, impulsiveness, and disorganization. Children who are inattentive have a hard time keeping their mind focused on any one task for long. They become easily bored or distracted. Children who are hyperactive seem to be in continual motion. They are overly impulsive and don't curb their automatic reactions. It appears that they do not think before they act and frequently they appear disorganized, forgetful, and unprepared.
However, because all children at times display occasional hyperactivity, short attention span, and impulsive thinking and behavior, especially during times of stress, unrest, or excitement, it is important not to misidentify them as having ADHD. Children with ADHD exhibit these symptoms much more consistently over time than other children their age or developmental level. In addition, anxiety, depression, and other emotional problems can produce symptoms that resemble ADHD.
Identifying the Signs
Although signs of this disorder are often evident during toddlerhood or even earlier, most children do not come to the attention of their pediatricians or mental health professionals until they start school. Like other behavioral disorders, ADHD is most often identified by adult people, not by the child. Adults have varying tolerances for excessive activity, so that the same behavior may be accepted as exuberant by one teacher but considered a serious problem by another. Some parents do not know what level of activity, concentration, and compliance to expect from their children at different ages and may worry about their child's level of exuberance, energy, and restlessness.
In addition, problems may be present at school but not in the home, or at home but not at school. Some children are bored, discouraged, restless, and unable to follow instructions at school, not because they have ADHD but because they don't find the type of structure or challenge that suits them. Some children who suffer from undiagnosed learning disabilities express their frustration through behavior. They may have difficulty concentrating. They can become restless and fidgety and, ultimately, disruptive in the classroom.
ADHD is a chronic disorder. Its symptoms can be mild, moderate, or more severe, depending on the child. Many times, a child will try harder to focus if he likes his teacher. If he's involved in a subject or task that he's good at or particularly interested in, such as during a favorite TV show or story hour, he may seem better able to contain himself. Children with ADHD usually have more problems in large groups and do better one on one. Some children with severe symptoms have problems constantly and in all settings: at home, at school, and at play.
There are three different types of ADHD. The least common one includes children who are predominantly fidgety and hyperactive, tending to blurt out answers in the classroom, but maintain adequate concentration. A child with the second type of ADHD is characteristically inattentive, easily distracted, and disorganized, but not hyperactive. These children daydream, forget, or lose things, procrastinate, and fail to complete their work. Children with the third type of ADHD have a combination of the symptoms and behaviors of the other two types. This third variety of ADHD is the most common and the most severe form.
In general, children with ADHD look normal physically and at times their behavior is normal, too. However, for children with this disorder, fidgety, restless, and distracted behavior is not just a temporary reaction to stress. If ADHD goes unrecognized and untreated, a child can experience a lifetime of emotional pain, frustration, academic underachievement, even failure, and social isolation.
In infancy, early indications of the disturbance may be reflected in temperament. The baby may sleep very little or for very short periods of time. When awake, the baby may be very demanding. Feeding problems such as poor sucking, crying during feedings, needing to be fed often for brief periods, or difficulty settling into a comfortable sucking rhythm can also be early indications of ADHD. Sometimes, these infants become picky eaters. Irritability, fidgeting, crying, and/or colic can make children hard to soothe or cuddle. They may not like being held. Sometimes, they develop self soothing behaviors such as excessive thumb sucking, head rolling, head banging, or rocking.
Once such children begin to crawl, they may be in constant motion with little regard to their parents' presence or absence. They may seem oblivious to and undeterred by parental warnings of danger. If the child is accident prone, which is often the case with ADHD, the youngster will require close supervision. Frequently, parents find it nearly impossible to maintain a daily routine with these children because they are so irregular.
As all parents know, toddlers and prescboolers are naturally active. Most have short attention spans, and many are fairly impulsive. For these reasons, identifying the child with ADHD at this developmental stage is often difficult. Children later diagnosed with ADHD tend to be toddlers who ran instead of walked. Always on the go, always changing focus, they seem in perpetual motion, without goal or purpose. They may impulsively bolt from the table before finishing meals, refuse to sit through a story, and fidget while watching television.
A young child with ADHD may be prone to intense temper tantrums. He may have great difficulties in entertaining himself and in playing cooperatively with others. Some ADHD children are very aggressive. Unstructured activities such as independent work are difficult. However, for many ADHD kids, even structured or focused activities like painting, drawing, or games are also problematic because of the difficulties in being able to concentrate and remain seated, making completion of the task unlikely.
Although some hyperactive children are precocious in terms of gross motor skills, they may still be clumsy and accident prone. For many, fine motor coordination and language ability are delayed. Sleeping problems can continue into the school age years.
While most preschoolers and young school age children can be impulsive, children with ADHD are impulsive to a degree that is distracting and dangerous. They may grab toys or hit other children without any obvious provocation. They may dash out into the street for no apparent reason. They might steal a candy bar or comic book on a whim without considering the consequences of their actions.
The symptoms of ADHD are usually evident by the time the child is five or six years of age (although, looking back, they usually were apparent earlier). The older child with such symptoms as restlessness, impulsiveness, and short attention span may have another emotional disorder such as depression, anxiety, bipolar disorder, or substance abuse. It is also possible they have milder ADHD that was not identified at a younger age.
Children with ADHD seem unable to delay their responses. At school, they often are impatient and unable to wait their turn. An overly impulsive child might blurt out an answer (not always correctly) before a question is completed or while another child is attempting to answer. The child's schoolwork may show lack of thought and focus. School papers and assignments are frequently incomplete or full of errors.
Typically, a hyperactive child in the classroom won't stay seated and is in constant motion, pacing or running about inappropriately during class. Children with ADHD may be so fidgety as to literally fall out of their chairs. Play and leisurely activities cannot be engaged in quietly the youngster with ADHD seems to be verbally impulsive and to talk incessantly.
Yet, the very same child may be able to concentrate for considerable stretches of time on certain activities that are enjoyed or that come easily, such as drawing cartoons, watching television, or playing video games. Such selective attention seems related to motivation and pleasure in the task. Children with ADHD have difficulties in social situations and frequently have few friends. Many of these children are less mature when compared to their peers.
It is still not clear whether hyperactive children have difficulty perceiving and understanding social cues or whether they perceive them correctly but fail to respond appropriately. In normal circumstances, most children adjust their behavior through learning so that they can enter into a game, for example, or a group project without interrupting the rhythm that has been established. Children with ADHD cannot easily adjust their behavior to the demands of specific situations. They are more likely to simply barge in and disrupt the process. They often appear very self centered.
On the playground, they might push into games and conversations without being invited. They might run into other children, pushing, hitting, shoving. While there may be no particular anger, hostility, or malicious intent in this intrusive physical contact, it often results in quarrels and fights with other children. At other times, school age children with ADHD may be oppositional and argumentative, characteristics that can become habitual as the child's personality develops.
Causes and Consequences
Despite years of research, the cause of ADHD is still not fully understood. Evidence to date indicates that there are many factors underlying ADHD, among them genetic and neurobiological vulnerabilities. The basic problem is thought to be in the area of the brain that inhibits responses. This leads to the inattention, impulsiveness, and physical over activity seen in ADHD. A child's environment may also contribute to the development of the disorder or worsen the symptoms.
In some cases, the cause of hyperactive behavior is not ADHD but high levels of lead in the blood; fetal alcohol syndrome (in which excessive alcohol consumed during pregnancy has a range of effects on the unborn child); exposure to other drugs in utero; the result of a serious head injury; or a consequence of an infection of the central nervous system. In the 1970s, attention focused on food additives, although later it was concluded that additives were not a cause of the syndrome. In the 1980s, public attention turned to sugar in its search for an explanation for ADHD. Many parents still limit sugar and foods rich in sugars but controlled studies have discounted the sugar theory as a cause for ADHD.
Pressures in the child's home, coupled with neurological vulnerabilities, seem to increase the likelihood that a child will manifest problems related to ADHD. The prevalence of children with hyperactivity, impulsiveness, and inattention is greater in disadvantaged, large inner city environments. This may be due to interrelated conditions such as poverty; malnutrition; lead poisoning; poor prenatal and neonatal health care (which can lead to prematurity or low birth weight); maternal drug or alcohol abuse during pregnancy; and family disturbances, including violence and drug and alcohol abuse. Any one or a combination of these elements can play a significant role in developing and perpetuating ADHD symptoms.
While the exact degree to which a chaotic environment contributes to ADHD symptoms is still unclear, it does appear that parents who are able to provide support, stability, educational stimulation, and hope can help children with ADHD compensate over time for their vulnerabilities.
The symptoms of ADHD in these children makes parenting more challenging. Dealing with ADHD symptoms, and the inevitable frustration that results, may cause many parents to doubt their parenting skills. Parents of children with ADHD report greater social isolation, self blame, and depression than other parents. When these factors translate into a parenting style that is more intrusive, controlling, and disapproving, the child's emotional development, competence, and self esteem can be adversely affected.
As parents try to establish limits and discipline, for example, many become exasperated by their child's inability or unwillingness to listen. Despite every effort to curtail certain behaviors, parents often complain that the child doesn't learn from mistakes or doesn't seem responsive to praise or punishment.
This vicious cycle of negative interaction, stress, and sense of failure for both child and adult are also seen in the classroom between teacher and child. In addition, a school or classroom setting that is unstructured and disorganized can intensify ADHD symptoms.
Once a child enters elementary school, he is expected to be able sit still and complete tasks for longer and longer periods of time. The more concentration required, the greater the likelihood that ADHD symptoms will interfere.
In addition to a child's conduct in class, his schoolwork will show the effects of the disorder. Unable to give close attention to details, he is prone to making careless mistakes. It might appear that the child does not listen when spoken to directly or does not follow through on instructions or finish schoolwork. Youngsters with ADHD may have difficulty organizing their thoughts and schoolwork.
Most hyperactive children avoid, dislike, or refuse to engage in tasks that require sustained attention. As a result, homework and schoolwork often go unfinished, especially when it is boring, repetitive, or difficult. In addition, they often don't finish chores at home.
Children with ADHD tend to underachieve at school, failing to reach their potential and functioning below their grade level in reading, spelling, and/or arithmetic. Because they have trouble paying attention and find it hard to organize their work, they actually may have trouble processing and remembering information.
In addition, children with ADHD may have difficulty remembering things in order (sequential memory). They may also have trouble controlling their pencils, required for handwriting and drawing, the result of poor fine motor skills. Clumsiness while skipping or running is an example of difficulty with large motor skills. Even when they are clearly intelligent, such children seem unable to discipline their thinking so that they can focus on or follow a particular line of thinking.
The less success ADHD children have with schoolwork, the less motivated they are to pursue academics. With many of these children, even their most concentrated efforts seem to bring little success.
A sense of failure may also permeate the social relationships of children with ADHD. Their impulsive behavior bothers other children. In addition to getting into trouble themselves, these children tend to get others into trouble. Consequently, they often find themselves unpopular with peers, and enduring friendships are rare. Sometimes, the only other children who are willing to play with a child with ADHD are those who are younger or have similar problems.
Since children with ADHD are impulsive they tend not to think about consequences, and this often leads to socially unacceptable or risky behavior. Excessively impulsive children may walk on a roof ledge, or lean way too far out an upper window. Risk taking behaviors are more common in children with ADHD, who may also be accident prone. It is hardly surprising that children with ADHD tend to have low self esteem. Many find themselves in trouble constantly or receiving lots of criticism. Many feel socially isolated and lack the mastery and competence that other children gain from navigating social and academic challenges. Therefore many children with ADHD enter a cycle of failure and criticism that is perpetuated both at school and in the family. Unless these children have the opportunity to experience adequate pleasure, love, and success, feelings of failure become chronic and can lead to depression.
ADHD commonly exists with other problems, such as specific learning disabilities. Children with ADHD may also have depression or anxiety disorders. Almost half of children diagnosed with ADHD are also diagnosed with oppositional defiant disorder or conduct disorder.
How to Respond
ADHD is a treatable condition that requires a comprehensive approach. More than two hundred studies have shown that stimulant medication can produce striking results. Other treatment approaches, singly or in combination, may include cognitive behavioral therapy, social skills training, parent education and support, and remedial education.
If your child is diagnosed with ADHD, learn as much as you can about the disorder. Talk with your child's doctor, teachers, and parents of other children with ADHD. Investigate what your child's school can do to provide remedial education or special tutoring to compensate for learning difficulties or to address associated reading disorders and other learning disabilities or language delays. Parents of children with ADHD are their youngster's best advocates and need to be involved in monitoring school progress and in getting their children the help they need. Many communities have ADHD parent support groups and parents often find comfort and help in meeting and talking with others in similar situations.
Cognitive Behavioral Therapy Behavioral therapy can help children control their aggression, modulate their social behavior, and regulate their attention and physical movements. Parents and teachers identify positive behaviors, for which the children are rewarded and encouraged. Cognitive therapy can teach older hyperactive children self control, self guidance, and more thoughtful and efficient problem solving strategies.
Social Skills Training When coupled with other therapy, social skills training has been effective in helping children smooth out their difficult social behaviors. Through such training, children can learn to evaluate social situations and adjust their behavior accordingly. The most successful therapies are those that provide training in the child's natural environments such as the classroom or in social groups as this may help the child apply the lessons learned directly to his life.
Typically parents participate in their children's social skills groups and provide opportunities outside the group to practice the skills the child has learned. For instance, parents might invite friends over for a variety of simple activities. Over time, they provide the opportunity for their children to progress successfully to more complex social activities.
Despite such programs, however, hyperactive children may continue to have socializations problems when involved in play and activities with the children without the disorder.
Parent Training Programs Some parents are helped through parent training programs. In these sessions, parents learn strategies for managing their children's behavior. These are practical approaches to dealing with a child with ADHD. For example, you need to be sure you have your child's attention when giving instructions; further, you need to issue instructions one step at a time rather than issuing multistep requests. Parents learn to increase structure in the child's life. They can help the child work toward successful experiences, which can help counteract some of the negative effects of the disorder. The emphasis is on observing the child and communicating clearly. Parents are taught negotiating skills, techniques of positive reinforcement, and other means of managing the behavior of the child with ADHD.
Family Therapy This approach addresses the family stress normally generated by living with ADHD. Using a variety of techniques, families can change patterns of communication or interactions in order to help the child with ADHD. Sometimes, in the course of treatment, it may be discovered that a parent also has the disorder. Treatment of that parent may be helpful since the adult's behavior can affect how the child responds to treatment.
Medication Since the 1930s, stimulants have been used to treat what we now call ADHD. Stimulant medications include methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and pemoline (Cylert). Such medications increase the child's attention and reduce excess fidgeting and hyperactivity, allowing the child to focus on his work. It is thought that the stimulant medications improve the brain's ability to inhibit distracting stimuli and decrease impulsiveness. In many cases, children with ADHD who take medication can concentrate for longer periods and are better able to complete tasks and comply with requests.
The most common side effects of stimulant medication are reduced appetite and difficulty falling asleep. Some children report stomachaches and headaches, especially during the first few days of treatment. If these side effects continue, they can often be controlled by reducing the dosage of medication for a few days. It is crucial that the treating physician monitor your child's height and weight to assure that physical growth is progressing normally.
Although the results from the use of such medication can be dramatic, using stimulants to treat a child with ADHD is a serious decision. It has been suggested, too, that in some cases the diagnosis of ADHD has been used to justify medicating children who are perceived as active, expansive, or difficult by adults who lack the patience and willingness to tolerate them. There are a variety of factors to consider, among them the severity and duration of disorder, the short term and long term benefits of medication, and the potential side effects. Ask your child's psychiatrist to describe how the decision is made whether, when, and how to prescribe medication as well s the kind of follow-up needed to monitor its use.
When stimulants fail to modify the symptoms, or cause problematic side effects, antidepressant medication may be helpful in treating the symptoms of ADHD. Among those prescribed are imipramine (Toftand), nortriptyline (Pamelor), and bupropion (Wellbutrin).
Children with ADHD are at higher risk for academic failure, social isolation, low self esteem, depression, and disruptive behavior. For some, it can be a lifelong disorder, but for those children diagnosed and treated early, the condition can be effectively managed and their lives can indeed be productive, successful, and fulfilling. Most of these children develop greater control over their behavior and become less impulsive as they grow and mature.
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See Also:
Facts for Families #6 - Children Who Can't Pay Attention,
ADHD Practice Parameter summary, or full text, and
AACAP PocketCards: Managing Attention-Deficit/Hyperactivity Disorder.
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