ADHD

Attention Deficit & Hyperactivity Disorder is shortly known as ADHD. This is the Disorder that makes it difficult for a child to pay attention and control impulsive behaviours. The affected child may be restless and overactive.

Impacts of ADHD may continue through adolescence and adulthood. Hyperactivity may improve but lack of attention and poor impulse control often continue through the adolescent / adulthood.

Other Associated Disorder with ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) often occurs with other disorders. About 2 in 3 of children with ADHD referred to clinics have other disorders as well as ADHD.

The combination of ADHD with other disorders often presents extra challenges for children, parents, educators, and healthcare providers. Therefore, it is important for doctors to screen every child with ADHD for other disorders and problems. This page provides an overview of the more common conditions and concerns that can occur with ADHD. Talk with your doctor if you have concerns about your child’s symptoms. 

Behaviour or Conduct Problems

Children occasionally act angry or defiant around adults or respond aggressively when they are upset. When these behaviours persist over time, or are severe, they can become a behaviour disorder. Children with ADHD are more likely to be diagnosed with a behaviour disorder such as Oppositional Defiant Disorder or Conduct Disorder. About 1 in 4 children with ADHD have a diagnosed behaviour disorder.

Oppositional Defiant Disorder

When children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with Oppositional Defiant Disorder (ODD). ODD is one of the most common disorders occurring with ADHD. ODD usually starts before 8 years of age, but can also occur in adolescents. Children with ODD may be most likely to act oppositional or defiant around people they know well, such as family members or a regular care provider. Children with ODD show these behaviours more often than other children their age.

Examples of ODD behaviours include

  • Often losing their temper
  • Arguing with adults or refusing to comply with adults’ rules or requests
  • Often getting angry, being resentful, or wanting to hurt someone who they feel has hurt them or caused problems for them
  • Deliberately annoying others; easily becoming annoyed with others
  • Often blaming other people for their own mistakes or misbehaviour
Conduct Disorder

Conduct Disorder (CD) is diagnosed when children show a behavioural pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These behaviours often lead to breaking the law and being jailed. Having ADHD makes a child more likely to be diagnosed with CD. Children with CD are more likely to get injured, and have difficulties getting along with peers.

Examples of CD behaviours include

  • Breaking serious rules, such as running away, staying out at night when told not to, or skipping school
  • Being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals
  • Lying and stealing, or damaging other people’s property on purpose
Treatment for disruptive behaviour disorders

Starting treatment early is important. Treatment is most effective if it fits the needs of the child and family. The first step to treatment is to have a comprehensive evaluation by a mental health professional. Some of the signs of behaviour problems, such as not following rules, are also signs of ADHD, so it is important to get a careful evaluation to see if a child has both conditions. For younger children, the treatment with the strongest evidence is behavioural parent training, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child’s behaviour. For school-age children and teens, an often-used effective treatment is combination training and therapy that includes the child, the family, and the school. Sometimes medication is part of the treatment.

Many children with ADHD also have a learning disorder (LD). This is in addition to other symptoms of ADHD, such as difficulties paying attention, staying on task, or being organized, which also keep a child from doing well in school.

Having a learning disorder means that a child has a clear difficulty in one or more areas of learning, even when their intelligence is not affected. Learning disorders include

  • Dyslexia – difficulty with reading
  • Dyscalculia – difficulty with math
  • Dysgraphia – difficulty with writing

Data from the 2004-6 National Health Interview Survey suggests that almost half of children 6-17 years of age diagnosed with ADHD may also have LD2. The combination of problems caused by ADHD and LD can make it particularly hard for a child to succeed in school. Properly diagnosing each disorder is crucial, so that the child can get the right kind of help for each.

Treatment for learning disorders

Children with learning disorders often need extra help and instruction that is specialized for them. Having a learning disorder can qualify a child for special education services in school. Because children with ADHD often have difficulty in school, the first step is a careful evaluation to see if the problems are also caused by a learning disorder. Schools usually do their own testing to see if a child needs intervention. Parents, healthcare providers, and the school can work together to find the right referrals and treatment.

Anxiety and Depression

Anxiety

Many children have fears and worries. However, when a child experiences so many fears and worries that they interfere with school, home, or play activities, it is an anxiety disorder. Children with ADHD are more likely than those without to develop an anxiety disorder. Almost 1 in 5 children with ADHD have a diagnosed anxiety disorder1.

Examples of anxiety disorders include

  • Separation anxiety – being very afraid when they are away from family
  • Social anxiety – being very afraid of school and other places where they may meet people
  • General anxiety – being very worried about the future and about bad things happening to them
Depression

Occasionally being sad or feeling hopeless is a part of every child’s life. When children feel persistent sadness and hopelessness, it can cause problems. Children with ADHD are more likely than children without ADHD to develop childhood depression. Children may be more likely to feel hopeless and sad when they can’t control their ADHD symptoms and the symptoms interfere with doing well at school or getting along with family and friends. About 1 in 7 children with ADHD have a diagnosis of depression1.

Examples of behaviours often seen when children are depressed include

  • Feeling sad or hopeless a lot of the time
  • Not wanting to do things that are fun
  • Having a hard time focusing
  • Feeling worthless or useless

Children with ADHD already have a hard time focusing on things that are not very interesting to them. Depression can make it hard to focus on things that are normally fun. Changes in eating and sleeping habits can also be a sign of depression. For children with ADHD who take medication, changes in eating and sleeping can also be side-effects from the medication rather than signs of depression. Talk with your doctor if you have concerns.

Extreme depression can lead to thoughts of suicide. For youth ages 10-24 years, suicide is the leading form of death. 

Treatment for anxiety and depression

The first step to treatment is to talk with a healthcare provider to get an evaluation. Some signs of depression, like having a hard time focusing, are also signs of ADHD, so it is important to get a careful evaluation to see if a child has both conditions. A mental health professional can develop a therapy plan that works best for the child and family. Early treatment is important, and can include child therapy, family therapy, or a combination of both. The school can also be included in therapy programs. For very young children, involving parents in treatment is very important. Cognitive behavioural therapy is one form of therapy that is used to treat anxiety or depression, particularly in older children. It helps the child change negative thoughts into more positive, effective ways of thinking. Consultation with a health provider can help determine if medication should also be part of the treatment.

Difficult Peer Relationships

ADHD can make peer relationships or friendships very difficult. Having friends is important to children’s well-being and may be very important to their long-term development.

Although some children with ADHD have no trouble getting along with other children, others have difficulty in their relationships with their peers; for example, they might not have close friends, or might even be rejected by other children. Children who have difficulty making friends might also more likely have anxiety, behavioural and mood disorders, substance abuse, or delinquency as teenagers.

  • Parents of children with ADHD report that their child has almost 3 times as many peer problems as a child without ADHD.3
  • Parents report that children with ADHD are almost 10 times as likely to have difficulties that interfere with friendships.
How does ADHD interfere with peer relationships?

Exactly how ADHD contributes to social problems is not fully understood. Children who are inattentive sometimes seem shy or withdrawn to their peers. Children with symptoms of impulsivity/hyperactivity may be rejected by their peers because they are intrusive, may not wait their turn, or may act aggressively. In addition, children with ADHD are also more likely than those without ADHD to have other disorders that interfere with getting along with others.

Having ADHD does not mean a child won’t have friends.

Not everyone with ADHD has difficulty getting along with others. For those children who do have difficulty, many things can be done to help them with relationships. The earlier a child’s difficulties with peers are noticed, the more successful intervention may be. Although researchers don’t have definitive answers on what works best for children with ADHD, some things parents might consider as they help their child build and strengthen peer relationships are:

  • Pay attention to how children get along with peers. These relationships can be just as important as grades to school success.
  • Regularly talk with people who play important roles in your child’s life (such as teachers, school counselors, after-school activity leaders, healthcare providers, etc.). Keep updated on your child’s social development in community and school settings.
  • Involve your child in activities with other children. Talk with other parents, sports coaches and other involved adults about any progress or problems that may develop with your child.
  • Peer programs can be helpful, particularly for older children and teenagers. Social skills training alone has not shown to be effective, but peer programs where children practice getting along with others can help. Schools and communities often have such programs available. You may want to talk to your healthcare provider and someone at your child’s school about programs that might help.

 

Risk of Injuries

 

Children and adolescents with ADHD are likely to get hurt more often and more severely than peers without ADHD. Research indicates that children with ADHD are significantly more likely to

  • Get injured while walking or riding a bicycle
  • Have head injuries
  • Injure more than one part of their body

Causes of ADHD:

 

According to NIMH (National Institutes of Mental Health, Current research suggests ADHD may be caused by interactions between genes and environmental or non-genetic factors.

Few more factors may cause ADHD such as

è Genetical mutations

è Excessive smoking and alcohol /drug usage during pregnancy

è Exposure to high level of environmental toxins like Lead at a young Age

è Low birth weight

ADHD Types:

1.   Predominantly Inattentive Presentation:  Having symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months. It is hard for the individual to organize or finish a task, to pay attention to details, or to follow instructions or conversations. The person is easily distracted or forgets details of daily routines.

 

2.   Predominantly Hyperactive-Impulsive Presentation:  Having

symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months. The person fidgets and talks a lot. It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller children may run, jump or climb constantly. The individual feels restless and has trouble with impulsivity. Someone who is impulsive may interrupt others a lot, grab things from people, or speak at inappropriate times. It is hard for the person to wait their turn or listen to directions. A person with impulsiveness may have more accidents and injuries than others.

 

3.   Combined Presentation: Having symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months. Symptoms of the above two types are equally present in the person.

Early Signs & Symptoms:

n  Difficulty in Paying Attention

n  Being Overactive

n  Behaving without thinking

n  Overlooking and careless in doing activities

n  Couldn’t have consistent attention during conversation, reading and playing

n  Lack of listening or seems to be ignorant when someone interacts to directly

n  Not following Instructions, losing focus quickly and get easily side-tracked.

n  Difficulty in performing tasks in sequence and organised activities.

n  Lack of time management and meeting the deadlines

n  Having problem in Keeping materials and belongings in order

n  Avoiding the tasks that require sustained mental effort

n  Become easily distracted by unrelated thoughts or stimuli

n  Forget the things kept and whereabouts.

n  Fidgeting and Squirming while seated

n  Getting up and moving around when staying seated is expected.

n  Running, dashing around or climbing in appropriate situations

n  Feeling Restless and Non-Stop Talking

n  Could not engage in play or hobbies quietly

n  Constantly on the move

n  Couldn’t wait for a turn in conversation, play and activities

n  Interrupting or Intruding on others.

 

 

Don’t Panic..!  The signs and symptoms mentioned above, doesn’t mean necessarily that your child is affected by ADHD. Even many other problems like anxiety, depression and few types of learning disabilities may have similar symptoms. 

Diagnosis:

If you are concerned about whether your child might have ADHD, the first step is to talk with a medical practitioner to find out if the symptoms fit the diagnosis. The diagnosis can be made by a mental health professional, like a psychiatrist or clinical psychologist, primary care provider, or paediatrician. Generally, ADHD being diagnosed in two methods.

1.    Conducting medical exam, including hearing and vision tests, to rule out other problems with symptoms like ADHD.

2.    Assessment through the checklist for rating ADHD symptoms and taking a history of the child from parents, teachers, and sometimes, the child.

 

Deciding if a child has ADHD is a several-step process. This page gives you an overview of how ADHD is diagnosed. There is no single test to diagnose ADHD, and many other problems, like sleep disorders, anxiety, depression, and certain types of learning disabilities, can have similar symptoms.

If you are concerned about whether a child might have ADHD, the first step is to talk with a healthcare professional to find out if the symptoms fit the diagnosis. The diagnosis can be made by a psychologist or psychiatrist or by a paediatrician.

The health professional should also determine whether the child has another condition that can either explain the symptoms better, or that occurs at the same time as ADHD. Read more about other concerns and conditions.

 

How is ADHD diagnosed?

Healthcare professionals use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth edition (DSM-5)1, to help diagnose ADHD. This diagnostic standard helps ensure that people are appropriately diagnosed and treated for ADHD. Using the same standard across communities can also help determine how many children have ADHD, and how public health is impacted by this condition.

DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development:

Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

n  Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.

n  Often has trouble holding attention on tasks or play activities.

n  Often does not seem to listen when spoken to directly.

n  Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).

n  Often has trouble organizing tasks and activities.

n  Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).

n  Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

n  Is often easily distracted

n  Is often forgetful in daily activities.

Hyperactivity and Impulsivity:  Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:

n  Often fidgets with or taps hands or feet, or squirms in seat.

n  Often leaves seat in situations when remaining seated is expected.

n  Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).

n  Often unable to play or take part in leisure activities quietly.

n  Is often “on the go” acting as if “driven by a motor”.

n  Often talks excessively.

n  Often blurts out an answer before a question has been completed.

n  Often has trouble waiting his/her turn.

n  Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:
  • Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
  • Several symptoms are present in two or more setting, (such as at home, school or work; with friends or relatives; in other activities).
  • There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
  • The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during schizophrenia or another psychotic disorder.

 

Diagnosing  ADHD in Adults

ADHD often lasts into adulthood. To diagnose ADHD in adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children. Symptoms might look different at older ages. For example, in adults, hyperactivity may appear as extreme restlessness or wearing others out with their activity.

ADHD Treatment:

ADHD is currently not curable. But the appropriate treatments may support reduction of symptoms and improve functioning. Currently available treatments are medication, training and therapy.

 

Medication:

Researchers found that medications reduce hyperactivity and impulsivity in many peoples. It brings improvement in their focus in learn and work.

There are three different types of ADHD Medications.

·         Stimulants

·         Non-Stimulants

·         Antidepressants

 

Stimulants: methylphenidate and amphetamine are believed effective as it increases the brain chemical dopamine, which plays essential roles in thinking and attention.

Non-Stimulants: In case a person had unlikely side effects for stimulants or it is non effective in a person, doctors may prescribe non-stimulant medications. Sometimes Non- Stimulants can be given in combination with a stimulant to increase effectiveness.

Non-Stimulants may take longer time to start working than stimulants, but can also improve focus, attention, and impulsivity in a person with ADHD. Atomoxetine, Clonidine and Guanfacine are the examples for Non-Stimulant medications.

Antidepressants:  These medications are used to treat adults with ADHD. Older depressants namely tricyclics are used like stimulants that affect the brain chemicals norepinephrine and dopamine.

All these medications are with potential benefits and side effects. Sometimes, different medications or dosages must be tried before finding the one that works for a person. It is highly recommended that  anyone taking medications must be closely administered by their prescribing doctor.

 

You may need to connect with your doctor immediately in case you are worried that it might be doing more harm than good. Your doctor may be able to adjust the dosage or change the prescription appropriately that may work better for your child.

 

Disclaimer: Please note that they are presented just for your information. Only trained health care providers can diagnose or treat ADHD.

Therapy:

Researches aren’t in favour that therapies are effective in treating ADHD symptoms. However, adding therapy to an ADHD treatment plan may help patients and families better cope with daily challenges.

For Children and Teens: Parents and teachers can help ADHD children to stay organized and follow directions with tools.

      Keeping a routine and a schedule

      Organizing everyday items

      Using homework and notebook organizers

      Giving praise or rewards when rules are followed.

For Adults: A therapist can help an adult with ADHD learn how to organize his or her life with tools such as keeping routines and breaking down large tasks into more manageable, smaller tasks.

 

Education and Training

Children and adults with ADHD need guidance and understanding from their parents, families, and teachers to reach their full potential and to succeed. Special Educators can educate the parents of a child with ADHD about the condition and how it affects a family. They can also help the child and his or her parents develop new skills, attitudes, and ways of relating to each other. Examples include:

·         Parenting skills training teaches parents the skills they need to encourage and reward positive behaviours in their children.

 

·         Stress management techniques can benefit parents of children with ADHD by increasing their ability to deal with frustration so that they can respond calmly to their child’s behaviour.

 

·         Support groups can help parents and families connect with others who have similar problems and concerns.

Adding behavioural therapy, counselling, and practical support can help people with ADHD and their families to better cope with everyday problems.

 

Behaviour Therapy, Including Training for Parents

What is behaviour therapy?

Research shows that behaviour therapy is an important part of treatment for children with ADHD. ADHD affects not only a child’s ability to pay attention or sit still at school, it also affects relationships with family and other children.  Children with ADHD often show behaviours that can be very disruptive to others. Behaviour therapy is a treatment option that can help reduce these behaviours. It is often helpful to start behaviour therapy as soon as a diagnosis is made.

The goals of behaviour therapy are to learn or strengthen positive behaviours and eliminate unwanted or problem behaviours. Behaviour therapy can include behaviour therapy training for parents, behaviour therapy with children, or a combination. Teachers can also use behaviour therapy to help reduce problem behaviours in the classroom.

  • In parent training in behaviour therapy, parents learn new skills or strengthen their existing skills to teach and guide their children and to manage their behaviour. Parent training in behaviour therapy has been shown to strengthen the relationship between the parent and child, and to decrease children’s negative or problem behaviours. Parent training in behaviour therapy is also known as behaviour management training for parents, parent behaviour therapy, behavioural parent training, or just parent training.
  • In behaviour therapy with children, the therapist works with the child to learn new behaviours to replace behaviours that don’t work or cause problems. The therapist may also help the child learn to express feelings in ways that do not create problems for the child or other people.

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Behaviour therapy for young children: Training for parents

The 2011 clinical practice guidelines from the American Academy of Pediatricsexternal icon (AAP) recommend that doctors prescribe behaviour therapy as the first line of treatment for preschool-aged children (4–5 years of age) with ADHD.  Parent training in behaviour therapy has the most evidence of being effective, but teachers and early childhood caregivers can use behaviour therapy in the classroom as well.

Why should parents try behaviour therapy first, before medication?

Behaviour therapy is an important first step because:

  • Behaviour therapy gives parents the skills and strategies to help their child.
  • Behaviour therapy has been shown to work as well as medication for ADHD in young children.
  • Young children have more side effects from ADHD medications than older children.
  • The long-term effects of ADHD medications on young children have not been well-studied.

The Agency for Health Care Research and Quality (AHRQ)3 conducted a review in 2010 of all existing studies on treatment options for children younger than 6 years of age. The review found enough evidence to recommend parent training in behaviour therapy as a good treatment option for children under 6 with ADHD symptoms and for disruptive behaviour, in general.

The review also identified four programs for parents of young children with ADHD that reduced symptoms and problem behaviours related to ADHD:

More recently, another intervention, Helping the Non-Compliant Childexternal icon, was shown to be effective for young children with ADHD1.  Other programs that help parents strengthen parent-child relationships and manage negative behaviour with positive discipline may also be effective.

 

Behaviour therapy for school-age children and adolescents

For children over the age of 6, behaviour therapy is an important part of treatment. The AAP recommends behaviour therapy together with medication. The type of therapy that is effective for young children, parent training in behaviour therapy, may also be effective for children with disruptive behaviour through age 12.4

Research evidence points to the effectiveness of several types of behaviour therapies for older children:

  • Parent training in behaviour therapy
  • Classroom behaviour management
  • Peer interventions that focus on behaviour
  • Organizational skills training
  • Combinations of behaviour treatments

Read about effective therapies here

Parent Education and Support

CDC funds the National Resource Center on ADHD (NRC), a program of Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD) The NRC provides resources, information, and advice for parents on how to help their child.  

Tips for Parents

Following are examples that might help with your child’s behaviour:

  • Create a routine. Try to follow the same schedule every day, from wake-up time to bedtime.
  • Get organizedexternal icon. Encourage your child to put schoolbags, clothing, and toys in the same place every day so your child will be less likely to lose them.
  • Manage distractions. Turn off the TV, limit noise, and provide a clean workspace when your child is doing homework. Some children with ADHD learn well if they are moving, or listening to background music. Watch your child and see what works.
  • Limit choices. Offer choices between a few things so that your child doesn’t get overwhelmed and overstimulated. For example, offer choices between a few options, such as this outfit or that one, this meal or that one, or this toy or that one.
  • Be clear and specific when you talk with your child. Let your child know you are listening by describing what you heard them say. Use clear, brief directions when they need to do something.
  • Help your child plan. Break down complicated tasks into simpler, shorter steps. For long tasks, starting early and taking breaks may help limit stress.
  • Use goals and praise or other rewards. Use a chart to list goals and track positive behaviours, then let your child know they have done well by telling your child or rewarding efforts in other ways. Be sure the goals are realistic—baby steps are important!
  • Discipline effectively. Instead of yelling or spanking, use timeouts or removal of privileges as consequences for inappropriate behaviour.
  • Create positive opportunities.   Children with ADHD may find certain situations stressful. Finding out and encouraging what your child does well — whether it’s school, sports, art, music, or play — can help create positive experiences.
  • Provide a healthy lifestyle. Nutritious food, lots of physical activity, and sufficient sleep are important; they can help keep ADHD symptoms from getting worse.

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