Clinics and Departments
What is ADHD?
Attention-Deficit/Hyperactivity Disorder (ADHD)
Most people recall a time when they had difficulty concentrating, focusing or listening. Most of us remember daydreaming in various situations, then “catching ourselves” and reminding ourselves to pay attention. These behaviors are part of normal human experience. However, some children, adolescents and adults struggle with persistent and pervasive attention problems. Over the years this difficulty has had a variety of different names and descriptions. Today it is called Attention-Deficit/Hyperactivity Disorder (ADHD).
ADHD is a diagnosis established by the American Psychiatric Association. It is a disorder in which an individual has significant difficulty paying attention. The person has a short attention span, is distractible, impulsive, and possibly engages in overactive behavior.
The differences in a person’s developmental stages from early childhood to adulthood are easy to see. For example, a six-year-old child’s ability to sit still, pay attention, and wait his turn is very different from that of a 12-year-old.
This developmental continuum must be carefully considered when looking at the possibility of an ADHD. To be diagnosed with ADHD, an individual’s behavioral characteristics must appear to be very different from those at his developmental stage. The behavioral symptoms must be excessive, pervasive, and must have an adverse effect on the individual’s ability to function in various settings.
Approximately three to five percent of all children are affected by symptoms of ADHD. That may be close to two million US children alone. ADHD affects two to three times as many boys as girls. Recent studies indicate that symptoms of ADHD usually persist into adolescence and adulthood. Current statistics suggest that two to four percent of adults are affected by symptoms of ADHD.
A specific cause of ADHD is not known at this time, although the disorder is considered to be a neurologically based condition. The development of sophisticated technology, such as Positron Emission Topography (PET Scans), has made it possible to discern tiny differences in brain structure and functioning when comparing an individual with ADHD to an individual without the disorder. In addition, there has been evidence of the involvement of a genetic link, as the symptoms tend to run in families. Children who have ADHD usually have at least one close relative who also has it. And at least one-third of all fathers who had ADHD in their youth have children who have the disorder. In addition, the majority of identical twins share the trait.
Understanding the “cause” of ADHD is complicated by its symptoms, which also are often characteristic of other disorders (such as anxiety or depression), other environmental factors, family concerns, and learning problems. Due to this complexity, it is important that the diagnosis of ADHD is made from a thorough assessment by a multi-disciplinary team of professionals. The assessment should include several hours of interview, observations, formal testing, and interpretive sessions. It is inadequate and ill advised to attempt to diagnose ADHD in one 15-minute office call.
Historically, ADHD was first described medically around the turn of the century. The current description of ADHD is available in the Diagnostic and Statistical Manual, 4th Edition. The term, Attention-Deficit/Hyperactivity Disorder, is the general term used for the diagnosis. There are three subtypes under the overall term of ADHD (Predominantly Inattentive Type, Predominantly Hyperactive-Impulsive Type, and Combined Type).
The following section is excerpted from the Diagnostic and Statistical Manual, 4th Edition.
o Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
o Often has difficulty sustaining attention in tasks or play activities
o Often does not seem to listen when spoken to directly
o 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)
o Often has difficulty organizing tasks and activities
o Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
o Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)
o Is often easily distracted by extraneous stimuli
o Is often forgetful in daily activities
o Often fidgets with hands or feet or squirms in seat
o Often leaves seat in classroom or in other situations in which remaining seated is expected
o Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents and adults, may be limited to subjective feelings of restlessness)
o Often has difficulty playing or engaging in leisure activities quietly
o Is often “on the go” or often acts as if “driven by a motor”
o Often talks excessively
o Often blurts out answers before questions have been completed
o Often has difficulty awaiting turn
o Often interrupts or intrudes on others (e.g. butt into conversations or games)
A. Either (1) or (2):
1. Six or more of the symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level
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, home or work).
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, Dissociative Disorder, or a Personality Disorder).
The diagnosis of ADHD is based on the following types:
Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the past 6 months.
An additional diagnosis is as follows:
Attention-Deficit/Hyperactivity Disorder Not Otherwise Specified: This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder per se.
This is a commonly asked question by parents who are often confused by the fact that their child can “sometimes” pay attention. Parents often note that their child’s attention span is excellent when he or she is engaged in activities such as playing computer games or building with Lego’s. When their child is required to print the 10 spelling words, complete 20 math problems, or clean his room, he or she is easily distracted, and needs to be closely monitored in order to complete these tasks. This apparent inconsistency in ability to sustain attention is related to the nature of the task at hand. It has been established that people attend better when immediate feedback is provided, and when tasks include variety. Given this fact, consider again a task such as completing 20 math problems---which will not be corrected until the next day in class. The feedback is delayed until the next day, and the task is repetitious. On the other hand, tasks or activities such as computer games, hands-on materials (such as Lego’s) and video games include both immediate feedback and variety.
There is no one test (neither a physical test nor a psychological test) which, used alone, can diagnose a possible ADHD. A comprehensive assessment from a team of professionals is needed to diagnose ADHD. The multi-disciplinary team discovers different types of information. The team may consist of various combinations of the following disciplines: a psychologist, a social worker, a nurse practitioner, an educational specialist, a psychiatrist or a behavioral physician. In addition, information from teachers is gathered. The information should reflect the child’s functioning over an extended period of time. This information is then integrated with clinical observations and assessment test data.
o Other mental health disorders
Parents should meet with the assessment team for an explanation of findings and discussion of the recommendations. In many cases, it is also beneficial for a child or adolescent to meet with team members to discuss findings and recommendations.
In addition, school personnel (principals, counselors, and school psychologists) and teachers, tutors, and professionals from outside agencies should meet with a team member to discuss results, recommendations, and implications of the assessment results.
Often the first steps in developing appropriate home and school interventions for individuals diagnosed with ADHD consists of insight and awareness, for behavioral symptoms associated with ADHD are easily misunderstood, and erroneous assumptions are easily made.
Most children diagnosed with ADHD in childhood continue to demonstrate symptoms of the disorder into adulthood. The specific symptoms, however, appear quite different as the child matures and learns coping strategies. Children with symptoms of “hyperactivity” often appear to be less physically active in adolescence, although they may continue to experience “internal restlessness.” In addition, adolescents and adults develop strategies whereby they “bypass” the symptoms of ADHD. In some cases individuals learn to “channel” the negative behaviors associated with these symptoms into positive outcomes (e.g., the ADHD child becomes an innovative entrepreneur due to high energy and a unique vision).
Children and adolescents with ADHD have a variety of needs. Some children require specific accommodations in the school setting, some need support with social-emotional functioning, and others need practical support. Medication also has been beneficial to most individuals. Generally, however, optimal treatment of ADHD includes a variety of interventions, which are individualized for a particular child’s needs. In other words, one treatment option alone is not recommended. In many cases the combination of treatment options works synergistically.
Parents are eager to find ways to help their children cope with ADHD. Parents are often willing to explore every possible option, and so they consider treatments that sound quite reasonable. Nonetheless, a few success stories do not substitute for scientific research.
Parents are encouraged to carefully investigate scientific testing before adopting a treatment which may be costly, time consuming, and may hold false promise. Several types of treatments have not been scientifically shown to be effective in treating the majority of children, adolescents or adults with ADHD:
Your child has been given a diagnosis of Attention-Deficit/Hyperactivity Disorder. ADHD is a condition affecting approximately three percent of school-age children. Characteristics of ADHD may include:
1. Poorly sustained attention and vigilance: Poor persistence of effort over time; interest lost quickly; work left incomplete.
2. Impulsivity: Difficulty delaying gratification; living for the moment; acting without thinking of consequences.
3. Hyperactivity: Difficulty regulating and modulating activity level to fit changing demands of environment; physically restless.
4. Diminished rule-governed behavior: Rules known but used inconsistently to control behavior; increased need for supervision and management.
5. Variability of task performance and inconsistent memory retrieval.
Part of your child's treatment plan may include a trial of stimulant medication. When children respond well to medication they are able to maintain their focus and concentration for longer periods of time. Secondary gains from medication may include less disruptive behaviors, less impulsivity, and more positive peer interactions. However, research suggests that the most effective intervention for children with ADHD is the use of medication in conjunction with modifications in the environment. The teacher's accepting and nonjudgmental attitude is extremely important, since the child with ADHD is not able to change or control certain behaviors merely by "trying harder."
The classroom teacher plays an important role in a child's successful adjustment. The following suggestions may be helpful in planning your child's educational program.
1. Have this child sit in front of the room, away from the door, activity centers, and attractive bulletin boards.
2. Give this child the option of a "private office" or study carrel for independent work. This child may need additional monitoring and support when working in groups.
3. Provide structure, predictability, and consistency. Simplify classroom routines and transitions when possible.
4. Stand near this child when presenting information or giving directions, and monitor his/her response.
5. Model strategies for organizing time, space and materials in the classroom.
6. Allow some restlessness and provide periodic exercise breaks. This child may benefit from a larger space around his/her desk due to high activity level.
7. Do not make recess or specialist activities (physical education, art, music) contingent on classroom performance.
1. Be sure this child's attention is focused when giving instructions or directions. Cue this child to prepare to attend with a pre-determined signal.
2. Give directions slowly using simple sentences and vocabulary. When needed, ask this child to repeat them in his/her own words.
3. Provide “advance organizers” (such as vocabulary lists, outlines of main ideas, or explanations of key concepts) to be covered in class.
4. Include visual cues, manipulative materials and active student participation in each lesson.
5. Reward thoughtful, “think aloud” approaches rather than speed of responding.
6. Provide this child with opportunity to prepare for discussions. Give this child information on the content to be covered so he/she has a frame of reference.
1. Reduce visual clutter (e.g. cute pictures, etc.) on worksheets. Reduce number of problems on page. Use enlarged type and allow additional space between sentences or problems.
2. Highlight key words in directions and central features on a page. Divide work pages into sections with specific time expectations for each section.
3. Shorten assignments but stress and reinforce accuracy. Decreasing workload to fit this child's attention span will encourage work completion and a sense of closure.
4. Break long assignments into daily tasks, and structure with concrete examples. Provide a sample of the finished product.
5. Provide self-correcting materials and computer-assisted instruction for immediate feedback.
6. Modify assignments consistently in both classroom work and in homework. Sending incomplete classroom work home often proves to be counter-productive for most children. When possible, homework should be at a level where this child is able to complete it independently.
7. Provide extra copies of textbooks to be kept at home. For each class, arrange a “study buddy” for this child to call with homework questions.
8. Avoid long tests. Provide frequent short quizzes and opportunity for retest, or for discussion to demonstrate mastery. This will be especially important when test scores are not consistent with daily assignments and classroom performance.
9. Provide alternate environments with fewer distractions for test taking.
10. Allow tests to be taken in an untimed condition.
1. Provide daily practice in use of such things as desk organizers, work folders, an assignment book and a planning calendar. Daily check-ins with teachers or a counselor often ensure that assignments have been recorded accurately and thoroughly.
2. Provide study guides for upcoming tests, or provide practice tests prior to unit tests.
3. Develop a system for keeping track of completed/uncompleted work. Provide detailed checklists to allow self-monitoring of satisfactory completion.
1. Include social skills and problem-solving training as part of the regular classroom curriculum.
2. Define and reinforce specific positive behaviors and productivity. Conduct a reinforcement survey with this child to identify reinforcement preferences.
3. Encourage this child to develop and use self-monitoring procedures (e.g. reminding his/her to check work for accuracy once it is completed).
4. Develop contingency contracts for specific behavioral goals with specific reinforcement included (e.g. this child will earn 20 extra minutes of computer time when 4 out of 5 math assignments are turned in with 90 percent accuracy).
5. Work closely with parents to maintain consistency regarding behavioral goals, homework expectations and reward systems.
Many adolescents with ADHD continue to need monitoring of homework and help with organization. Building a support system within the school setting is an important step toward independence. A coach or a mentor can provide direct teaching of study skills and organizational strategies and on-going supervision of their use. A counselor can serve as an advocate with other teachers and provide positive support in resolving conflict relationships.
These strategies and direct suggestions may help your adolescent take more responsibility for his/her own learning:
CHAAD (support group for Children and Adults with Attention-Deficit/Hyperactivity Disorder) (800) 233-4050 or http://www.chadd.org
NIMH (National Institute of Mental Health) http://www.nimh.nih.gov
ADD Warehouse (Books, videos, materials for individuals diagnosed with ADHD) (800) 233-9273
Attention! The Magazine for Families and Adults with Attention-Deficit/Hyperactivity Disorder For a subscription call (301) 306-7070.
Barkley, Russell. Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. Guilford Press 1995.
Hallowell, Edward and Ratey, John. Driven to Distraction.Simon and Schuster, 1994.