ADHD in children

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Overview

What is ADHD?

Attention deficit/hyperactivity disorder (ADHD) is a developmental disorder  characterised by difficulties with concentration, attention and impulse control, which impact on the person’s day-to-day life.

ADHD begins in childhood and around 6-7% of children are diagnosed with this disorder.1 Whilst symptoms typically improve as children get older, about 65% of children diagnosed with ADHD continue to have some symptoms of ADHD into adulthood, with about 15% continuing to meet full criteria for ADHD as adults.1-3

Children with ADHD often have difficulty sitting still, following direction and settling into quiet tasks, and often act before thinking things through. Even when they try to focus on their work, children with ADHD are often easily distracted by things going on around them. Because of these difficulties, they can have problems keeping up in class, and making and keeping friends.4

Signs and symptoms

The key signs and symptoms of ADHD cover two main areas of difficulty; inattention and hyperactivity/impulsivity.

Inattention
  • Difficulty concentrating
  • Difficulty staying focused
  • Forgetfulness
  • Trouble organising tasks and activities
  • Tendency to lose things
Hyperactivity/impulsivity
  • Fidgeting and restlessness
  • Difficulty sitting for long periods of time
  • Difficulty engaging in quiet activities
  • Difficulty waiting turn
  • Acting or speaking before thinking things through.

For a diagnosis of ADHD the child must have several symptoms of either inattention or hyperactivity/impulsivity, or both, across two or more settings such as at home and at school. Symptoms must also have been present before 12 years of age.

There are three types of ADHD, depending on the main difficulties the child is experiencing. These are:

Predominantly inattentive: The child mostly has symptoms of inattention, rather than hyperactivity or impulsivity.

Predominantly hyperactive-impulsive: The child mostly has symptoms of hyperactivity and impulsivity, rather than inattention.

Combined: The child has symptoms of both inattention and hyperactivity-impulsivity.

Children with the combined type are more frequently referred to services, possibly because the range of behavioural and social difficulties might be more noticeable.

For very young children, it is important to remember that skills of attention, concentration and impulse control are still developing. A short attention span, being easily distracted or acting impulsively is quite common at this age and not necessarily a sign of ADHD. A careful assessment is therefore needed to figure out what is typical and not typical for a child at each age and stage of development.

What causes ADHD?

There is no single cause of ADHD; rather, there are a range of factors relating to a person’s genes, neurobiology (the structure and function of the brain) and environment that increase the chance of developing ADHD.5

Genes

There appears to be a strong genetic component to ADHD, and ADHD often runs in families. Research suggests a number of genes might be involved, rather than one single gene.5-7

Neurobiology

In children with ADHD, research has found some differences in areas of the brain and in brain activity that relate to movement, information processing, learning, memory, attention, and the regulation of emotions, thoughts and behaviour.8-10

Environment

Certain environmental factors might also play a role in the development of symptoms of ADHD. These include:5

  • Pregnancy and birth factors: Maternal smoking, alcohol and substance misuse, and stress during pregnancy, as well as infant low birth weight and prematurity are all factors linked to ADHD.
  • Early life relationships and opportunities to learn: Growing up in a family with high conflict, or without good opportunities to learn skills for self-regulation, attention and concentration can lead to difficulties in these areas.
  • Certain environmental toxins: Toxins such as lead can affect brain development and behaviour.
  • Dietary factors: For some people (even without ADHD) attention and concentration might be affected by nutritional deficiencies (e.g., zinc, magnesium, polyunsaturated fatty acids) and sensitivities to certain foods (e.g., sugar, artificial food colourings). There is no evidence however  that these cause ADHD and a medical practitioner should be involved to evaluate these issues if they are considered of possible concern.

How is ADHD assessed?

Assessment is often completed by a number of professionals with training and experience in ADHD, with their findings put together to make a diagnosis. In the assessment of ADHD in children, this team of professionals often includes:11

A paediatrician – a medical doctor with specialist training in the assessment and treatment of childhood health issues

A psychologist – a mental health professional with training in the assessment and treatment of developmental, learning and behavioural difficulties

A psychiatrist –a qualified medical doctor who has done extra training to specialise in mental health

Another allied health professional – this might include a speech pathologist, who assesses and treats a range of speech and language issues in children, or an occupational therapist, who works with children’s fine and gross motor skills and other aspects of daily living. This all depends on whether the child might have other learning problems other than ADHD which need evaluating.

This team of professionals assess for the following:

  • Does the child or young person present with ongoing signs of inattention, hyperactivity or impulsivity?
  • Do these symptoms significantly and negatively impact on the child’s day-to-day learning and functioning?
  • Do these symptoms occur in different settings (e.g. home and school)?
  • Were these symptoms present before age 12?
  • Could another reason better explain the symptoms?12

Answering these questions involves talking to the parents and the child, taking a detailed history of the child’s development, physical health, mental health, and behaviour, and careful consideration of other information such as teacher and school reports.11, 13

During an assessment, parents as well as educators are often asked to complete questionnaires and checklists.

A psychologist might also assess the child’s memory, attention and other aspects of their learning. The psychologist might also observe the child in different settings, such as at school , to see how they behave with different demands on their behaviour.11, 13, 14

Treatments that work

As with assessment, treatment is often provided by a team of professionals, usually a psychologist and a paediatrician, working together. They often work with parents and the child as well as provide support and advice to the child’s educators. It is important for the psychologist, the parents and the educators to work together to provide the best care and support for the child’s learning and for parents to feel part of the team.

Treatment varies according to the needs of the child and their family. Children with mild ADHD without other developmental or behavioural issues generally do well with family support around behavioural management strategies. Children with more difficult to manage symptoms or a variety of different concerns often benefit from a combination of medication and psychological strategies, particularly behavioural management.13

Effective treatments and interventions include:

Medication

A number of ADHD medications have been found to be effective in the short-term, although there appears to be no ‘permanent’ positive effect.13, 15 In Australia, the medications available for the treatment of ADHD are

  • Short-acting stimulants (e.g. Ritalin 10, Attenta, dexamphetamine).
  • Long-acting stimulants (e.g. Ritalin LA and Concerta) and atomoxetine (Strattera).16

Where medications are used, they are best used as part of a comprehensive treatment plan that includes age appropriate psychological, social and educational support.17

Behavioural Parent Training

Behavioural parent training involves the parent(s) learning about ADHD, the use of a range of positive parenting and effective disciplinary strategies, and the use of problem-solving to address day-to-day issues.18

Social skills training

Social skills training involves training a parent or educator to teach, model and encourage positive social behaviours, and to help the child use these behaviours to improve social skills and relationships with peers.19

School-based interventions

School-based interventions involve supportive strategies such as changing the layout of the classroom to make it less distracting for the child, modifying work, or putting in place clear behavioural goals and applying fair, logical and immediate consequences for appropriate and inappropriate behaviours.19

Addressing other learning difficulties

Children with ADHD often have other learning difficulties making life at school all the more difficult for them. It is important for the child’s learning abilities to be fully assessed and any difficulties addressed and supported both at home and in the educational setting.

Seeking help

Ways to access treatment

Psychological treatment is becoming more accessible with a variety of ways available to access psychological advice, support and treatment for ADHD. This can be via:

  • Parenting and self-help books
  • Online treatment programs, sometimes called eTherapy
  • Seeing a mental health professional such as a psychologist, in person.

When using self-help books and eTherapy programs, it is important to choose ones that have a good reputation, have research to support their approach, and which are recommended by experts in the field.

You can speak with your GP or a mental health professional about which approach might best suit you.

When to seek professional help

If a parent or teacher thinks a child has problems with attention, hyperactivity or impulsivity, or if a young person thinks they have these difficulties, a referral should be made to a professional, such as a psychologist, with experience in assessing ADHD and developmental issues in children.

Psychologists are highly trained and qualified to diagnose and work with children and young people with ADHD, using methods based on the best available research. Psychologists understand the factors that can affect attention and concentration and how to help children, and their parents and teachers, to work on improving these skills and reduce the impact of ADHD. Clinical and educational psychologists play a particular role, as they have expertise in understanding developmental expectations and childhood challenges.

To locate a registered psychologist in your area, call the APS Find A Psychologist Service on 1800 333 497 or visit www.findapsychologist.org.au. Your GP can also organise a referral to a registered psychologist experienced in working with ADHD. Check with your GP whether you might be eligible for rebates or reduced rates.

Tips for supporting children with ADHD

  • Use praise. Praise should be specific and immediate to highlight and reward behaviours you would like to encourage.
  • Pay attention. Make good eye contact with the child, listen attentively and respond in a caring manner.
  • Spend focused time together. Choose an activity that your child is interested in and get involved, free of direction or negativity.
  • Use effective commands. Use commands only when necessary and keep them simple and clear. It is important that the child is paying attention and it can be helpful to allow some time for the child to comply. Praise for listening and following through can help to reinforce positive behaviours.
  • Find a quiet space for the child to work in. At school, find a space that is free from distraction, away from the door (where people come and go), away from the window (and distractions outside) and near the front of the classroom, facing the teacher and the whiteboard. Sit them with a ‘buddy’ who is a good role model, who can help reinforce instructions and expectations. At home, find a quiet space to do homework and make sure it is free from clutter, toys, electronic media, and other distractions.
  • Break tasks down into smaller chunks. Smallertasks are easier to complete, easier to organise and are less overwhelming.
  • Include breaks in activities and tasks. Breaks after work is completed can help a child to refocus on the next task.
  • Help the child stay organised. Depending on the age of the child, use schedules and reminders to help your child develop skills to organise themselves. A list of routine activities on the fridge or bedroom door can be helpful.
  • Use incentive systems. Incentive systems are a way of providing concrete, immediate rewards for positive behaviours. Target behaviours should be clearly defined and the reward chosen should be meaningful to the child; younger children might receive a small treat such as a sticker or favourite activity, while older children may like to collect points for a larger reward.
  • Use problem-solving. Effective problem-solving includes agreeing on what the problem is, brainstorming solutions, agreeing on a solution, trying it out, and checking on the outcome. Simplify this process for use with young children.
  • Use planned ignoring. Ignoring mild problem-behaviours can help to decrease their frequency over time. Planned ignoring needs to be consistent and done in a calm manner. It is important not to ignore the child, only the behaviour, and to attend to your child’s needs in a caring manner. Aggressive, harmful, or destructive behaviour should not be ignored, but addressed immediately.
  • Use time-out consistently, but only occasionally. Time-outs should usually only be used if the above techniques have not been successful. They can allow the child to ‘cool-down’, and allow time away from reinforcement of problem behaviour (such as making other children laugh).
  • Contributor(s)
    APS Member Publications
  • Publish date
    14 Nov 2016
  • References
    View
  • Reviewer(s)
    Vicki Anderson, PhD
    Head of Psychology
    RCH Mental Health Theme Director
    Clinical Sciences Research
    Psychological Sciences & Paediatrics
    University of Melbourne

References

  1. Willcutt, E. G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: A meta-analytic review. Neurotherapeutics, 9(3), 490-499. doi: http://dx.doi.org/10.1007/s13311-012-0135-8
  2. Mick, E., Faraone, S., Biederman, J., & Spencer, T. (2004). The course and outcome of ADHD. Primary Psychiatry, 11, 42-48.
  3. Ramtekkar, U. P., Reiersen, A. M., Todorov, A. A., & Todd, R. D. (2010). Sex and age differences in attention-deficit/hyperactivity disorder symptoms and diagnoses: Implications for DSM-V and ICD-11. Journal of the American Academy of Child & Adolescent Psychiatry, 49(3), 217-228. doi: http://dx.doi.org/10.1016/j.jaac.2009.11.011
  4. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington DC: Author.
  5. Thapar, A., Cooper, M., Eyre, O., & Langley, K. (2013). Practitioner review: What have we learnt about the causes of ADHD? Journal of Child Psychology and Psychiatry, 54(1), 3-16. doi: http://dx.doi.org/10.1111/j.1469-7610.2012.02611.x
  6. Faraone, S. V., & Mick, E. (2010). Molecular genetics of attention deficit hyperactivity disorder. The Psychiatric Clinics of North America, 33(1), 159-180. doi: http://dx.doi.org/10.1016/j.psc.2009.12.004
  7. Li, Z., Chang, S.-h., Zhang, L.-y., Gao, L., & Wang, J. (2014). Molecular genetic studies of ADHD and its candidate genes: A review. Psychiatry Research, 219(1), 10-24. doi: http://dx.doi.org/10.1016/j.psychres.2014.05.005
  8. Castellanos, F. X., Lee, P. P., Sharp, W., Jeffries, N. O., Greenstein, D. K., Clasen, L. S., . . . Walter, J. M. (2002). Developmental trajectories of brain volume abnormalities in children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Medical Association, 288(14), 1740-1748. doi: http://dx.doi.org/10.1001/jama.288.14.1740
  9. Shaw, P., Eckstrand, K., Sharp, W., Blumenthal, J., Lerch, J., Greenstein, D., . . . Rapoport, J. (2007). Attention-deficit/hyperactivity disorder is characterized by a delay in cortical maturation. Proceedings of the National Academy of Sciences, 104(49), 19649-19654. doi: http://dx.doi.org/10.1073/pnas.0707741104
  10. Epstein, J. N., Casey, B., Tonev, S. T., Davidson, M. C., Reiss, A. L., Garrett, A., . . . Shafritz, K. M. (2007). ADHD‐and medication‐related brain activation effects in concordantly affected parent–child dyads with ADHD. Journal of Child Psychology and Psychiatry, 48(9), 899-913. doi: http://dx.doi.org/10.1111/j.1469-7610.2007.01761.x
  11. National Institute for Health and Care Excellence. (2013). Attention deficit hyperactivity disorder: NICE quality standard 39. Retrieved from https://www.nice.org.uk/guidance/qs39
  12. Sparrow, E. P., & Erhardt, D. (2014). Essentials of ADHD assessment for children and adolescents. Hoboken, NJ: John Wiley & Sons, Inc.
  13. Wilens, T. E., & Spencer, T. J. (2011). Attention-Deficit/Hyperactivity Disorder. In P. Howlin, T. Charman & M. Ghaziuddin (Eds.), The SAGE handbook of developmental disorders. Thousand Oaks, CA: SAGE Publications.
  14. National Institute for Health and Care Excellence. (2016). Diagnosis and management of ADHD in children, young people and adults: NICE clinical guideline 72. Retrieved from https://www.nice.org.uk/guidance/cg72 (Original work published 2008).
  15. Bolea-Alamañac, B., Nutt, D. J., Adamou, M., Asherson, P., Bazire, S., Coghill, D., . . . for the Consensus Group. (2014). Evidence-based guidelines for the pharmacological management of attention deficit hyperactivity disorder: Update on recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 28(3), 179-203. doi: http://dx.doi.org/10.1177/0269881113519509
  16. The Royal Childrens Hospital Melbourne. (N.D.). ADHD - Stimulant medication. Retrieved 19/09/2016, from http://www.rch.org.au/kidsinfo/fact_sheets/adhd_stimulant_medication/
  17. Connor, D. F. (2014). Stimulant and nonstimulant medications for childhood ADHD. In R. Barkley (Ed.), Attention-Defcicit Hyperactivity Disorder: A handbook for diagnosis and treatment (4th ed., pp. 666-685). New York, NY: The Guilford Press.
  18. Chacko, A., Allan, C., Ulderman, J., Cornwell, M., Anderson, L., & Chimiklis, A. (2014). Training parents of youth with ADHD. In R.  Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment (4th ed., pp. 513-536). New York, NY: The Guilford Press.
  19. Mikami, A. Y. (2014). Social skills training for youth with ADHD. In R. Barkley (Ed.), Attention-Deficit Hyperactivity Disorder: A handbook for diagnosis and treatment (4th ed., pp. 569-595). New York, NY: The Guilford Press.

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