ADHD: not your one-size-fits-all diagnosis

ADHD stands for Attention-Deficit / Hyperactivity Disorder, and it occurs in a little over 7% of children under the age of 18, making it a common neurodevelopmental disorder. It is often first diagnosed in childhood and lasts into adulthood. While there is no cure for ADHD (Attention-Deficit/Hyperactivity Disorder), utilizing available treatments can help reduce symptoms and improve overall functioning. Those treatments often include a combination of the following: medication, education, training and therapy.

What Are the Subtypes of ADHD?

There are three subtypes of ADHD: predominantly inattentive, predominantly hyperactive, and combined. Unfortunately, we have witnessed many medical professionals and educators identify these subtypes as distinct disorders to parents, referring to them as ADHD and ADD, rather than ADHD-Predominantly Inattentive, ADHD-Predominantly Hyperactive-Impulsive, or ADHD-Combined. They most likely do this to distinguish between children that have “hyperactivity” and those that do not, but it is important to understand what subtype your child falls under.

A History of ADHD diagnosis and treatment

The medical field has documented symptoms similar to what is now known as ADHD going back over 200 years. Physicians noted the inability to attend with consistency and frequent fidgeting, and that these cause conflicts within the family. 

The first use of stimulant medication with children was in 1937. In the 1960s, as mental illnesses were being formalized through the first edition of the Diagnostic and Statistical Manual (DSM), initially inattention and hyperactivity were listed under other disorders, such as Hyperkinetic Reaction of Childhood and learning disabilities. It was only in the DSM-III, in 1980, that the disorder was identified as Attention Deficit Disorder with or without Hyperactivity.  

In 1987, with the fourth revision of the DSM, the disorder was re-named Attention Deficit Hyperactivity Disorder. At this time, the subtype of inattention was removed and assigned to “undifferentiated ADHD.” After a series of studies in the late 1980s showed that there was a distinct difference between those with hyperactivity and those without, the DSM released their Text Revision in 1994, with the three subtypes we currently have under the umbrella of ADHD. 

In addition, it was recognized that this was not just a disorder of childhood, but one that was chronic and persistent into adulthood. After this revision, the definition of ADHD in the DSM lined up with the definition in the International Statistical Classification of Diseased and Related Health Problems (ICD), which is used by World Health Organization.  

What Are the Causes of ADHD?

Currently, like many disorders, the exact causes of ADHD are unknown, but it is most likely caused by interactions between genes and the environment. Factors that may contribute to the development of ADHD include genetics, cigarette smoking and alcohol or drug use during pregnancy, exposure to environmental toxins at a young age, low birth weight, and brain injuries.  

It is important to understand that ADHD is not just a childhood disorder; although the symptoms begin in childhood, it is likely to continue through adolescence and adulthood. Specifically, while a person may see an improvement in hyperactivity, difficulties with inattention, disorganization, and poor impulse control often continue to affect a person with ADHD throughout their teens and adulthood.   

How is ADHD Diagnosed?

If you are concerned that your child has ADHD, please talk to a doctor or therapist to find out if the symptoms meet the criteria for a diagnosis. Qualified professionals who can diagnose include mental health professionals such as psychologists and psychiatrists, or primary care providers such as a pediatrician. For children under the age of 3, you can contact your local early intervention agency or the local public school if your child is 3 or older.

Evaluating for ADHD

According to the American Academy of Pediatrics (AAP), it is recommended that when evaluating for ADHD, providers should speak to parents, teachers and other caretakers of the child, to determine what the child’s behavior is like at home, school, or with peers. It is important that your child is also screened for other disorders, as children with ADHD are more likely than other children to also be diagnosed with behavior disorders such as Oppositional Defiant Disorder or Conduct Disorder. Other frequent related disorders are learning disorders, anxiety, and depression.

The evaluator will use the guidelines in the Diagnostic and Statistical Manual, Fifth edition (DSM-V) to help determine if a diagnosis of ADHD is warranted. They are likely to evaluate children and adolescents ages 4 to 18 years if they are having academic or behavioral problems and show inattention, hyperactivity, or impulsivity. The AAP guidelines recommend that healthcare providers also use rating scales and other sources to document the symptoms.

Where ADHD is Assessed?

ADHD may be assessed in a doctor’s office, or in a psychologist’s office. For younger children, they may be assessed at a school or early intervention office. The evaluator or healthcare professional may want to meet with your child individually, to have them complete different types of written, spoken, or computerized assessments. Parents and guardians may also choose to have a complete neuropsych evaluation completed, which will typically assess intelligence, academic achievement, and social, emotional.

How is ADHD Treated?

While there is no cure for ADHD, utilizing available treatments can help reduce symptoms and improve overall functioning. Those treatments often include a combination of the following: medication, education, training and therapy.

ADHD and Medication

Please note that the following information should not be considered medical advice; it is an overview of current medication approaches, but all questions about how to treat ADHD pharmacologically should be reviewed with a healthcare professional.

Medication for ADHD primarily addresses and reduces hyperactivity and impulsivity, while also improving one’s ability to focus, work and learn. Medication is likely to begin with stimulants, which increases dopamine in the brain. Dopamine plays an essential role in thinking and attention. Examples of stimulants include Focalin, Adderall and Vyvanse.  If stimulants are not effective or the side effects were significant, doctors may prescribe a non-stimulant, such as atomoxetine and guanfacine (which are marketed under the namebrands of Strattera and Intuniv, respectively). These medications typically take longer to start working, but can also improve focus, attention and impulsivity.

As all medications have both benefits and side effects, it is important to communicate openly with your child’s doctor about what you are seeing. In addition, consider that sometimes several different medication or dosage sizes must be attempted before finding which one works best; further, as your child grows in height and weight, their medication will most likely need to be adjusted, and what used to work may no longer work as well or vice versa. Persons who take medications for ADHD should be closely monitored by their doctor.

While medication has been shown to be the most effective treatment for ADHD, it is often used in conjunction with therapy or education. The medications allow the brain to be more available for learning, and then a therapist or teacher can help improve the application of behavioral management and executive functioning skills.

For children 6 years of age and older, the AAP recommends behavior therapy and medication, preferably together. For children under 6 years of age, behavior therapy and parent training in behavior management are recommended as the first line of treatment.

ADHD Training and Therapy

Behavior therapy has been shown to be an effective treatment for ADHD, and leads to improvements in children’s behavior, self-control, and self-esteem.

Parent training over individual play or talk therapy is recommended for children under 6, as they are not yet mature enough to change their behavior without their parents help.

For school-aged children and adolescents, the AAP recommends combining medication with behavior therapy. Options for therapy at this age include parent training in behavior management, behavioral interventions in the classroom, peer interventions that focus on behavior, and organizational skills training. These approaches are most effective if used together.

In behavior therapy, families will be taught how to create and apply proactive strategies such as creating routines and schedules, getting organized, managing distractions, limiting choices, helping your child plan, and using goals and praise. The CDC's page on Parent Training in Behavior Management offers helpful questions that should ask a provider to determine if they are using a proven approach.

Persons with ADHD benefit from consistent schedules, from morning wake-up to bedtime, as it helps them know what to expect and what the limits are. A typical symptom of ADHD is disorganization; you can help your child from a young age by encouraging them to put clothes, toys, and backpacks in the same place every day after use.

As all children are individuals, you will need to watch your child to determine what level of distraction is too much when they are trying to focus on homework; some students must have no noise, while others learn better if they an move or listen to background music. TV and any visual media are a distraction that needs to be removed when all children are doing homework. While children with ADHD often seem to seek a lot of stimulation, paradoxically, they need help not feeling overwhelmed or overstimulated. Offering a limited number of choices, such as when picking out an outfit or a toy, will help reduce behavior escalations.

While all children need help in early elementary breaking down complicated tasks into simpler, shorter steps, children with ADHD often need help doing this through adolescence and adulthood. This is frequently a source of frustration for parents because we expect children to develop more independence as they grow up; it will happen but providing guidance and direct instruction may need to happen for longer than with a child who does not have ADHD.

Helping your child build their self-esteem is also a component that cannot be forgotten; children with ADHD unfortunately experience a higher incidence of negative reinforcement and attention, told “no,” and being rejected by their peers. You can create positive opportunities and experiences by encouraging your child to participate in activities that they do well and providing praise for positive behaviors.

Research has also shown that nutritious food, lots of physical activity, and getting the recommended amount of sleep for a child’s age are important in the management of symptoms of ADHD. While many children with ADHD are drawn to video games, and often demonstrate “hyperfocus” when playing, at least 30 minutes of daily physical activity such as riding a bike or going for a run, have been shown to significantly reduce hyperactivity.

Disciplining a child with ADHD can be both proactive and reactive. Using behavior charts to identify goals and track positive behaviors is a proactive approach to discipline and to developing independent life skills. Once your child has achieved their realistic goal, give them praise or reward their effort in other ways. If a child does need to be disciplined, effective directions, timeouts and removal of privileges are recommended consequences for inappropriate behavior over scolding, yelling, or spanking.

ADHD Education

It is recommended that parents of children with ADHD learn as much as they can about the disorder. The organization CHADD is a clearinghouse for evidence-based information about ADHD, and their website has links to information for people with ADHD and their families. In addition, the National Resource Center on ADHD has a call center where ADHD Information Specialists can answer questions about ADHD (1-866-200-8098).

As a parent with a child with ADHD, it is also important to have guidance and support for yourself. Stress management techniques increase one’s ability to deal with frustration so you can respond calmly to your child’s behaviors. Support groups can help connect parents and families with others who have similar challenges and concerns.

Additional information on services for children with special needs can be found at the Center for Parent Information and Resources, or you can visit in person.

School-based Interventions

For students who qualify, special education services through an Individualized Education Plan (IEP) are available at public schools. If a child does not meet the criteria for an IEP, they may qualify for a 504, which provides accommodations to the learning environment. Examples of accommodations that can be provided through IEPs and 504 Plans include, but are not limited to:

• extra time on tests,

• instruction and assignments individually tailored to your student,

• positive reinforcement and feedback,

• using technology to assist with tasks,

• breaks or time to move around,

• efforts to limit distractions in the environment, and

• extra help with getting and staying organized.

While there is limited research on what accommodations are most effective, research has shown that setting clear expectations, providing immediate feedback, and communicating daily with parents or guardians through a daily report card leads to positive results.

There are a variety of interventions that can be implemented in the school setting. Staff can give frequent feedback and attention for positive behaviors; provide extra warnings for transitions and changes in routines; selective ignoring of negative behaviors; and when students with ADHD are demonstrating hyper-focus, they may need extra assistance in shifting their attention. For tasks and assignments, directions and expectations should be clearly written and communicated, and staff should check for understanding from the student; either break up or help students break up longer assignments into smaller, specific steps; allow for breaks and time for movement; and use organizational tools such as a binder or homework folder. 

Students may also benefit from access to fidget tools, ball chair or standing desk, social skills groups, proximity control, and a daily behavior report card. The types of interventions and accommodations that will work best for your child will be discussed as part of an IEP or 504 plan, but if your child does not meet the criteria, please continue to communicate with the teacher, as they may be implementing strategies that are helpful supports to your child. Additional ideas for school personnel can be found here.

If you need help from our specialist ADHD tutor, contact us today!

To learn more about the Individual with Disabilities Education Act (IDEA), please visit http://idea.ed.gov/.

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Additional References:

Lange, K. W., Reichl, S., Lange, K. M., Tucha, L., & Tucha, O. (2010, December). The history of attention deficit hyperactivity disorder. Retrieved February 15, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3000907/

Parent Training in Behavior Management for ADHD. (2019, September 30). Retrieved February 16, 2020, from https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html

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