ADHD symptoms diagnosis and treatment
From trouble at school to conflicts at home--children who are trapped in a cycle of frustration might be suffering from AD/HD. Warren Umansky, PhD, and Barbara Steinberg Smalley offer a thorough explanation of one of today's most misunderstood and misdiagnosed diseases and reveals his breakthrough, home-based program for helping children with AD/HD.
AD/HD: What it is and isn't
Robert, a third-grader, walks to school most days. His school is no more than a five-minute trek from home, yet even when Robert leaves on time, he is often 30 minutes late.
His classmates don't like him very much. They say he's bossy and claim he's always picking on them. Robert has problems in the classroom as well. He spends the majority of his time under or near his desk rather than sitting down and working. His handwriting is sloppy, his work is messy and his assignments are frequently left unfinished. He's constantly losing things and can't seem to keep up with the class when they are reading aloud. And rarely does he have the right materials out to complete a given task.
At home, Robert is equally disorganized. His parents say he is extremely messy and has to be repeatedly reminded to complete simple chores. In the neighborhood, Robert has few friends his own age. When he plays with them, a fight typically ensues over sharing, hurt feelings and so forth. Consequently, Robert plays mostly with children who are older or younger than he is.
Robert was recently diagnosed as having Attention Deficit/ Hyperactivity Disorder (AD/HD) -- and he's far from alone. AD/HD is thought to affect some 3 percent to 5 percent of today's school-age children in the United States. And while this disorder seems to have emerged from nowhere to become a near epidemic over the last decade, it's hardly new.
In fact, AD/HD has been recognized since the early 1900s, and is one of the most widely researched of all childhood disorders. Over the years, however -- and to reflect researchers' growing advances in concept and theory about this disorder -- AD/HD has assumed many aliases.
In the 1930s, for example, children who exhibited AD/HD-like symptoms were described as having "Minimal Brain Damage." In the 1960s, that label changed to "Minimal Brain Dysfunction" and was considered relatively rare. By the 1970s, however, it was called "Hyperkinesis," and up to 200,000 children were thought to have the disorder.
In the late 1980s, the term Attention Deficit Disorders (ADD) was coined, and affected children were categorized as having ADD with or without hyperactivity. The current name, Attention Deficit/Hyperactivity Disorder -- or AD/HD -- was first used in 1994.
What is AD/HD?
The American Psychiatric Association redefined AD/HD in 1994 to describe three subtypes:
1. AD/HD Predominantly Inattentive. Jill, 11, fits this category. Though bright and intelligent, she has trouble paying attention to details, and, as a result, tends to make careless mistakes on classwork and homework. Her teachers often reprimand Jill for gazing out the window instead of listening to directions. But Jill can't help it. A chirping bird outside distracts her from the math problem in front of her.
2. AD/HD Predominantly Hyperactive-Impulsive. Eight-year-old Sam falls into this subtype. He's always tapping his pencil, squirming in his seat, or otherwise fidgeting in class. His teachers often send notes home saying, "Sam can't stay seated or quiet and often blurts out answers instead of waiting to be called on." At home, when friends come over, Sam has trouble waiting his turn while playing games, and he's constantly interrupting his mom when she's on the phone.
3. AD/HD Combined Type. A child who falls into this category is inattentive as well as hyperactive and impulsive -- like Robert, whom you read about earlier. One of the reasons Robert is often late for school -- even when he leaves on time -- is that he might spot a frog along the way and decide to chase it for a while. Once he is in school, his teacher calls out Robert's name several times a day because he is often under or near his desk rather than sitting down working. Robert rarely finishes his assignments in the classroom, because he can't seem to pay attention long enough to complete them. And when his class is reading aloud, he has trouble keeping up with them, because his mind wanders. At home, his parents say Robert is a whirlwind. He rarely sits still, even when eating. His parents must also repeatedly remind him to do his chores and stay focused on his homework.
People used to think that AD/HD was the result of some type of brain damage, but scientists now know that's not true. Granted, the exact causes of this disorder remain a mystery; nevertheless, cutting-edge research using computerized imaging technology and other sophisticated diagnostic tools is revealing fascinating clues to why some youngsters' brains have a propensity to AD/HD, while others do not.
Scientific evidence suggests that the level of neurological activity is quite different in certain parts of the brain in individuals with AD/HD compared to those who do not have the disorder. Differences have also been found in the size of various parts of the brain. Furthermore, at least in some cases of AD/HD, these central nervous system differences appear to have a hereditary component.
Some researchers have described AD/HD as an inhibition disorder. That is, children are unable to put the brakes on useless movements, can't control their distractibility and inattention, and can't overcome their tendency to daydream. It is this inhibition theory that puts AD/HD in a family with certain other disorders, such as depression, obsessive-compulsive disorder, and tics.
What it's not
AD/HD is a biological, not an emotional disorder, though it can cause its victims to experience emotional problems at home, in school, and in social settings. Neither is AD/HD a learning disability, although many children with AD/HD also have learning disabilities. Nor is AD/HD caused by poor parenting or inadequate teachers, although a disorganized home life and school environment can make its symptoms worse.
Some suspect diet as the culprit, but extensive research offers proof positive that too much sugar, aspartame (brand name: NutraSweet), food additives, food coloring, and food allergies do not cause AD/HD, either. Nor does watching too much television or playing too many computer or video games, although these may reflect an environment that lacks good supervision and may nurture the development of AD/HD-like characteristics in a child.
What is true is that many children with AD/HD also suffer from other conditions, including depression, anxiety, enuresis (bedwetting), and tics. And for the frustrated parent and the unhappy child, sorting out which symptoms are biologically based, which are learned behavior, which are controllable or not controllable, and which are severe enough to interfere with the child's success presents a significant dilemma.
Of course, not all youngsters who misbehave, who have trouble paying attention in school, or who have difficulty making friends have AD/HD. In fact, a host of physical, emotional, and situational problems can masquerade as AD/HD. Which is why it's imperative that a child be properly diagnosed before being treated.
With no virus or bacteria to look for, no X-rays to take or blood tests to administer, how is a diagnosis for AD/HD made? Usually it involves input from a team of professionals -- and from the child's parents.
First, a medical doctor performs a thorough physical exam -- which often includes neurological tests -- to rule out any physical causes (such as vision problems or hearing loss) for the difficulties a child is experiencing. Many physical and medical problems, such as thyroid dysfunction, may cause behavior that mimics AD/HD.
Once physical causes are ruled out, a psychologist may be consulted. She may begin by taking a comprehensive history from the child's parents and consulting with the child's teachers. In addition to asking questions about a child's level of achievement, as well as social and emotional functioning, the psychologist looks for signs of family crises (death, job loss, divorce, a recent move) that can trigger behavior problems that can be mistaken for AD/HD.
Gathering input from teachers and other caregivers is equally essential, as symptoms that appear only at school or at home may indicate that the problem is not AD/HD, but something related to a specific setting.
Classroom and home behavior is most often evaluated using checklists. These checklists allow professionals to get a better idea of a child's typical behavior -- particularly behavior that may not be obvious from observation. Two different checklists are presented. One lists problem behavior while the second states positive behavior. There are many commonly used checklists for parents and teachers that incorporate one or both of these formats.
Naturally, documenting a child's behavior in different settings is an important part of the diagnostic process. In fact, for a correct diagnosis to be made, a child must exhibit symptoms in at least two different settings. Thus, the psychologist will frequently observe a child at school as part of the data-gathering process.
So, what does the psychologist look for in the school setting? A number of characteristics that can support a diagnosis of AD/HD, as well as ideas to help the child improve his or her performance in the classroom. For example, the psychologist might note how a child's seat placement contributes to distractions and how it affects his ability to copy material from the chalkboard or get assistance from another child or the teaching staff.
The psychologist will likely observe how much time the child spends paying attention to assigned work versus the amount of time spent daydreaming or working on other, unassigned tasks. She might observe how the child gets along with his peers, as well as the types of children he gets along with best -- or worst.
The psychologist will likely monitor how successful the child is at paying attention to and completing independent work, and compare that to his performance in class discussions or in small groups. She will also note the frequency and intensity of the child's problem behavior -- and how the teacher responds to the child.
The problem is that a child with AD/HD may show different behavior in different settings, at different times of day, with different people, and when different levels of challenge are presented. Therefore, relying on the report of one observer or formulating an impression of a child from an isolated observation may offer only a narrow view of the child's problem. For a diagnosis to be accurate, it is important to compare and contrast a child's performance under a number of conditions and to analyze observations from various individuals. For this reason, the psychologist may observe a child several times, on different days.
Can the diagnostic process move forward without the input of a psychologist? Yes, it can. But some professional must take the lead in gathering information and documentation to help the physician make a diagnosis and to help parents and teachers respond to the child's needs. The parents' professional partner may be a private or school psychologist, another mental health professional, a supportive teacher or school administrator or even a friend who has traveled the same path.
When evaluating a child for AD/HD, professionals rely on a profile of characteristics that tend to differentiate children who might have AD/HD from those who do not. This profile is then compared with a list of criteria to make an official diagnosis.
Here are details of the three subtypes of AD/HD:
AD/HD Predominantly Inattentive
A diagnosis of this subtype of AD/HD requires that at least six of the following symptoms have been present for at least six months; they must interfere with normal functioning in social, academic and occupational skills; they must be present in at least two different settings; and they must be inconsistent with the child's developmental level:
1. Often fails to give close attention to details or makes careless mistakes in school work, work, or other activities.
2. Often has difficulty sustaining attention in tasks or play activities.
3. Often does not seem to listen to what is being said to him or her.
4. Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand directions).
5. Often has difficulty organizing tasks and activities.
6. Often avoids, expresses reluctance about, or has difficulty engaging in tasks that require sustained mental effort, such as school work or homework.
7. Often loses things necessary for tasks or activities (such as school assignments, pencils, books, tools, or toys).
8. Is often easily distracted by extraneous stimuli.
9. Often forgetful in daily activities.
AD/HD Predominantly Hyperactive-Impulsive
What was once called ADD with hyperactivity has been renamed AD/HD predominantly hyperactive-impulsive type. For a diagnosis to be made of this condition, at least some of the following symptoms must have been present before seven years of age; at least six of the symptoms must have been present for at least six months; they must interfere with normal functioning in academic, social, and academic skills; they must appear in two or more settings; and they must be inconsistent with the child's developmental level:
1. Often fidgets with hands or feet or squirms in seat.
2. Leaves seat in classroom or in other situations in which remaining seated is expected.
3. Often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
4. Often has difficulty playing or engaging in leisure activities quietly.
5. Is always "on the go" or acts as if "driven by a motor."
6. Often talks excessively.
7. Often blurts out answers to questions before the questions have been completed.
8. Often has difficulty waiting in lines or awaiting turn in games or group situations.
9. Often interrupts or intrudes on others (for example, butts into others' conversations or games).
AD/HD Combined Type
Diagnosing this mixed subtype of AD/HD requires that a child meet the criteria for both inattentive and hyperactive-impulsive subtypes. Moreover, at least some of the symptoms must have been present before seven years of age; they must appear in at least two different settings (at school, at home, in recreational or social settings); they must clearly impair social and academic functioning; and they must not be due to other specified developmental or psychiatric disorders.
If you are a parent, it is important that you be well-prepared in providing documentation of your child's behavior, that you be able to describe his behavior and performance in various situations, and that you consider other factors that may be causing your child to perform as he does. Professionals will use the symptoms listed above -- together with other information from physical exams and reports from teachers and observed behavior -- to determine if your child has AD/HD.
What's normal, what's not
All children are overly active some of the time. Many also have short attention spans and may act without thinking. Several factors, however, distinguish youngsters with AD/HD from those who do not have this problem.
First, it's true that many of these behavior patterns are developmental in nature. In other words, they appear in children at certain ages, but youngsters typically outgrow them. In children with AD/HD, however, many such behavior patterns persist. These youngsters either do not outgrow the behavior or the behavior disappears for a while, then returns.
Second, children with AD/HD often exhibit more such behavior than do children without the disorder. During a typical child's early years, for example, the majority of parents deal with a few of these behavior patterns. But parents of children with AD/HD deal with far more such behavior and for a much longer period of time.
Finally, parents can usually control a majority of undesirable behavior in children who do not have AD/HD by using good behavior management strategies. Youngsters with AD/HD, however, tend not to respond to most behavior management strategies or show great inconsistency in their response. A harsh reprimand, time-out, or restriction, for example, may be enough for most children to be convinced to straighten up. But these approaches are not likely to have long-lasting effects on a child with AD/HD.
Describing the child with AD/HD
Children with AD/HD are not all the same. They may exhibit some characteristics frequently and others less frequently or not at all. Yet, having a clearer understanding of which behavior may be a consequence of AD/HD may help parents to better understand their child and to be less frustrated by their behavior. In a slight departure from the list of specific symptoms presented earlier, consider these descriptions, which characterize the kinds of behavior one most often sees in children with AD/HD:
Fidgets, squirms or seems restless
Children with AD/HD are often described as "always on the move." In the classroom, they are the toe tappers or the ones who are constantly fiddling with other objects on or in their desks. They may chew on their collar or gnaw pencils. At home, during mealtime, they may toy with their silverware or food. Children with AD/HD also often demonstrate new and creative ways of sitting in a chair: on their legs, with legs propped up on a desk or table, or half-standing and half-sitting.
Has difficulty remaining seated
Teachers report that children with AD/HD are frequently out of their seats for a variety of reasons. They need a drink of water. They need to sharpen a pencil. They need to go to the bathroom. In fact, teachers agree that it's not unusual to find a child with AD/HD wandering around the classroom for no apparent reason.
At home, a youngster with AD/HD usually eats on the go because he has a difficult time remaining seated for an entire meal. Homework time also suffers, because the child is unable to sit still long enough to complete his assignments. And when it comes to enjoying activities that require participants to sit for any length of time -- such as concerts, lectures and church or synagogue services -- parents often resign themselves to the fact that they cannot take their child along. If they do, they spend excessive amounts of time reminding him to remain seated and stay quiet.
Is easily distracted
Children with AD/HD lose their concentration very easily if there are sounds or movements around them. Consequently, in school they have difficulty focusing on independent seatwork if, for example, a reading group nearby is making noise, the classroom gerbil is exercising, or a child sitting next to them is wearing a watch with a loud ticking noise. That's because many youngsters with AD/HD are simply unable to disregard distractions like these.
Homework becomes a chore, as well, when the television or stereo is on in a nearby room, or when people are coming and going near the homework area. Oddly enough, however, children with AD/HD may appear freer from distraction when playing video games or watching television. This is likely due to the multisensory nature (sound, color, and constant action) of these activities. Consequently the ability to pay attention to these activities is not sufficient to rule out a diagnosis of AD/HD.
Has difficulty waiting his turn
Many children with AD/HD can't wait in line as well as other youngsters of the same age. Some may try to force their way to the front of the line. Others fidget or constantly touch other children or things while waiting their turn, or they may gyrate or dance around in line.
Blurts out answers
Children with AD/HD would make ideal quiz show contestants, and they may excel at classroom drills where quick answers are rewarded. But in a structured classroom setting, these children often stand out as being impatient and uncooperative. Unable to muster the self-discipline needed to hold back an answer until they are called upon, children with AD/HD will call out an answer as soon as they think they know it.
Moreover, in some instances, their comments may be totally unrelated to the specific class activity or discussion. This probably occurs because of the associations the child makes in response to a question. For example, the question, "What is the capital of Montana?" may get the child thinking of the family trip to Montana last year, the plane landing in Helena (the capital), their horseback riding excursion at Yellowstone, and the park ranger they stopped to talk to. When the child answers, "the park ranger," there is no way for the teacher to know that the child's reply springs from having the answer, though her thoughts have speeded right past the appropriate response.
Has difficulty following directions
Children with AD/HD usually fare better when dealing with a single set of instructions. In fact, many become totally lost when they are given several instructions at one time. Say a parent tells a child to put on her pajamas, brush her teeth, and come back for a "goodnight kiss." Five minutes later, the child is wandering around aimlessly or engaged in her room playing with her CD player, not having even begun to do what she was told.
The same pattern occurs in school. When students are given numerous directions for several worksheets at a time, the child with AD/HD may either remember instructions for the first worksheet but not remember others, or remember instructions for the last worksheet. Consequently, these children frequently appear to be out of touch with what is going on in the classroom. They also have difficulty remembering what they are supposed to do for homework or which books to take home. Even if they write down assignments, the information may often be garbled or wrong.
Has difficulty sustaining attention
A classic sign of AD/HD is the number of incomplete papers the child brings home from school. Children with AD/HD have difficulty completing assignments, and the appearance of their papers is usually a good indicator of the disorder. They may complete the first few problems on a page, but the remainder of the page is blank. Or their papers will look as if they rushed through the work in an attempt to get everything finished without regard to quality or correctness.
On the flip side, some children with AD/HD are so meticulous that they may do their work over and over until it is perfect. But this extra time devoted to perfection often prevents them from completing other important tasks on their to-do list.
Shifts from one uncompleted task to another
Parents of youngsters with AD/HD often describe their children as having difficulty playing by themselves or as moving from one play activity to another without devoting much attention to any of them. Teachers agree. They describe students with AD/HD as very impulsive in learning centers and as likely to discontinue working at a project before its completion. Furthermore, these children often leave remnants of their activities around their desk, the classroom, or the house.
Even when warned to calm down, children with AD/HD have a tough time maintaining a quiet state. They are also easily aroused by other children. As a rule of thumb, the louder and busier an environment is, the louder and busier the child will be. In fact, many parents with just one child who live in a relatively quiet home often have a difficult time believing that their child with AD/HD is as busy and loud in the classroom as the teacher says he is. But after further probing, these parents usually come up with similar descriptions of how their child typically behaves with them outside the home, such as at restaurants or at the mall.
A child with AD/HD is often described as being very talkative and asking questions that are repetitive or that make little sense, "Like an out-of-control tape recorder that is locked on playback at a faster speed than normal," according to one parent. Some parents may be quick to defend such behavior: "She's perky, just like her mom," or, "He's all boy." But when it interferes with a child's success and is combined with other symptoms of AD/HD, it is reason for concern and action.