Attention Deficit Hyperactivity Disorder (ADHD) in School-Age Children


Image: Carnation, Lilly, Lilly, Rose by John Singer Sargent

Carnation, Lilly, Lilly, Rose by John Singer Sargent

Introduction

“You’re lazy.” “You’re stupid.” “I know you could do better in school if you just tried.” “Why can’t you calm down?” Although most children hear at least one of these questions and/or comments at one time or another, children who suffer from Attention Deficit Hyperactivity Disorder (also known as ADHD, AD/HD or ADD) hear them all the time – from parents, peers, teachers, even strangers. In the past, children with this disorder have been labeled by their parents and teachers as troublemakers or underachievers, by their peers as weird. Teenagers who have ADD often indulge in criminal behavior or drug and alcohol abuse. The medical community used to label them as brain-damaged.

Children with ADD lack some of life’s essential coping skills. They can’t pay attention, can’t sit still and have trouble fitting into the structure of their school and family. They may be forgetful, disorganized, impulsive, and hyperactive.

Roughly speaking, ADD children fall into two groups; those who are hyperactive and those who are not. The non-hyperactive child may never be diagnosed, and may just be seen as a daydreamer and a poor student. The hyperactive child usually comes to the attention of parents and teachers because of anti-social or restless behavior. What these two different personalities share is the inability to maintain attention or focus.

ADD has been, and continues to be, a disorder that is not widely understood. One reason for this is that there is no definitive test for ADD, only an evaluation of a cluster of symptoms. Another frustrating aspect of the disorder which has held back understanding is that symptoms vary widely in children, not only in number and type but in intensity. On top of this, the symptoms can vary in a certain child from day to day and hour to hour.

The history of the names attached to ADD demonstrates how difficult this disorder has been to pin down. When the symptoms first began to be noted and researched in the late 19th century, the patients studied were suffering from a brain injury or illness, and their disorder was eventually identified as Minimal Brain Damage. In the 1960s the name was changed to Minimal Brain Dysfunction, and around 1970 children were generally called Hyperactive or Hyperkinetic to reflect the most visible symptom. By 1980, the lack of attention was considered a more consistent red flag, and the name was changed to Attention Deficit Disorder. In the 1988 version of the Diagnostic and Statistical Manual of the American Psychiatric Association the name was changed to Attention-Deficit Hyperactivity Disorder (ADHD), with a separate category, Undifferentiated Attention Disorder (UAD), to reflect children who exhibited attention difficulties with no hyperactivity. Although ADHD currently seems to be the most popular label, here the disorder will be referred to as ADD, so as to include children that are not hyperactive (UAD is rarely used as a tag).

Estimates of the number of school-age children who suffer from ADD range widely. In the past it was believed that more boys than girls (80% to 20%) had ADD, due to hyperactivity being more evident in boys. Only severely affected girls were recognized and evaluated. However, as hyperactivity is now not considered an essential component of the disorder, more girls are being diagnosed, and that number will likely change.

Causes

The causes of ADD are not fully understood, and relatively little is known as far as biological aspects. In some cases there is a genetic link, often to the father or another close male relative, but in other cases there can seemingly be none. Although ADD can occur if there are complications at birth, this accounts for only a small percentage of cases. Most ADD children are not braindamaged. However, it is known that ADD occurs from birth, although symptoms may not be apparent until later.

Although many theories have been advanced to explain ADD, including those of food allergies, diet that includes too much sugar or caffeine, or side effects of medication, the most popular theory is currently that of a breakdown in the chemical messenger system in the brain. ADD sufferers are believed to lack sufficient amounts of the neurotransmitting chemical called dopamine. This theory is the basis of most treatment courses which include medication.

Symptoms

As noted, it is difficult to make a diagnosis of ADD. Not only are there several official classifications, but permutations and intensity of symptoms vary widely. Muddying the already murky waters is the fact that there are several syndromes or disorders that often occur along with ADD. Among these are tic disorders or Tourette’s Syndrome, Oppositional Defiant Disorder, Conduct Disorder and true learning disabilities. In 1969 psychologist C. Keith Connors developed the Connors Teacher Rating Scale, which listed thirty-nine behaviors and asked the teacher to rate the child accordingly using a scale from zero to three. While helpful, the scale was criticized because it was slanted toward defining a child with aggressive or hyperkinetic behavior. Over the years the scale has been modified, and currently the Connors Abbreviated Rating Scale is widely used.

Connors Abbreviated Rating Scale for ADD

  1. Excitable and impulsive
  2. Difficulty learning
  3. Restless in the “squirmy” sense
  4. Restless; always up and on the go
  5. Denies mistakes or blames others
  6. Fails to finish things
  7. Childish or immature
  8. Distractible or has an attention span problem
  9. Moods change quickly and drastically
  10. Easily frustrated

Each characteristic is assigned 3 points. A score of 15 or higher is cause for further evaluation. Symptoms of ADD are often not picked up on until the child enters school. This is usually the first time that a child has had to fit into a group and learn and demonstrate knowledge of specific information.

As there is no typical ADD child, the deficit of attention is what teachers should look for, as that is the one consistent symptom. While these children may be able to concentrate on things they like, such as sports or television, in school not only are they faced with the necessity to process information, which is difficult for them, but many of their other traits also conspire to interfere with their learning.

Image: Boys in the Pasture by Winslow Homer

Boys in the Pasture by Winslow Homer

The major trait is their distractability. All stimuli affect these children equally. A lawnmower outside the classroom or a dropped pencil inside will capture and hold their attention as much as the teacher’s voice. They cannot select which is most important, so fixing their attention on anything, especially in the often disruptive atmosphere of school, is next to impossible. Some children liken this difficulty to switching channels on a TV and being unable to stay on one channel.

Another trait, their impulsivity, can lead to both academic and peer problems. ADD children will often start a test without even reading the directions. They will call out an answer in class without raising their hand. They very often have few or no friends because of their tendency to speak or act without thinking or considering the social implications of their words or actions. One case of an eight-year-old boy painfully illustrates this. Wanting to be popular, he invited all the boys in his neighborhood to a party. Unfortunately, as he gave out the invitations, he hugged all the boys, not considering that this impulse was not socially acceptable. (2) Due to their impulsivity, ADD children often won’t wait their turn or follow rules in games, and this can quickly alienate other children.

Lack of organizational skills is another ADD trait which interferes with the child performing well in school. They often struggle over homework for hours, only to forget to bring it to school. They also continually forget to bring books back and forth to school or write homework assignments down. They have difficulty keeping track of time or of their possessions.

Parents and teachers must be aware that one of the most puzzling aspects of ADD is its inconsistency. A child that does fine one day, both academically and behaviorally, can fail a test and be disruptive the next. Teachers and parents often castigate the child, or may be plain frustrated, as they are aware that the child can do well. In the past it was assumed that the child was just not tryincr on his schoolwork or “acting up” as far as his behavior.

Diagnosis

Diagnosis is a complex process. Once it has been established that a child fits the criteria for ADD, a complete physical is usually given to rule out the possibility of a medical cause for the symptoms. The behavioral history of the child and the medical history of both the child and the family will be examined to provide the doctor with clues and confirmation of the diagnosis. The process should also include some psychological and educational tests and observation by a psychologist.

Treatment

Treatment is necessarily multi-modal, with several approaches being combined to form an effective program: medication, therapy, parent training in behavior management and a modified school program.

Medication is effective in about 80% of children to varying degrees. Traditionally, the most popular of these medications is Ritalin, a stimulant. The medication can have a transforming effect on some children, allowing them to concentrate and calm down. However, the effectiveness wears off after four hours, and the child must be carefully monitored to determine how often per day he should be dosed. Two other stimulants which are not as often prescribed are Dexadrine and Cylert. In some cases anti-depressants are prescribed, but these are much less popular than the stimulants, partly due to numerous side-effects, and are only used in rare cases, such as children who have tic disorders.

The second prong of a multi-modal treatment program is therapy, which is usually necessary on a short-term basis at the least. Most ADD children have low self-esteem. If it has not developed due to their own frustration and anger with themselves, their self-esteem has beaten down by constantly being criticized and blamed by parents, teachers, parents of friends, and even strangers who may see them act up in a supermarket. The family is usually included in some part of the therapy as the presence of ADD in a family is at the least disruptive. At the worst it can lead to divorce or psychic damage to the family members, especially siblings, who are often neglected while attention is paid to the “difficult” child. Parents often have to “unlearn” techniques they have used to cope with their ADD child and be made aware of the often negative comments and attitudes that they have developed toward the child, and work toward re-developing these in a more positive, constructive manner.

Parents must play a large role in managing the ADD child, and not leave everything up to the doctor(s) and the school. Not only do they need to reinforce and support what the teacher is doing at school, but they need to learn management techniques for home. Some parents utilize a point system, with points being given for good behavior and effort on schoolwork. These points can than be traded for privileges which have been awarded a certain number of points in advance.

Parents must understand that ADD children cannot be governed by the same set of rules as other children. If a child needs a five minute break from doing homework, the parent needs to be able to recognize and respect that. If a child keeps forgetting schoolbooks, the parent can request an extra set of schoolbooks for home, instead of chastising the child for forgetting them.

As ADD children need a calm, predictable atmosphere, the family may have to make modifications in their homelife to that end. Large gatherings or parties at home may have to be scrapped, or arrangements made for the child to be elsewhere at the time. An ADD child may need to be prepared in advance for such big events as vacation travel, the first day of school, or a guest coming to stay to avoid overexcitement. Any disruption of the normal routine can upset an ADD child.

The child’s social life should not be neglected, as this is an essential part of self-esteem and social development skills. In Maybe You Know My Kid, Mary Cahill Fowler, herself the parent of an ADHD child, suggests that the parents “target” a friend for their child. She says, “…make the target child someone with whom the ADHD child has already experienced some positive connection. For instance, if the ADHD child came home from school one day and said, ‘Johnny was nice to me,’ Johnny could become a good candidate to be the target child.” (3) The hope is that, with carefully supervised activities designed by the parent of the ADD child which will prevent their child from acting up, a friendship can be encouraged and social bridges can be built.

In school, teachers must be prepared to make changes and accommodations for an ADD child, and in many cases plan a special program. There are many small changes that can help, such as moving the child to the front of the classroom or next to an academically and behaviorally strong student. Teachers can develop a signal (such as tapping a pencil on the child’s desk in passing) when they sense the child’s mind is wandering.

A teacher should also take the time to make sure the child has read and understood directions before beginning a test or assignment, and not just plunged right in as many ADD children do.

Constructive discipline such as time-outs can help ADD children regain their balance in a potentially volatile situation.

A daily report card can be utilized, more for the child and teacher than for the parents, to detail how the child did in areas of behavior and completing work, and rewards or simple encouragement can be used to reinforce good “reports.” It can also be used to tie in with the parent’s point system to create a cohesive management system.

A reasonable amount of effort on the teacher’s part can turn the most difficult child in the classroom into a manageable and potentially rewarding student. On the other hand, a teacher who does not understand ADD can be a nightmare for the child. One illustration of this situation is the experience of Tracey Gold, the actress on “Growing Pains,” who suffers from ADD. She was diagnosed with the disorder after having been a poor student for most of her academic life, despite intensive time spent on schoolwork and being an avid reader. Due to reworking of her classwork and different study techniques, she improved in school. However, in one situation, a teacher accused her of having someone else write her paper, as he/she did not believe she possessed the vocabulary to write it. Even though she verbally defined all the words pointed out in the paper, the teacher insisted, “…I know you’re not capable of doing this work.” (4)

Non-Traditional Treatment

Some parents looking for a quick and easy solution to their child’s problem have attempted to follow such non-traditional treatments as dietary changes (the most popular being the Feingold or Kaiser Permanente diet), megavitamin therapy, relaxation and biofeedback, sensory integration therapy and chiropractic manipulation. However, not only are most of these methods ineffective under study, in addition they do not take into account the behavioral modification that must take place in and around ADD children.

At one time it was believed that children grew out of ADD in their teens. However, longitudinal studies which followed ADD children into adulthood found that at least 50% of these children continued to have some part of the condition as adults. Adults with ADD often have trouble holding down jobs, have problems with substance abuse, and can be moody in a way that mimics manicdepressive illness with its extreme highs and lows.

The tools that one employs while dealing withworking with non-ADD children are the same ones that one uses with an ADD child: self-education, patience and compassion. The only difference is that more of each is needed to help the ADD child. This little bit more, while very small to us, can make a world of difference for them.

Notes

(1) Connecticut Association for Children with Learning Disabilities
(2) Moss p. 60
(3) Fowler p. 63
(4) Gold p. 49

Sources

Periodicals

Adduci, Lynne “My child couldn’t pay attention.” Woman’s Day, Sept. 3 ’91, p. 102.
Garber, Stephen W., Garber, Marianne Daniels, and Spizman, Robyn Freeman Is your child hyperactive? Inattentive? Impulsive? Distractible? Redbook, Oct. ’90 p. 32.
Gold, Bonnie and Byron, Ellen “School was a nightmare for Tracey.” Redbook, March ’90, p. 46.
Marks, Jane “Why is our child failing?” Parents’ Magazine, Sept. ’92 p. 69.

Books

Bain, Lisa J. Parent’s Guide to Attention Deficit Disorders (Dell, 1991).
Fowler, Mary Cahill Maybe You Know Mfr Kid (Carol Publishing Group, 1990).
Moss, Robert A., M.D. Why Johnny Can’t Concentrate (Bantam, 1990).
Quinn, Patricia 0., M.D. and Stern, Judith M., M.A. Putting on the Brakes (Magination Press, 1991).
Wender, Paul H., M.D. The Hyperactive Child Adolescent, and Adult (Oxford University Press, 1987).

Video

Connecticut Association for Children with Learning Disabilities Presents “Understanding Attention Deficit Disorders” (1988).

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