ATTENTION DEFICIT HYPERACTIVITY DISORDER

Learning is a complex process, requiring much effort and time on the part of a child. Parents and teachers expect a child to learn; and children themselves expect to learn. A child who has difficulty learning might frustrate the most patient adult, but more importantly, can frustrate himself.

How can learning go wrong?

There can be several impediments to learning. Hearing or visual problems obviously can be impediments. Emotional upset, such as a difficult school situation or stress at home, can distract a child from learning. Physical problems, such as insufficient sleep or a chronic illness, will inhibit performance. However, some children have innate stumbling blocks to learning, called Learning Disabilities.

The common thread is that the child must pay attention at each step, long enough for the learning sequence to be completed. The child must be able to filter out distractions as he listens to the teacher, absorbs the lesson from the chalkboard, or finds the main idea in a reading passage. If not, the child does not learn. These problems are called Attention Deficit Hyperactivity Disorder, or ADHD. These children frequently have short-term memory difficulties as well.

Who has ADHD?

ADHD is a common problem in children. Estimates vary, but some experts find that up to 5% to 10% of all school children have some degree of ADHD. Also, 30% to 50% of children with ADHD have learning disabilities in addition to their attention problems. For many (but not all) children with ADHD, there are clear familial tendencies towards distractibility and attention problems.

What are the characteristics of children with ADHD?

The diagnosis of ADHD rests on identifying easy distractibility, a short attention span, and impulsivity.

1. Easy Distractibility – means that a child is easily distracted by other stimuli he is interested in from tasks he needs to complete. If the child is distracted by external stimuli, he will be pulled from task to task, and may flit around the room; these children may be called “hyperactive.” If the child is distracted by internal stimuli such as their own thoughts, they may seem “dreamy” or “inattentive.”
2. Short Attention Span – means that, once a child has been distracted, and then returns to the original activity, he forgets what he was doing and has to start all over again. This makes his progress with any activity (schoolwork, play, or chores) slow and disorganized. Many reminders may be required to finish a task.
3. Impulsivity – is a classic behavioral characteristic of children with ADHD: The child may impulsively talk out of turn, make careless errors, or be prone to injury because he wants to avoid leaving a thought unsaid or a task unfinished. Impulsive behavior may disrupt the classroom setting.

When does a child with ADHD need treatment?

Everyone shows the characteristics of distractibility, short attention span, and impulsiveness from time to time. These are simply three aspects of personality, not a disorder by themselves. But problems arise when there is a mismatch between the personality and the environment, to the point that the child’s life is disrupted.

Children with ADHD have trouble in three areas: at school, at home, and socially with friends.

1. At school, these children may have academic difficulties. They may have trouble remembering things they are taught. Handwriting may be very sloppy and hard to read. Reading can be difficult, especially reading with comprehension, because the distractibility makes them forget what they read before the paragraph is finished. The impulsiveness may cause careless errors. These children often forget to hand in homework assignments, even if completed. Teachers understandably may complain if a child with ADHD disrupts the classroom.
2. At home, homework may be a struggle, because the disorganization and distractibility makes homework last an excessive amount of time. For younger children, cooperation with household chores may be difficult because they cannot follow multi-step directions, or they may be distracted halfway through the job. Frequently, many reminders are needed to finish a task. Older children, if chronically frustrated, may become oppositional and defiant.
3. Socially, children with ADHD are frustrating to make friends with. Other children may have difficulty staying friendly with a child who is impulsive, interrupts, has difficulty following rules, or has emotional outbursts. Frequently, children with ADHD gravitate towards other similar children, or withdraw to watch large amounts of TV or video games.

Excessive difficulty in any of these three areas because of distractibility, short attention span, and impulsiveness may warrant treatment. Altering the environment should be the first response.

What happens over time to children with untreated ADHD?

In some children, an attention deficit may go unnoticed. It occasionally may disappear over the years; some children have no symptoms by puberty. Other children with attention symptoms may develop effective strategies to counteract them, and they perform well in school. But for many children with ADHD, the struggle through the early grades may cause their self esteem to drop and their motivation to falter. In addition, if basic skills (such as reading or arithmetic facts) are not solidly established in 1st and 2nd grade because ADHD has interfered with learning, performance in later grades will suffer. Some children eventually lose interest in a social and educational system that never rewards them, and by adolescence may begin to engage in antisocial behavior.

How can I find out if my child has ADHD?

Sometimes, the diagnosis of ADHD can be suspected through observations of parents and teachers. A medical exam is required to rule out physical causes for poor attention. Hearing and vision tests will be needed. Sometimes, testing by a psychologist is required to rule out a learning disability. This does not involve delving into inner emotional conflicts, but rather includes objective testing of intelligence, memory, perceptual abilities, and other functions of learning.

Many parents and teachers fill out extensive forms or rating scales to help with the diagnosis. These may be of some benefit, but do not substitute for the direct observation of a child’s behavior and capabilities by the parents and competent teachers.
Review of past reports about behavior, or keeping a behavior diary for a period of time, is quite helpful. It is useful for teachers to keep notes about: academic progress, reading ability (especially compared to grade level and especially with regard to reading comprehension), attention and participation in class activities, ability to follow directions, ability to complete work quickly and accurately, organization, interactions with peers in structured and free-time activities, and self-esteem. It is useful for parents to keep notes about: cooperation with adults, social interactions with friends, self-esteem, organization, ability to follow directions and do chores, attention span, distractibility, and impulsiveness.

How is ADHD treated?

There are several aspects of the proper treatment of ADHD.

If possible, all distractions in the environment must be eliminated. The child may need to sit at the front of the class to help him ignore distractions from around the classroom. His desk at school and at home must be clear of extra books, toys, and other objects. Organizational strategies for work can be developed. The child may need a written list of books he needs to bring home at the end of the day. (The teacher should be able to provide one; some children fortunately can identify a reliable friend to act as a “homework buddy.”) Homework time can be budgeted. Assignments may need to be broken into small, easily finished pieces, so that the child does not impulsively decide that the task is overwhelming.
1. The home life must be organized; if the home routine is hectic and unpredictable, a distractible child will have difficulty. It is a good idea to prepare the backpack, clothes, and lunch the previous night (and keep them in a designated spot). Also, if parents similarly prepare themselves each evening for the next day, the morning routine is much simpler. It is comforting to review the next day’s schedule and plans before the child goes to bed. Keeping a master calendar up-do-date and visible in the kitchen not only helps the child plan his week, but role-models an organized life-style.
2. Tutoring may be required for the child to catch up on skills that his classmates have already acquired. Often, tutoring in study skills is helpful.
3. The child’s self esteem must be nurtured. Frequent praise, for completing even small tasks, is essential. A child can take pride in accomplishment in noncompetitive sports (dancing, karate, etc.) or hobbies that emphasize a child’s natural talents. Occasionally, if a child is very discouraged or the family situation is stressful, counseling can be very helpful, especially with older children.
4. Children with ADHD have a hard time learning to predict the consequences of their behavior because they tend to be impulsive. However, they can learn to control their behavior. Some parents find parenting classes (such as those at Child, Inc.) to be helpful.
5. TV is dangerously attractive for children with ADHD. It offers a very strong stimulus, but makes no demands, and their time is wasted. I recommend limiting TV (including video games and movies) to 10 hours per week.
6. Demystifying the disorder for the child is important. The child must be reassured (usually repeatedly) that he is not “retarded,” or even “slow,” but that he is just as smart as other children. He simply has a problem with a certain part of his memory, and needs help to learn to deal with it. The child (and his friends and family) can learn that having ADHD and needing a tutor or medicine doesn’t make you “dumb,” any more than being nearsighted and needing glasses makes you “dumb.” (This is less problematic now than in years past, as public awareness of ADHD has grown.)
7. Medication is not necessary for every child with ADHD, but many children benefit from it.

For some children, the difference is dramatic, and for others the change is subtle.

Some children with ADHD need medicine only during school. However, most children function better at home and in social situations when taking their medicine, and are less likely to injure themselves. These children do better when on medicine all day, 7 days per week.

What are the side effects of stimulant medications?

Most children on stimulants have no significant side effects. Insomnia, headache, abdominal pains, loss of appetite, fatigue, or rashes have been reported and their persistence may require stopping the drug. Many of these symptoms will disappear within a week or two. Larger than usual doses may cause poor growth, but the commonly used doses do not generally have this effect. However, periodic (every 6 months) weight and height measurements at checkups is recommended.

Occasionally, a child on stimulants will develop tics (involuntary movements or sounds). This will resolve if the med is stopped or even changed. Some experts feel that the medication does not cause the tic, but merely precipitates its early appearance in a child who would have developed it later. This is an unusual side effect, but if you have noticed that your child has tics or if there is a family history of tics, please discusses it with us prior to starting the medication.

Many myths exist about the side effects of these medicines. They are not addictive and there is no withdrawal when medication is stopped. They do not cause seizures. They do not lose their effectiveness with long-term use (although as the child grows, the dosage may need to be adjusted). They do not cause learning disabilities, although children with ADHD sometimes have other learning disabilities, as described above. A certain number of children with ADHD have other emotional disabilities but the medication is certainly not their cause.

How are stimulants prescribed?

Stimulants come as tablets, capsules and even a patch . Normally, a child starts with the lowest dose. Every week or two, after consulting the doctor, the dose is increased until a beneficial effect is noted. If a maximal dose is reached without noticeable effect, or if significant side effects are seen, the drug is stopped. The medication can only be filled with a written, dated prescription that must be picked up, not a telephone order. No refills are permitted by law.

You must call the doctor well before the medication runs out; don’t wait until the bottle is empty! We will ask you for follow-up information on the child’s progress with each refill; this is important but time-consuming.

It is very important to remember that medication is only part of the treatment of ADHD. It would be a mistake to “let the pill do the work.” The other treatments described above (altering the environment, organizational strategies, and so on) are just as important.
The child’s mood and health should be periodically reviewed. A checkup with the pediatrician every six months is strongly recommended.

How long does a child exhibit ADHD symptoms and need treatment?

The characteristics of distractibility, short attention span and impulsiveness are life-long personality traits; it is unusual to “grow out of” them. But one can learn to compensate for them, capitalizing on one’s strengths and working around one’s weaknesses.

Many children do not learn the insight to recognize their own distractibility and short attention span (or the beneficial effect of their medication) until late in Junior High School. But by high school (and occasionally earlier) many children have learned coping skills that help them reduce or eliminate their need for medication. However, this is highly dependent on the environment the children find themselves in. Some need to restart medication in college, for example, when workloads increase and supervision is more distant.