Understanding ADHD

Joe is an active, energetic nine-year-old boy. He likes baseball, riding his bike, and playing video games with a friend.

Since he began the first grade, his teachers have reported that he has some trouble with learning. They think Joe is smart enough to get good grades-if he could only sit still and finish his work. They report that he has trouble concentrating and frequently interrupts during classroom activities. Socially, Joe's teachers do not see a problem, unless he plays with another very "enthusiastic" child.

At home, though, Joe has frequent angry outbursts, intense conflict with his younger brother, and often refuses to do his chores. A family friend recently mentioned that Joe might have ADHD. What would you do if Joe were your child?

Almost all of us know of a child, adolescent, or adult being treated for Attention Deficit-Hyperactivity Disorder (ADHD). Despite widespread awareness of ADHD, parents and teachers often describe confusion over what this disorder is all about.

Parents say that it is hard to know how ADHD is different from an "active" or "strong-willed" child. At school, teachers sometimes see children who argue or disobey as having ADHD. Other times, people label children with emotional problems like depression or anxiety as having ADHD because they are irritable, fidgety, or have trouble concentrating.

What is ADHD? How can it interfere with school and relationships? How can you tell if a child you know might need testing for this disorder?

Less than six percent of all children are thought to have ADHD. Boys are five times more likely to be diagnosed with the disorder, although girls may more often be overlooked. ADHD becomes noticeable as early as three or four years of age. Sometimes it is not identified until early adolescence or adulthood, when academic or work performance falls behind what is expected.

ADHD consists of three problem areas: distractibility, impulsivity, and hyperactivity.

Distractibility (also called "inattention") is the inability to stay focused on a task or activity. For ADHD children, this becomes more of a problem during long, boring, or repetitive tasks. The typical ADHD child loses interest in activities much more quickly than other children.

Think of the second area, impulsivity, as "acting before thinking." Impulsive children often interrupt others, have difficulty waiting their turn, and are greater risk takers than others. They are more likely to act without thinking, especially if they're excited or frustrated.

The final problem area, hyperactivity, means a child is more physically active than usual. ADHD children with hyperactivity are always "on the go." In school, they are fidgety and restless. They frequently get out of their seat or are unable to sit still.

Many times, children do not have difficulties in all three areas. Some only have problems keeping their attention on a task (ADD without hyperactivity). Others are overactive, but still manage to pay attention to what is going on around them. Usually, though, children have some symptoms of all three. Between 30-60 percent also will have symptoms as adolescents and adults.

The primary problem ADHD creates for people is with persistence of effort. ADHD individuals have a harder time staying focused on a task than most other people their age. Their ability to stay with a task is also more variable. That is, sometimes ADHD children stay focused. Other times, they bounce from one activity to another, never settling on one. Because of this, other people often view individuals with ADHD as lazy and unmotivated.

In fact, these children simply have more trouble sticking with certain kinds of activities than others. The table below lists the situations in which ADHD children's attention to a task will be better and where it will be more difficult for them to stay focused and persist on a task.

Task qualities where keeping focused is easier and harder for children with ADHD

Better vs. Worse
one-on-one vs. group activities
novel/new tasks vs. familiar/routine tasks
frequent feedback vs. infrequent feedback
immediate reward vs. delayed reward
high level of consequences vs. low level of consequences
early in day vs. late in day
supervised vs. unsupervised

As you can see from the table, children with ADHD have a harder time concentrating and controlling their behavior when a task is boring or repetitive. The same is true when the task takes place later in the day, when children don't receive feedback, or when there is a delay in consequences for performance.

If you think of an ADHD child trying to do homework after school, you can see why this is often an area where the child struggles. Homework does not give you feedback. (You often do it without knowing for sure if you are right or wrong.) It is usually boring to the child. It happens late in the day. And the consequence for not doing it is very delayed-usually the next day when the teacher discovers the child didn't do it.

On the other hand, many parents report that their ADHD child can stay in front of a video game for hours. Think of the qualities of a video game, and you can begin to appreciate why it is easier for a child with ADHD to stay focused on this task. The game is one-on-one. It is highly engaging and interactive. It offers immediate rewards and punishments for behavior. (You get points if you perform well, your guy "dies" if you don't, and it happens right away.)

This is also why many of these children prefer more stimulating entertainment such as outdoor or sports activities over more passive activities like reading or quietly snuggling with a parent. The more stimulating and engaging something is, the more likely it will attract and hold an ADHD child's attention.

This difficulty sticking to some kinds of activities without getting bored, fidgety, or impulsive also can affect school performance. This makes sense if you think of what a school setting demands from a child. Beginning about the first or second grade, children have to sit still and pay attention to the teacher. They must do work quietly at their desks. Most often, the information flows one way and is not highly interactive. The classroom is a group setting where it is often hard for ADHD children to ignore the many interesting things their classmates or the room offer.

During classroom games or free play-when emotions are running higher than usual-children with ADHD often have trouble with impulse control. It is not that these children do not know how they should behave. ADHD is not a skills deficit. It is just that in the "heat of the moment," they have difficulty stopping and thinking before they act. This is due to poor behavior controls when they're excited or their need to be active when the stimulation level is low.

Socially, children with ADHD often have more difficulties than others. These children are often described as excitable. They have little patience, and become frustrated quickly compared to others their age.

Due to both their impulsivity and their difficulty sticking to one activity at a time, children with ADHD more often have conflicts with their peers. They then react more aggressively when a conflict does occur, although they are usually sorry for their behavior afterward. Again, it is not that children with ADHD do not know what to do. It is that they have trouble doing what they know.

When impulsivity or overactivity is the primary symptom of ADHD, children are also at risk for developing an Oppositional Defiant Disorder (ODD). About 65 percent of children have both conditions (ADHD and ODD). ADHD does not cause ODD. Rather, because children with ADHD bump into rules and expectations more than usual, they begin to think that they "can't do anything right." They may feel angry, resentful, and demoralized. ODD occurs when they express their feelings through oppositional and defiant behavior.

ODD first appears at home, most often between mother and child because Mom is usually the primary caretaker. She most often has to manage the ADHD child's impulsive and poorly regulated behavior. Children with ADHD have more trouble finishing chores and following verbal instructions than is typical. (They become interested in something else part-way through). They seem to get out every toy they have without playing with any of them for very long. Children with ADHD quickly become bored and complain of having nothing to do. Worse yet, they may think of something to do!

Over time, a pattern of relating sometimes develops in which the parent begins to think, "Isn't there more to parenting than disciplining my child?" Meanwhile, the child begins to think, "How come I'm such a bad kid?" Punishment for misbehavior then begins to include anger as both parent and child become frustrated.

When discipline is necessary, parent and child develop a pattern of angrily "locking horns" over issues. The child becomes more defiant and oppositional. Keep in mind that most parents can recognize this process occurring in their home once in a while, as well. It is just that it more often becomes a style of relating when a child so frequently bumps into and breaks the rules.

Julie is an eight-year-old girl who started having difficulty attending to her school work. She became increasingly disruptive in the classroom. Initially, her teacher suspected Julie had attention deficit disorder and had planned to urge Julie's mother to see the family pediatrician about starting Julie on medication.

During a parent/teacher conference, however, Julie's mother confided to the teacher that she and her husband were in the process of getting a divorce. There was a lot of tension at home. A review of Julie's school records revealed that up until this school year, she had been a diligent worker and an easy student to have in the classroom.

Diagnosis of attention deficit disorder is a complex process. Almost everyone has difficulty paying attention at times, but the majority of people do not have ADHD. There are many childhood problems associated with inattention or distractibility including anxi-ety, depression, even physical illness. When there are significant family problems at home, it is common for children to display ADHD-type symptoms at school.

Unfortunately, too often the most obvious symptoms of inattention and impulsivity receive the most attention when there is actually another underlying problem. It is too easy to apply the label ADHD before carefully considering other diagnostic possibilities. Labelling a child as ADHD can sometimes just mask another important problem. In the past few years, we have seen many cases in which medication treatment only delayed identifying and treating more significant emotion-al problems.

For this reason, a thorough diagnostic workup is important when parents or teachers suspect attention deficit disorder. Important parts of this evaluation, which is usually completed by a psychologist or other mental health professional, include:

1. An evaluation of developmental and family history. The professional carefully interviews family members and often asks them to complete specialized questionnaires to gather this information.
2. An objective assessment of present functioning at home and school. The current standard is using parent and teacher rating scales, which compare a certain child's ratings with those of his or her peers. The professional also must review the academic record of a child to look for patterns suggesting earlier problems.
3. Objective tests of attention. There are psychological tests available that measure how well a child can attend to a boring task over a certain period of time. Although some children with ADHD can do well on these tests in a clinical setting, most have difficulty and show signs of inattention and impulsivity.
4. Screening for other disorders. It is essential to determine if there are emotional factors that can better explain why a child is inattentive, hyperactive, or impulsive.

After the professional finishes a complete diagnostic workup, it is important to seek treatment. Although there are no "cures" for attention deficit disorder, it can be managed. There are several treatment options available.

The most common form of treatment is using medication such as Ritalin or other stimulants. They often help children become more alert or attentive. There are several other medications used to treat ADHD, including some antidepressants. More than 750 studies suggest medication is an effective treatment for some kinds of ADHD.

For many years, professionals used a treatment called "cognitive-behavioral therapy." This treatment emphasized helping children to stop and pay attention to what is happening around them before they responded. Some of the early proponents of this form of therapy now question its usefulness. Although children can learn the techniques in the therapist's office, too many don't seem able to apply this knowledge in real world situations.

Many researchers and clinicians are now turning to parent training techniques. Many children with ADHD present challenging behavior problems-like oppositional defiant disorder. Parents must be skilled in knowing how to cope with inattentive or hyperactive behavior.

Again, although this is not a cure for ADHD, effectively managing it in the home significantly reduces the stress and relationship problems that can develop as a result of ADHD.

School Performance

• easily bored
• poor organization and planning
• procrastinates
• difficulty waiting his or her turn
• always losing homework
• can't sit still
• trouble staying focused on work or lectures

Relationships

• poor listening skills
• interrupts others
• often described as selfish or immature
• quick to become angry or frustrated
• trouble following through on commitments
• makes impulsive comments that hurt others' feelings or create embarrassment

Self-Esteem

• low sense of self-worth
• demoralized
• privately views self as stupid or a failure
• may feel guilty for letting people down

ADHD in Adults
Recent studies suggest that 30-60 percent of children with ADHD continue to have symptoms into adulthood. In adults, some of these ADHD symptoms show themselves in problems with:  

Work and School Performance:

• bored by tedious material
• poor planning and organizational skills
• procrastinates
• restless
• always running behind
• frequent, impulsive job changes-can't stay focused on paperwork, lectures, or repetitive tasks

Relationships:

• poor listening skills
• interrupts others
• difficulty managing finances
• often called selfish or immature
• quick to become angry or frustrated
• trouble following through on commitments to others
• makes impulsive comments that hurt others' feelings or creates embarrassment

Self Esteem:

• low sense of self worth
• demoralized
• privately views self as stupid or a failure
• may feel guilty for "letting people down"

As with childhood ADHD, these symptoms are also associated with other emotional disorders. It is critical to an accurate diagnosis to have a thorough evaluation to rule out some of these other disorders.