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ADHD: A Primer for Parents andEducatorsBY ANNE M. HOWARD, PHD, Chicago School of Professional PsychologySTEVEN LANDAU, PHD, Illinois State University Attention-deficit/hyperactivity disorder (ADHD) is a complex disorder characterized by three coresymptoms of inattention, impulsivity, and hyperactivity. Although all children display these behaviors tosome degree, children with ADHD have far more significant symptoms than other children their age.
Because these symptoms are pervasive, they tend to interfere with the child’s behavior at home, in school,and among peers. Fortunately, with early identification and intervention, most children with ADHD canlead successful lives.
OVERVIEW OF ADHDADHD is one of the most common reasons for a child to be referred for support services in school, andaffects approximately 3–7% of elementary school children. Symptoms may be first recognized as early aspreschool.
Types of ADHDAccording to current diagnostic practice, there are three subtypes of ADHD. Children who have severeproblems with inattention and concentration are termed ADHD - Predominately Inattentive subtype.
Although the term ADD is outdated and no longer widely used, some professionals and parents continueto use the ADD label to describe children who daydream, appear lethargic, have cognitive difficulties, butwho do not have problems with impulse control or hyperactivity. Girls are more likely diagnosed than boysas Predominately Inattentive.
In contrast, boys are more likely diagnosed with one of the other subtypes of ADHD, either ADHD - Predominately Hyperactive/Impulsive (i.e., significant problems with hyperactivity and impulse controlwithout attention problems) or ADHD – Combined (i.e., significant problems with hyperactivity, impulsecontrol, and attention). Children with ADHD – Combined are likely to encounter academic difficulties assoon as they enter school.
Causes of ADHDAlthough a precise cause of ADHD may never be known, it is helpful to consider it a complex disorder thatresults from multiple factors. The cause or causes of ADHD may vary across individuals, and more thanone cause may be necessary for ADHD to emerge. Although parenting style and childrearing practices donot directly cause ADHD, how parents, siblings, and the school responds to symptoms of ADHD can affectchildren’s development and their ability to overcome secondary problems associated with the disorder.
Genetic and biological factors. Research with families and twins have led most experts to consider ADHD a biologically-based disorder, at least partiality caused by genetic or neurological factors. A childwho has a close relative with ADHD is about five times more likely to have ADHD than children in general.
Also, there is cutting-edge research on brain structure and function among individuals with and withoutADHD that suggests important neurological differences. Some neuroimaging studies indicate that thefrontal lobes of the brain used in planning, problem solving, and impulse control may be different inchildren with ADHD (Castellanos et al., 2002; Shaw et al., 2006).
Environmental toxins. Research also indicates that alcohol or cigarette use during pregnancy may be a cause of ADHD (Knopik et al., 2005; Thapar et al., 2003). In addition, some studies have implicatedexposure to lead as a possible cause. Although some believe that sugar in the child’s diet causes ADHD, The Charlesworth Group, Wakefield +44(0)1924 369598 - Rev 7.51n/W (Jan 20 2003) numerous research studies have failed to establish a link their life span. In contrast, children who display problems between the child’s diet and risk for attention or behavior in peer relationships are less resilient and more vulnerable to life stressors. In addition, they tend tospend time with others who experience similar adjust- There is no doubt children with ADHD experiencechallenges in many aspects of daily living, at home, at school and interacting with peers. Some of these ADHD is a medical condition and should be diagnosed problems may result from the ADHD-related symptoms, by a qualified professional. In many cases, the child’s whereas other problems may be due to the same factors pediatrician is the first professional to whom families that cause ADHD. Regardless of the cause, each area of turn for an evaluation. Based on training, psychiatrists, poor performance should be addressed with an appro- school psychologists, child clinical psychologists, neurol- ogists, and clinical social workers may also be qualifiedto diagnose ADHD. However, in most states, only medical doctors (e.g., pediatrician, psychiatrist, neuro- The average child with ADHD receives lower grades, falls logist) can prescribe medication in the treatment of behind in classroom learning, and shows a significant difference between ability and actual academic perform-ance. Up to one-third of these children will repeat a grade during their elementary school years. This No single test, questionnaire, laboratory procedure, or academic underachievement probably represents a observation alone is sufficiently reliable when diagnosing problem in performing rather than a true problem in ADHD. In addition, no single source of information learning. In other words, these academic difficulties (parent or teacher) should be considered sufficient for a usually seem to result from the combination of reliable and accurate diagnosis. An appropriate ADHD insufficient attention, impulsive work habits (i.e., being evaluation uses multiple methods and multiple sources too fast and inaccurate), and disruptive classroom of information, including diagnostic interviews with behavior, rather than an inability to learn expected skills.
parents and teachers, ratings of the child’s behavior, However, at least 25% of children with ADHD have and direct observations in all settings where problems significant learning problems (e.g., a Learning Disability) in addition to their attention problems.
In addition, the child’s academic performance should be examined thoroughly, including evaluation of aca- demic accuracy, work productivity, the child’s learning Significant problems with aggression and oppositional style, and response to changes in instruction.
behavior are found among a majority of children with Pediatricians or mental health professionals may then ADHD. Because of insufficient self-control, including determine if the assessment results are consistent with problems with anger management and explosive emo- the diagnostic criteria described by the American tions, these children may engage in fighting, lying and Psychiatric Association. During assessment, profes- stealing, violations of major rules, and destructiveness.
sionals should consider if there are other problems and Children who are inattentive may be perceived as disorders that better explain the child’s pattern of difficulties. The focus of the assessment should not belimited to a diagnostic determination per se, but to a full delineation of the nature and extent of the child’s Many children with ADHD experience serious problems in peer relations. Numerous studies indicate thatclassmates may view students with ADHD as the least preferred work or play partners among all children in Because children with an official diagnosis of ADHD vary general education (e.g., Hoza, 2007). These difficulties tremendously in their respective symptoms and areas of with social relations can emerge within minutes of first impairment, intervention plans must be developed based contact, develop during the preschool years and then persist through adolescence into adulthood.
Unfortunately, peer rejection can have harmful FBA. One valuable assessment strategy often consequences. Children who have socially appropriate employed by school psychologists or school social friends and positive relationships with peers are much workers is functional behavioral assessment (FBA).
more likely to show successful adjustment throughout FBA involves systematically observing the child to The Charlesworth Group, Wakefield +44(0)1924 369598 - Rev 7.51n/W (Jan 20 2003) determine why a behavior occurs (i.e., its purpose or function). This information leads to efforts to replace These interventions are designed to increase positive, the child’s inappropriate behaviors with more desirable desirable behavior and reduce problematic, disruptive and appropriate behaviors. The success of this behavior through a system of feedback and contingen- approach contradicts the notion that all children with cies (i.e., reinforcers and loss of rewards). Reward-based ADHD will benefit from the same treatment strategies.
interventions, such as the token economy (i.e., earningpoints or stickers for later rewards), help the child to Academic assessment. Due to the frequent overlap self-monitor his/her behavior and receive positive (or co-occurrence) of ADHD and Learning Disabilities, feedback for meeting behavioral goals.
it is highly recommended that a formal psychoeduca- Behavioral interventions may also include social tional assessment be conducted to identify current skills training (e.g., developing skills to wait one’s turn academic performance and potential underlying learn- or learning how to listen to others) or organizational skill ing problems that may exacerbate the child’s perform- development, such as maintaining a homework log or ance difficulties in school. Because ADHD affects setting daily schedules with clear expectations (e.g., behavior and learning in the classroom, instructional interventions should be emphasized and implemented Finally, behavioral interventions that involve consist- as early as possible. Effective classroom accommoda- ent communication between home and school will yield tions (formal modifications) may be necessary to the greatest benefits. There is strong evidence that parent ensure the child’s continued success in general support and involvement in school-based interventions lead to improved effectiveness. Teachers commonly usedaily reports and ratings to communicate the child’s progress to parents, and the parents can then dispense One of the most difficult decisions faced by parents of reinforcers at home based on the intervention plan.
children with ADHD concerns treatment options.
Fortunately, there are a number of scientifically-based interventions for ADHD. The two most widely Some teachers may feel overwhelmed by the respons- researched treatment options include the use of ibility of providing individualized instruction or behavioral psychostimulant medication and behavioral interven- interventions for students with ADHD, but effective tions. The most comprehensive research to date strategies can be implemented with parents, peers, and indicates that combined treatments (i.e., medication children with ADHD themselves. Additionally, assistive plus behavioral interventions) tend to have the most technology can be used to enhance attention to success in reducing symptoms and improving the academic instruction (e.g., computer programs).
child’s overall functioning (e.g., social and school There are also a number of proactive strategies outcomes) (Van der Oord, Prins, Ooserlaan, & teachers can incorporate into their routine with minimal effort. Examples include preferential seating to reducedistractions, reducing or chunking assignments, and using nonverbal cues to redirect the inattentive child The most frequently prescribed class of drugs for (e.g., hand gestures). Other school-based interventions ADHD treatment involves central nervous system include class-wide peer tutoring, home-school notes, and stimulant medications. These include methylphenidate self-management programs with a response-cost system (Ritalin, Concerta, Metadate), dextroamphetamine (i.e., child tracks his/her own behavior and earns tokens (Dexedrine, Dextrostat), and amphetamine (Adderall).
for appropriate actions and loses tokens for inappropri- In addition, atomoxetine (Strattera), the first non- stimulant drug approved by the Food and DrugAdministration to treat ADHD, has shown promising therapeutic effects for some children. It is important Often children with ADHD require additional services for parents to work closely with the child’s teacher and and supports beyond what is usually available within a prescribing physician to make sure the child is general education classroom. Some may be eligible for receiving the proper medication and at an optimal special education services, while others may be best dose. Not all children with ADHD will respond favorably to medication, and the best dose ofmedication for problems in one area (such as class- room instruction) may not be the ideal dose in another The diagnosis of ADHD alone does not qualify the area (playground behavior or family activities).
student with ADHD for special education services, The Charlesworth Group, Wakefield +44(0)1924 369598 - Rev 7.51n/W (Jan 20 2003) unless the child is considered Other Health Impaired Knopik, V. S., Sparrow, E. P., Madden, P. A., Bucholz, K.
(OHI). In order to be classified as OHI, the school team K., Hudziak, J. J., Reich, W., et al. (2005).
determine that the health condition (ADHD) significantly Contributions of parental alcoholism, prenatal sub- interferes with learning and performance in school.
stance exposure, and genetic transmission to child Specifically, the school team whether or not the child’s ADHD risk: A female twin study. Psychological condition is chronic (i.e., at least 6 months), results in limited alertness (i.e., significant difficulty attending to Shaw, P., Lerch, J., Greenstein, D., Sharp, W., Clasen, L., tasks) and adversely affects educational performance.
Evans, A., et al. (2006). Longitudinal mapping of Aside from OHI eligibility, since children with ADHD cortical thickness and clinical outcome in children have an elevated risk for other difficulties, including and adolescents with attention-deficit/hyperactivity oppositional-defiant disorder, conduct disorder, depres- Archives of General Psychiatry, 63, 540– sion and/or anxiety, and learning disability, some may qualify for some level of special education services under Thapar, A., Fowler, T., Rice, F., Scourfield, J., van den the categories of Behavior Disordered/Emotionally Bree, M., Thomas, H., et al. (2003). Maternal smoking during pregnancy and attention deficit Special education service options vary widely across states and across districts within states, but federal law American Journal of Psychiatry, 160, 1985–1989.
defines general eligibility standards and requires the Van der Oord, S., Prins, P. J. M., Oosterlaan, J., & development of an Individualized Education Program Emmelkamp, P. M. (2008). Efficacy of methlyphe- (IEP) that outlines measurable academic and/or beha- nidate, psychosocial treatments and their com- vioral goals for children who qualify for services. The IEP bination in school-aged children with ADHD: A is developed in collaboration with parents, educators, meta-analysis. Clinical Psychology Review, 28, 783– community service providers (at parent discretion), and In many cases, students with ADHD require modifica- Barkley, R. A. (2000). Taking charge of ADHD: The tions or accommodations in their instructional program, complete authoritative guide for parents (rev. ed.).
but do not require, and are not eligible for, special education supports. In other words, the learning and Monastra, V. J. (2004). Parenting children with ADHD: 10 behavioral needs of many children with ADHD can besuccessfully addressed within general education. Section Lessons that medicine cannot teach. Washington, DC: 504 plans are mandated by federal law (The Rehabilitation Act of 1973) and ensure a free, appropri-ate education for all children who have physical or mental impairments that substantially limit one or more Barkley, R. A. (2006). ADHD in the classroom: Strategies major life activities (such as learning). If appropriate, a for teachers [DVD]. New York: Guilford Press.
504 plan might include accommodations such as: DuPaul, G. J., & Stoner, G. (2003). ADHD in the schools: extended time on tests, modified assignments, a quiet Assessment and intervention strategies (2nd ed.). New workspace, or computer-assisted instruction, to name a few. Parents should contact their child’s school if they Power, T. J., Karustis, J. L., & Habboushe, D. F. (2001).
feel their son or daughter may benefit from these Homework success for children with ADHD: A family- school intervention program. New York: GuilfordPress.
Rief, S. F. (2008). The ADD/ADHD Checklist: A practical Castellanos, F. X., Lee, P. P., Sharp, W., Jeffries, N. O., reference for parents and teachers (2nd ed.). San Greenstein, D. K., Clasen, L. S., et al. (2002).
Developmental trajectories of brain volume abnor- Stoner, G., & DuPaul, G. S. (2008). Classroom interven- malities in children and adolescents with attention- deficit/hyperactivity disorder. Journal of the AmericanMedical Association, 288, 1740–1748.
Hoza, B. (2007). Peer functioning in children with Kraus, J., & Martin, W. (2004). Cory stories: A kid’s book about living with ADHD. Washington DC: Magination The Charlesworth Group, Wakefield +44(0)1924 369598 - Rev 7.51n/W (Jan 20 2003) Zeigler Dendy, C. A., & Zeigler, A. (2007). A bird’s-eye view of life with ADD and ADHD: Advice from young survivors Anne M. Howard, PhD, is a recent graduate of Illinois State (2nd ed.). Cedar Bluff, AL: Cherish the Children.
University and currently a post-doctoral fellow at theChicago School of Professional Psychology. Steven Landau, PhD, is a Professor in the Department of Psychology at Children and Adults With Attention-Deficit/Hyperactivity National Resource Center on ADHD: http://www.
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Source: http://psychology.illinoisstate.edu/selandau/331/ADHD%20Primer.pdf