ROBERT M. NEWELL, PH.D.
FORENSIC AND CLINICAL PSYCHOLOGY
Specializing in Behavioral Healthcare for Children &
Adolescents, Families, Couples, and Adults.
WHAT EVERY PARENT NEEDS TO KNOW ABOUT
ADHD IN CHILDREN AND ADOLESCENTS
This information is provided to you to help you learn more about ADHD and how it may affect your child and family. Please CONTACT ME with any questions you may have after reviewing this information, or if you would like to schedule an appointment to have your son or daughter evaluated for ADHD.
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Attention Deficit Hyperactivity Disorder (ADHD) is the most commonly diagnosed mental disorder of childhood. It is estimated to affect three to five percent of school-age children, and it occurs three times more often in boys than in girls. On average, about one child in every classroom in the United States needs help for this disorder. ADHD is under-recognized, with less than a half of the affected children and adolescents receiving an accurate diagnoses. Of the children and adolescents who are correctly diagnosed, only a few receive appropriate treatment. Left untreated, ADHD may have a significant negative impact on the wellbeing of a child and his/her family, and may result in problems that continue into adulthood.
ADHD is a chronic neurobiological disorder that interferes with a child’s ability to regulate his/her activity level (hyperactivity), inhibit behavior (impulsivity), and/or maintain attention on certain tasks (inattention). In order to meet the diagnostic criteria for ADHD, the behaviors must be excessive (i.e., they must occur at a level that exceeds what is considered normal based on the child’s age and developmental status), long-term (i.e., they are not just a reaction to a recent stressful event), and pervasive (i.e., they must occur in multiple settings and situations). In addition, the behaviors must appear before age seven, must persist for at least six months, and must cause an impairment in a child or teen’s ability to function in at least two areas of his/her life, such as school and home.
► CLICK HERE to read about how Dr. Phil got it wrong about ADHD in his September 28, 2004 TV show entitled “Parenting with Pills”.
The primary symptoms of ADHD are hyperactivity, impulsivity, and inattention. These also are deferred to as the “core symptoms” of ADHD. A child or adolescent may display symptoms that mostly are hyperactive, mostly inattentive, or a combination of both. All children are restless at times, act without thinking, and daydream when they should be concentrating on something else. However, when a child or adolescent displays a level of hyperactivity, impulsivity, distractibility, and/or poor concentration that is beyond what is expected for his/her age and that affect his/her academic performance and family and social relationships, their problems may be due to ADHD.
Because the symptoms vary so much across settings, ADHD is not easy to diagnose. This is especially true when inattentiveness is the primary symptom. Different symptoms may appear in different settings, depending on the demands the situation may pose for the child's self-control. A child who "can't sit still" or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a "discipline problem," while the child who is passive or sluggish may be viewed as merely unmotivated. Yet both may have different types of ADHD.
· Hyperactivity. Children who are hyperactive always seem to be in constant motion or always “on the go.” They may display problems sitting still, may roam around the room, tap a pencil noisily, squirm and fidget in their seat, and may talk incessantly. Adolescents who are hyperactive may not display a similar level of behavioral symptoms compared to younger children, but they report feeling more restless internally compared to other teenagers their age.
· Impulsivity. Children who are overly impulsive have great difficulty thinking before they act, and seem to have very little ability restrain their immediate reactions. They may blurt out answers to questions or make inappropriate comments, or run into the street without looking, or have difficulty waiting for their turn in games. Adolescents who are impulsive may choose to do things that offer an immediate reward, as opposed to engaging in activities that require a sustained effort but have offer delayed rewards. They may also tend to engage in high risk behaviors.
· Inattention. Children and adolescents who are inattentive have a difficult time maintaining their focus on one thing, and may get bored with a task after only a few minutes. The problem is not that they are easily distracted, but instead that they have difficulty maintaining a deliberate and sustained focus on a task that does not hold their interest. If they are doing something they really enjoy (like playing video games), they have no trouble paying attention. But they have tremendous difficulty maintaining a sufficient level of deliberate and sustained attention that is required to organize and complete a task or for learning something new. Homework is particularly hard for these children. They forget to write down assignments or leave it at school, or they forget to bring home book or other important materials that are necessary to complete the homework. Their homework often is completed with careless errors and incomplete answers. The process of completing homework is very frustrating to both children and parents, and takes an inordinate amount of time and energy compared to children who do not have ADHD. Children and adolescents with the Inattention features of ADHD seldom are impulsive or hyperactive. Their problems are in paying attention and sustaining their focus. These children often appear to be daydreaming, "spacey," or “checked out;” or are easily confused, slow moving, and lethargic. They may have difficulty processing information as quickly and accurately as other children. When the teacher gives oral or even written instructions, this child has a hard time understanding what he or she is supposed to do and makes frequent mistakes. Yet the child may sit quietly, unobtrusively, and even appear to be working but not fully attending to or understanding the task and the instructions. These children and adolescents don't show significant problems with impulsivity and over activity in the classroom, on the school ground, or at home. They may get along better with other children than the more impulsive and hyperactive types of ADHD, and they may not have the same sorts of social problems so common with the combined type of ADHD. As a result, children and adolescents with the inattentive features of ADHD often are overlooked. However, these children need help just as much as children with other types of ADHD who cause more obvious problems in the classroom.
► CLICK HERE to review the specific criteria that doctors use to make the diagnosis of ADHD.
The diagnosis of ADHD should only be made by a qualified individual with appropriate training and experience such as a child psychologist, child psychiatrist, or a pediatrician. The diagnosis of ADHD is a clinical diagnosis made on the basis of the child’s past history and current observable behaviors in multiple settings with input from parents and teachers. Unlike other disorders in childhood such as diabetes, there is no lab test that can confirm the presence of ADHD. The diagnosis is made based on clinical presentation, and the key elements of the diagnostic process include a thorough history covering the symptoms, diagnosis, possible coexisting conditions, as well as medical, developmental, school, psychosocial and family histories. It is helpful to determine what precipitated the request for evaluation and what approaches have been used in the past.
Not every child who is overly hyperactive, inattentive, or impulsive has ADHD. The diagnosis requires that such behavior be demonstrated to a degree that is inappropriate for the child or teen’s age, that the behaviors must have been evident before age seven, that the behaviors have continued for at least 6 months, and must impair the child or teen’s functioning in at least two areas such as school, at home, or in the community or other social settings. Based on these criteria and child or teen who displays some symptoms but whose schoolwork or friendships are not impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active on the playground but functions well elsewhere receive an ADHD diagnosis.
To assess whether a child has ADHD, several important questions must be considered:
· Are the child’s behaviors excessive, long-term, and pervasive? That is, do they occur more often than in other children the same age?
· Are the child’s behaviors an on-going problem, and not just a temporary response to a situation?
· Do the child’s behaviors occur in several settings, or do they occur only in one specific place like the playground or in the schoolroom?
The child’s behavior pattern is compared against a set of criteria and characteristics listed in the Diagnostic and Statistical Manual (DSM-IV-TR) used by psychologists and psychiatrists to make diagnoses.
Some parents see signs of inattention, hyperactivity, and impulsivity in their toddler long before the child enters school. A parent may notice that the child may lose interest in playing a game or watching a TV show, or may run around completely out of control. Because children mature at different rates and are very different in personality, temperament, and energy levels, it's useful to get an expert's opinion of whether the behavior is appropriate for the child's age. Parents can ask their child's pediatrician, or a child psychologist or psychiatrist to assess whether their toddler has an attention deficit hyperactivity disorder or is, more likely at this age, just immature or unusually exuberant.
ADHD may be suspected by a parent or caretaker or may go unnoticed until the child runs into problems at school. Given that ADHD tends to affect functioning most strongly in school, sometimes the teacher is the first to recognize that a child is hyperactive or inattentive and may point it out to the parents and/or consult with the school psychologist. Because teachers work with many children, they come to know how "average" children behave in learning situations that require attention and self-control. However, teachers sometimes fail to notice the needs of children who may be more inattentive and passive yet who are quiet and cooperative, such as those with the predominantly inattentive form of ADHD.
What Causes ADHD?
Over the past few decades, a number of theories have been developed about the cause of ADHD. At one time, it was widely held that ADHD was caused by poor diet and food allergies. However, current research shows that ADHD is a bonafide neurobiological disorder, and that it tends to run in families. Thus, ADHD has a strong genetic influence, and research studies indicate that about 25 percent of children with ADHD have a close relative who also suffers from the disorder, and at least one-third of all fathers who had ADHD as a child have children with ADHD. This compares to a rate of about five percent in the general population. Research findings on twins also provides strong evidence of a genetic link. Researchers continue to study the genetic contribution to ADHD and to identify the genes that cause a person to be susceptible to ADHD.
When a parent first learns that his or her child has ADHD, one of the first questions they may ask is "Did I somehow cause this?" There is very little compelling evidence at this time that ADHD is caused purely due to social factors such as parenting behaviors. However, this is not to say that environmental factors do not influence the severity of the symptoms, and especially the degree of impairment and suffering the child may experience. There is a substantial body of research that suggests that parenting behaviors and other environmental factors can have a substantial impact on both the primary and secondary symptoms of ADHD, but such factors do not seem to cause the disorder by themselves.
The Impact of ADHD
Although ADHD is a neurobiological disorder, some of the symptoms and consequences of ADHD are psychological and emotional. The behavioral symptoms of ADHD (e.g., inattentive, forgetful, impulsive, sometimes defiant and aggressive) arouse emotional reactions in other people, which in turn has an impact on the ADHD child. As a result, interpersonal and relationship problems occur which then impact a child’s psychological and emotional development. These are known as the “secondary symptoms” of ADHD and includes problems such as depression, low-self esteem, anxiety, and so forth. These secondary symptoms of ADHD can have an extremely devastating affect on a child that can last a lifetime.
Disorders That Can Co-Occur with ADHD
Coexisting conditions occur in most children and adolescents clinically treated for ADHD. ADHD can co-occur with other disorders such as learning disabilities (15 to 25 percent), language disorders (30 to 35 percent), conduct disorder (15 to 20 percent), oppositional defiant disorder (up to 40 percent), mood disorders (15 to 20 percent) and anxiety disorders (20 to 25 percent). Up to 60 percent of children with tic disorders also have ADHD. Impairments in memory, cognitive processing, sequencing, motor skills, social skills, modulation of emotional response and response to discipline are common. Sleep disorders are also more prevalent. There are other conditions or situations besides ADHD that can affect attention and concentration -- depression or anxiety, for instance. And some children and adults who have been traumatized (through abuse or assault, for instance) may exhibit a posttraumatic stress syndrome that can seem like ADHD at times. If you suspect that your child or teen might have ADHD, it's important to seek help from a qualified child psychologist.
· Learning Disabilities. Many children with ADHD—approximately 20 to 30 percent—also have a specific learning disability (LD). In preschool years, these disabilities include difficulty in understanding certain sounds or words and/or difficulty in expressing oneself in words. In school age children, reading or spelling disabilities, writing disorders, and arithmetic disorders may appear. A type of reading disorder, dyslexia, is quite widespread. Reading disabilities affect up to 8 percent of elementary school children.
· Oppositional Defiant Disorder. As many as one-third to one-half of all children with ADHD—mostly boys—have another condition, known as oppositional defiant disorder (ODD). These children are often defiant, stubborn, non-compliant, have outbursts of temper, or become belligerent. They argue with adults and refuse to obey.
· Conduct Disorder. About 20 to 40 percent of ADHD children may eventually develop conduct disorder (CD), a more serious pattern of antisocial behavior. These children frequently lie or steal, fight with or bully others, and are at a real risk of getting into trouble at school or with the police. They violate the basic rights of other people, are aggressive toward people and/or animals, destroy property, break into people's homes, commit thefts, carry or use weapons, or engage in vandalism. These children or adolescents are at greater risk for substance use experimentation, and later dependence and abuse. They need immediate help.
· Anxiety and Depression. Some children with ADHD often have co-occurring anxiety or depression. If the anxiety or depression is recognized and treated, the child will be better able to handle the problems that accompany ADHD. Conversely, effective treatment of ADHD can have a positive impact on anxiety as the child is better able to master academic tasks.
· Bipolar Disorder. There are no accurate statistics on how many children with ADHD also have Bipolar Disorder. Differentiating between ADHD and Bipolar Disorder in childhood can be difficult. In its classic form, Bipolar Disorder is characterized by a disturbance of mood cycling between periods of intense highs (i.e., mania) and lows (i.e., depression). But in children, Bipolar Disorder often seems to be a rather chronic dysregulation of mood with a mixture of elation, depression, and irritability. Furthermore, there are some symptoms that can be present both in ADHD and Bipolar Disorder, such as a high level of energy and a reduced need for sleep. Of the symptoms differentiating children with ADHD from those with Bipolar Disorder, elated mood and grandiosity of the bipolar child are distinguishing characteristics.
· Tourette's Syndrome. A very small proportion of children with ADHD have a neurological disorder called Tourette's syndrome. Individuals with Tourette's syndrome have various nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others may clear their throats frequently, snort, sniff, or bark out words. These behaviors can be controlled with medication. While very few children have this syndrome, many of the cases of Tourette's syndrome have associated ADHD. In such cases, both disorders often require treatment that may include medications.
Treatment for ADHD can involve a combination of medication (when necessary), psychotherapy for the child or teen to learn coping skills and organizational skills, parent training to improve parents’ ability to manage a child’s negative behaviors effectively, psychoeducation for both parents and child, and coordination with school personnel to focus on school performance. The most important aspect of effective treatment for ADHD is that it requires a “team effort” approach between providers, parents, children, and school personnel.
Attention Deficit/Hyperactivity Disorder (ADHD) is one of the most common and most studied disorders that occurs in children. Although there is no known cure, treatment for ADHD has improved in recent years. Through a combination of medications, behavioral therapy, and parent effectiveness training, the functioning of most ADHD children can be improved. The effective long-term management of ADHD requires active teamwork between clinicians, parents, and teachers to ensure the best outcomes.
DR. ROBERT M. NEWELL
Copyright © 2004-2007 Robert M. Newell, Ph.D. All rights reserved.