Despite being one of the most common mental disorders that develops in children — experts estimate that three to five percent of kids in the U.S. have it — Attention Deficit Hyperactivity Disorder (ADHD) remains a much misunderstood disorder. According to the National Institute of Mental Health, it is "a brain disorder marked by an ongoing pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development." It can affect anyone, but is most common in males. Until around 20 years ago, ADHD wasn't recognized as a disorder that persists into adulthood, meaning millions of adults with the disorder still haven't been officially diagnosed.
Even today a delay in diagnosis is possible; while ADHD symptoms can appear as early as between the ages of 3 and 6, they may be mistaken for emotional or disciplinary problems or missed entirely in quiet, well-behaved children.
In preschool kids, the most common ADHD symptom is hyperactivity. What’s another (misused) label for a hyperactive kid? A badly behaved one. But ADHD is so much more than bad behavior. In fact, kids with ADHD "misbehave" for very different reasons than kids who don't have ADHD.
"ADHD involves difficulties with focusing attention, impulsivity, and behavior challenges that are excessively intense, situationally inappropriate, and lack goal directedness," explains Mayra Mendez, Ph.D., LMFT, licensed psychotherapist and program coordinator for intellectual and developmental disabilities and mental health services at Providence Saint John's Child and Family Development Center in Santa Monica, California.
In a child with ADHD, their ongoing pattern of inattention, hyperactivity and impulsivity might result in them wandering off task, moving around constantly, fidgeting, tapping or talking excessively, being socially intrusive and excessively interrupting others. In a classroom setting, these might be classed as "bad" behaviours. But kids with ADHD don’t behave like this because of defiance or lack of comprehension.
"The difference between misbehavior and ADHD behavior is the degree to which the maladaptive behaviors occur," says Mendez. "Maladaptive behaviors are inconsistent with the developmental level of the child. For example, let’s take the case of an 8-year old who is waiting for an appointment at the doctor’s office. This 8-year old persistently fidgets, runs around the waiting room, is unable to focus attention on a game/book/task for more than a few seconds, speaks in a loud, intrusive tone, and talks constantly to his caregiver by yelling from across the room. The child’s behaviors may raise the question of ADHD as the elevated level of intensity, the duration, and the intrusiveness of these behaviors suggest behavior that is outside the range of typical, age-expected misbehavior."
One important thing to know about ADHD is that it is far from a "one size fits all" disorder. "All cases of ADHD do not look the same and often do not share the same set of symptoms or behaviors," says Stephanie N. Marcy, Ph.D, psychologist at Children's Hospital Los Angeles. "Some might argue the diagnosis if their child can watch television or play video games for an extended amount of time. Parents must understand that these misconceptions can be harmful to the child. Parents also need to be open to treatment and recommendations as they differ among ages. It is extremely important to have a very thorough evaluation conducted not only to confirm or deny ADHD in the child, but to be able to properly target the right form of intervention to fit their needs."
Recent advances in early identification and understanding treatment of ADHD symptoms have had a positive impact on children with ADHD and their families, says Mendez, with benefits including a reduction of symptom severity, family stress and parent-child conflict, reduced risks of impairments in major life activities (at home, in school, in the community and with peers) and health-related problems, and accelerated brain growth.
In 2011, the American Academy of Pediatrics published guidelines approving ADHD medication treatment for children as young as 4 years of age. While medication is a supported best practice modality to treat the disorder, Marcy is hesitant to suggest medication and therapy simultaneously, primarily because families are often reluctant to start with medication. "From preschool ages through first grade, I prefer starting with an in-depth evaluation of the child," she explains. "From there, I move to behavioral therapy that involves school support and parent training, not medication. Parent involvement is crucial, they are responsible for implementing the change, setting up expectations and instilling routine in the child’s life. In the older age groups, I typically begin with an extensive evaluation (7-8 hours of testing) followed by therapy, both family and individual for a few months. The last piece of the puzzle is medication if after these forms of treatment, significant improvement in the child has still not been shown."
Mendez offers the following tips for parents to support attention and regulation in their child diagnosed with ADHD:
More support and advice for parents is available at Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD).
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