Attention Deficit Disorder

Attention Deficit Disorder and Attention Deficit with Hyperactivity Disorder are medically defined conditions which are usually controversial. Although these names are American in origin the conditions were first identified in the UK in the early years of this century. Children who showed an "abnormal incapacity for sustained attention, restlessness, fidgetiness" were thought to have serious deficiencies in "volitional inhibition" of a biological origin. By chance it was discovered in 1937 that the psycho stimulant amphetamine used reduced hyperactivity and behaviour problems.

In the 1950's and 1960's the term "Minimal Brain Damage" became a catchall description of children with learning and behavioural problems for which no clear cause could be found. It is only in the eighties that European and American thinking moved away from identifying the causes to treating the behaviour. Although the term hyperactivity described many of these children there has been a shift towards the view that the hyperactivity a consequence of poor attention and implusiveness.

Claims for the evidence of ADD/ADHD vary widely from about 3% to as much as 10% of the school population. It may be that one child in each primary classroom could meet the criteria for diagnosis. Although most cases come to light during primary education there is usually a lengthy history of difficulties. There will also be a significant number of children and adults who had not been identified and who will come to light as diagnostic thinking develops and information spreads more widely.

ADD is a condition which shares characteristics with many other conditions. Diagnosis is often a lengthy process of observation, testing of approaches and identifying specific difficulties. Often students with ADD will also suffer from literacy, organisational or co-ordination difficulties. Each difficulty will need to be investigated carefully with appropriate action taken to help the student.

Students with ADD/ADHD are varied in their characteristics and the severity of their difficulties. They are easily distracted, forget instructions, switch activities at whim, respond to 1:1 suppression or attention, have poor short-term memory skills and often seem to be day dreaming. They also seem able to recall events and information which is important to them and can focus almost obsessionally on some, often apparently irrelevant, issue. They are also frequently insatiable, never satisfied. repetitive and persistent long after everyone else gives up.

They often speak out without thought and can rise quickly to perceived threats or challenges. They often have a sharp sense of "justice" and are often acutely aware of breaches of rules, especially after the event. They are sometimes "out of time" socially, act silly in a crowd, misread social cues, overpower / "boss" others, lose friends, and need lots of reassurance.

The ADD/ADHD child can often be restless, fiddling, rocky, tapping, touching and always on the move. Poor coordination, awkwardness, poor handwriting and inability to attend to two tasks are frequently present. They are often blind to mess, have problems "getting started", and may find it difficult to plan an activity or piece of work.

Their mood is often swinging from good to bad without explanation. It is often the degree of contrast between sufferers and the general population and between one time and another, which marks the condition and gives rise to a realisation that they are "out of step".

The great difficultly is deciding when all these characteristics combine to support a diagnosis of ADD/ADHD. Most "normal" children will display some of these characteristics at the same time. However, they will not be persistent nor will they have a severe and damaging effect on the child's normal development. There will also be a interaction, actually with learning but also with the child's environment. Since adults create or maintain most of the child's environment changes by adults such as parents and teachers will have an effect on the child and the child's behaviour. Changing, or trying to change, the child's environment is an important step in treating and diagnosing ADD/ADHD. Where planned changes in adult behaviour have not changed the child's behaviour significantly other approaches might be needed and self esteem boosting too.

The family can be helped to accept that the child has a biologically based problem that no amount of force or fighting will beat out of him. Because they are impulsive "normal" methods of punishment and "talking to" the child will often be wasted. Although poor parenting can make bad behaviour worse and more frequent ADD/ADHD can seem to make good, caring parents seem poor. Parents need to focus on only the important irritations. They need to be calm and to avoid escalating situations. Routines help and consistently applied rules aimed at changing small aspects of behaviour are most effective. Patience is essential, but frequently stretched, so frequent rewards are needed for parents especially praise from people they respect.

Self esteem is usually low in these students because few activities are successfully completed. Every success must be celebrated and activities chosen to give opportunities. Team activities are less certain Diagnosis

Although many professionals claim that their particular, and often idiosyncratic, method is the only way to diagnose ADD/ADHD the complex interactions and symptoms mean that there cannot be a single conclusive "test" for ADD/ADHD. There are two internationally used diagnostic definitions of ADD/ADHD, which used to be dramatically different but are each developing and sharing common concepts. Diagnosis, by which ever definition, can be approached in four steps.

1. Be aware of the possibility of ADHD

The child under-functions at school for intellect and under-behaves at home for the quality of parenting; i.e. they are significantly out of step with brothers, sisters and peers.

2. Rule out ADD/ADHD lookalikes

Exclude major developmental delay, normal pre-schooler behaviour, primary problems of family dysfunction.

3. Collect information leading to diagnosis

Test profiles, continuous performance test, parent/teacher questionnaires, brainwave tests.

4. Take a careful history AND observe the child

"When she walked she was into everything"

"At the start of school he was disruptive and distractible"

"She only works well when stood over"

"He goes on and on and never lets a matter drop"

"He's impulsive, short fused, and socially out of tune"

"She's disorganised and has a poor short-term memory"

Managing ADHD

The most effective ways of helping the ADD/ADHD student will be through changes to their environment and how others, especially adults, interact with them. Helping the school and the classroom teacher. Helping the parents by structuring the home for peace! Helping the student by boosting self esteem and developing outside interests. Considering carefully and trying, if appropriate, other therapies and approaches. And finally, there IS the option of considering medication.

The school can be helped by an explanation of how the behaviours seen are not naughtiness. That the child can't help it, it is not a challenge to the teacher, and it is not something that the teacher is doing wrong. Encouraging calm, consistent and persistent approaches where firmer and willingness to back down are used appropriately is essential. The school and teachers need their skills to boost self esteem because they often rely on timely activity an social skills. Every opportunity should be taken to "brief" the student in preparation for future activities but care must be taken not to isolate them or overload them with "extra tuition". The words each adults speaks need to be measured carefully because they are often taken literally and can easily crush confidence.

Diet does not seem to cause ADD/ADHD behaviour. However, current research suggests that less than 10% of ADHD children are significantly affected by natural or artificial preservatives, additives and colourings in the diet. As irritability and overactivity seem to be the most diet sensitive behaviours there may be a worsening of the student's tolerance with consequent learning and behavioural difficulties. Likewise it seems unlikely that too much or too little sugar would affect ADD/ADHD behaviours but again there may be an increase in irritability or over activity which could worsen the situation.

Helping the student improve handwriting and other co-ordination or organisational skills, perhaps through occupational therapy, will help self esteem. It will also reduce the overhead of effort required for each piece of work leaving greater resources for focussing attention.

There is much controversy regarding biofeed-back, multivitamins, eye-exercises, tinted lenses or filters and the SEMERC Information Servicey integration therapy. It seems prudent to put sustained effort into proven therapies and environmental adjustments before following any unproven or fringe approach
Medication for ADD/ADHD

Stimulant medication was first used in 1937 and the drug known as Ritalin (Methylphenidate) has been used since 1958. The approach and the medication is well researched and used. Although there are fears that such drugs are addictive and dangerous there seems to be little hard evidence of this or of serious side effects. Perhaps there is a greater argument for concern that by suppressing the child's behaviours to fit adult expectations the child's rights are being abused. On the other hand those that suffer the behaviours, including the child, lose a great deal by the disruption experienced.

The main medications used in ADHD are Dexamphetamine (Descedime) and Methylphenidate (Ritalin) which have been shown to be effective, in the short term, for up to 80% of ADHD children. The longer term benefits are less clear but some doctors suggest that lifetime use may be necessary. There are after non stimulant drugs which are used alone or in combination with stimulants especially where co-existing medical conditions preclude the use of Ritalin etc.

These stimulants are not sedations, they enhance normal brain function, and start acting. They start to work within 30 minutes and their effect passes in 3-5 hours. They can be targeted on critical times such as the school day when focussed attention will bring greatest benefits. For the child in school it may be necessary to have two, or more small doses to maintain the effect through the day.