Attention Deficit Hyperactivity Disorder (ADHD)

by Claire Laurent

You are probably at your wit's end. Your child is more than just noisy and boisterous: he's often rude and completely disorganised, losing his books and clothes, forgetting what you asked him to do just a minute ago. He is out of your control and you find it hard to understand just what's going on in his head.

image to accompany feature
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There can't be many parents who haven't wondered at sometime or other if their bouncy, defiant child is hyperactive. However, hyperactive children are more than just a handful: they have a recognised disorder that affects behaviour, learning and communication.

Some, like 11-year-old Sean become so violent and angry that they are excluded from mainstream school and attend a school for children with emotional and behavioural difficulties. Sean's mother says that Sean was violent from the moment he could walk, biting and kicking others and in particular his younger sister. Sean says: 'It's like another person coming into my body and controlling me and I can't stop.' For more on 'emotional and behavioural difficulties'.

what is it?

The term hyperactive has been around since the 1900s. In Europe it is called hyperkinetic disorder, but it is most commonly known as Attention Deficit Hyperactivity Disorder or ADHD, although it's still sometimes referred to by its old name of Attention Deficit Disorder (ADD). It's thought to affect about 1% of all children in this country and about 3-4% of school age children in the United States, where the criteria for diagnosis is broader than in the UK.

Children with ADHD have three core symptoms:

Overactive behaviour/marked restlessness – excessive running about or climbing, always on the go, unable to sit still and fidgeting
Poor concentration/inattentive behaviour – seeming not to listen, difficulty in understanding instructions or completing tasks
Impulsive behaviour – blurting out the first thing that occurs to them, interrupting or intruding on others' conversations and games, talking constantly.

Children with ADHD may find learning to read difficult because they find it hard to pay attention, but around 50% of children with ADHD may also have some specific difficulty with learning, perhaps with mathematics, reading or spelling. Socially, they often have problems making friends because of the way they disrupt games, which can have a devastating effect on their self-esteem. However, it is just as likely that they don't realise how their behaviour affects other people.

Children from all cultural and social groups may be diagnosed with ADHD. Five times as many boys as girls are diagnosed with the condition and this may be because boys are more likely to express themselves through boisterous, disruptive activity than girls.

diagnosis

For a diagnosis of ADHD to be made, children in the UK must have all three core symptoms of marked restlessness, inattentiveness and impulsiveness, and must have had them since before the age of seven. It also should be behaviour that occurs in school and at home. In the US, children may be given a diagnosis of ADHD if they have only attention deficit or only hyperactivity/impulsivity, which may explain why more children are diagnosed there.

If you are concerned about your child's behaviour, discuss it with your GP and your child's teacher. Ask your GP for a referral to a paediatrician, child psychiatrist or an educational psychologist to be thoroughly assessed. For more information on 'psychiatrist' and 'educational psychologist'.

'There is no doubt we are diagnosing ADHD more, says consultant child and adolescent psychiatrist, Quentin Spender. 'This is partly cultural. Symptoms that in the past would have been regarded as normal childhood behaviour tend to be regarded as a problem now.'

While it's vital to diagnose ADHD before overactive behaviour becomes problematic and antisocial, it's also important not to diagnose it too early. 'If you try and diagnose ADHD too young, you are going to include children who don't have it severely enough to justify medication or you might miss other problems that you need to look at first, says Dr Spender. 'The risk is, if you wait too long, secondary problems develop, such as being labelled as the disruptive child and having a negative view from teachers and other pupils.'

what causes ADHD?

in the genes

It's thought that genetic factors play a significant role in ADHD. And the parents or grandparents of a child diagnosed with ADHD may well recognise themselves in their ADHD child. However, no single gene has been identified as causing ADHD and it's more likely that several genes are involved.

in the environment

There is no evidence that the way parents behave actually causes ADHD. Certain risk factors such as heavy smoking by the mother in pregnancy, or minor degrees of brain damage at birth as well as prematurity, have been identified as making ADHD more likely in the child.

In some children the symptoms of ADHD can be improved by excluding certain foods from their diet, such as additives, preservatives and a variety of other foods such as chocolate and wheat. In other children it's possible that dietary supplementation may help, for instance with essential fish oils, but as yet evidence on this is incomplete.

In addition, everyday life in the Western World is hectic, which doesn't help a child who already has poor attention span. 'We are all trying to do too much, it's hardly surprising there's a problem in maintaining uninterrupted concentration,' says Dr Spender. 'Parents have less time and there's a lack of space where children can go out and play. Parents don't let their children out and when they're in the house they're rattling around and not getting exercise.'

treatment

Managing ADHD tends to be a two-pronged process involving drug treatment and behaviour management. Drug treatment can often control ADHD symptoms and give a child the chance to mix well and do well at school. However, parents are naturally concerned about their child being on long-term medication, especially for something that appears to be about behaviour rather than illness.

Parents can learn to manage their child's behaviour through specific techniques such as positive attention, labelled praise, clear commands and breaking up tasks into small achievable steps. For more advice, see what can parents do? below. 'The problem with behaviour management is that it's very time consuming, especially for parents with an ADHD child,' says Dr Spender. 'In my clinical experience these techniques work better with children who are already on medication. Recent research from the States has suggested that the combination is more effective than either alone.'

The drug most commonly used to treat ADHD is Ritalin or methylphenidate. It is a stimulant drug, which in children with ADHD works on the areas of their brain that control focused attention and activity. It is believed to work by increasing the neurotransmitter chemicals dopamine and noradrenaline in certain parts of the brain. It doesn't cure ADHD but has been shown to be successful in 70-90% of children with ADHD. It produces sufficient calm for the child to succeed in tasks and improve their behaviour. Children need to be seen at regular intervals by a specialist to check for any side effects.

The most common side effects are loss of appetite and difficulty in sleeping. 'Quite often children can't eat their lunch because they have had Ritalin – but they make up for it in the evening,' says Dr Spender. 'Ritalin not only reduces appetite but also increases metabolic rate too, so although all children get taller, some have little if any weight gain. There is pretty strong evidence that it doesn't affect long-term growth.'

Ritalin doesn't work for all children with ADHD and will not work for those who have been misdiagnosed and perhaps have another condition such as a specific learning difficulty or intellectual disability. Therefore, a thorough assessment and diagnosis first is important. If successful, children tend to take it for several years until they and their parents feel they can manage their everyday behaviour more easily.

If ADHD is diagnosed late as it was for Sean, the problems with behaviour may be too extreme to be handled at home and in mainstream school, and the answer may be a school for children with emotional and behavioural difficulties. Here, once given the opportunity and close support to tackle their own behaviour, many ADHD children make rapid progress and may return to mainstream school. For more information on 'emotional and behavioural difficulties'.

what can parents do?

Living with a child with ADHD is difficult and exhausting and is not due to being a bad parent. However, there are specific ways of talking, playing and working with your child that may help you cope. The following techniques from the Mental Health Foundation and the Foundation for People with Learning Disabilities, can be used to good effect and may be worth passing on to anyone who looks after your child. For further information, see help and info below.

Make eye contact with your child before trying to talk to him. Children with ADHD take no notice if called from another room.
Keep instructions simple: children with ADHD have short-term memories and will forget long-winded requests.
Give specific praise for good behaviour – eg, 'Well done for hanging up you coat.' Indirect praise within earshot is good for self-esteem: 'John was a great help clearing up today.'
Keep calm. If you get angry or upset your child will copy your behaviour.
Distract your child from difficult behaviour by commenting on something else.
Use a 'quiet time' method to deal with tantrums – a special place your child can go to until he calms down.
Help with routines. Your child will need lists and charts for everything. It may help to colour-code books to subjects – for example, everything green is to do with geography. Keep a timetable pinned up and get your child to check it as he packs his schoolbag.
Give clear advance warnings when something is about to finish or change. Use buzzers or alarm clocks.
Give only two choices and avoid the option of saying 'no', for example, 'are you going to put your coat on now or when we're outside?'
Play with your child. Let him choose the game and give him your full attention for a short time. It's worth doing this for 10 minutes each day.

(April 2002, resources updated June 2005)

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