Understanding and managing Attention Deficit Hyperactivity Disorder (ADHD) in children

Measurement of ADHD

There is much debate over the most appropriate ways to measure ADHD. Psychologists use rating scales, questionnaires and other tests that have different versions for collecting information from the child, their parents/caregivers and their teachers (both in the home and in the classroom). Observation of the child’s behaviour is usually undertaken to supplement the tests. Cognitive tests of attention and its impact on memory and learning can be helpful in establishing and analysing the attentional disorder. Other measures used by psychologists include IQ tests; tests of learning, reading and mathematics; scales that assess behaviour and social interactions; as well as information about the child’s birth and early developmental milestones, including any significant life events such as injuries and hospitalisation.

Diagnosis

The formal diagnosis of ADHD is complex. There are two main criteria, or symptom groups, that are currently used to make a diagnosis - attentional symptoms and hyperactivity symptoms.

Most ADHD children display characteristics of both hyperactivity and inattention. In the first instance, many cases of ADHD come to the attention of parents/caregivers, teachers and psychologists when children are excessively active, impulsive, inattentive and act in a non-compliant, defiant way.

Key symptoms

Each symptom (inattention and hyperactivity) must persist for six months or more and be exhibited across various settings.

The key features associated with symptoms of inattention include:

• Failing to give close attention to details and difficulty sustaining attention in tasks or play;
• Not listening when spoken to;
• Not following through on instructions and failure to finish tasks;
• Difficulty organising tasks and activities;
• Avoiding, disliking or being reluctant to engage in tasks that require sustained mental effort;
• Losing things necessary for tasks or activities; and
• Being easily distracted.

The key features associated with symptoms of hyperactivity (sometimes known as hyperactivity-impulsivity) include:

• Fidgeting with hands or feet and squirming while seated;
• Getting up when remaining seated is expected;
• Running about or climbing excessively;
• Difficulty playing or engaging in leisure activities and always ‘on the go’;
• Talking excessively and blurting out answers before a question is completed; and
• Interrupting others.

While ADHD is recognised as a disorder that is distinct from some of the other childhood disorders, it frequently overlaps with other conditions such as Conduct Disorder. This can make diagnosis difficult. Further, many ADHD symptoms are not unique to the disorder. This means that symptoms of ADHD can be non-specific indicators of other childhood disorders, including behavioural difficulties or learning disorders.

Assessment or diagnosis of ADHD is often undertaken in the first instance by a medical professional such as a paediatrician or child psychiatrist. It is also common for child clinical psychologists, clinical neuropsychologists and educational and developmental psychologists to be involved in the diagnosis of ADHD. Clinical neuropsychologists are more likely to be involved where brain or cognitive deficits are implicated. Educational and developmental psychologists are involved when there are educational and learning difficulties and behavioural problems at school, and clinical psychologists where behavioural or emotional disturbances are the obvious outcomes of the disorder and should be included in the treatment/intervention.

Psychologists involved in the treatment and management of the disorder focus primarily on how the disorder affects behaviour and learning and what can be done to improve them. They assess the impact on the family and assist the parents/caregivers to manage the child.

Assessment of the child’s behaviour at home and in school must also be undertaken.

These are the places where treatment will take place and where behavioural improvements will be noticed. Accurate diagnosis is essential for successful treatment/intervention.

Difficulties associated with the assessment of children with ADHD include:

• The changing definition of diagnostic criteria over time;
• Changes in the disorder as the child grows older;
• Differences in expectations regarding children’s behaviour; and
• The focus of research predominantly on young, white, middle class boys.

Diagnosis is also influenced by consideration of the causal factors believed to be involved in ADHD. In the past research concentrated on finding an underlying brain dysfunction that could account for ADHD, but more recently research has begun to examine how cognitive impairments such as learning difficulties and memory problems are linked with the disorder.

Treatment/intervention

Treatments range from medication through to training for parents/caregivers and/or teachers, as well as cognitive and/or behavioural management programs for the child.

Pharmacological treatment is generally used in more severe cases to help focus the child’s attention. Psychological treatments are primarily oriented towards developing skills for adaptive behaviour at school, at home and with peers. These treatments are appropriate for nearly all cases as they are focussed on the management of behaviour and learning and are directed at the individual child, the parents/caregivers and school personnel.

The most commonly prescribed medication is typically a stimulant such as dexamphetamine and methylphenidate (Ritalin). The high level of prescription of these medications has caused community concern, and has been associated with an overemphasis on the biological aspects of ADHD.

What psychologists offer

One treatment intervention aimed at improving behaviour in children diagnosed with ADHD is parent/caregiver training about the nature of the disorder, and in behaviour management techniques. Psychologists develop programs aimed at assisting parents/caregivers in managing their child's behaviour. These have been shown to have both short and long-term beneficial effects. Such programs train parents/caregivers to set limits for their child, to provide structured routines, to deal with non-compliance, temper outbursts and other disruptive behaviours, and to find other appropriate services.

Education for teachers

Teachers can benefit from programs aimed at assisting them to manage children whose behaviour is disruptive in the classroom. Like parent/caregiver training, teachers are trained to deal with the learning and behavioural problems frequently associated with ADHD. Behavioural problems are frequently noticed at school and it has been found that

ADHD children perform best in a highly structured classroom environment. Educational interventions include the use of praise and reward for on-task behaviour, using behavioural management techniques such as monitoring via score cards, ways of improving self-regulation (both at home and at school), and enhanced encouragement and support from the teacher. Educational and developmental psychologists can assist by devising suitable programs for the teacher and by monitoring the child's behaviour. Many schools have access to educational and developmental psychologists (sometimes referred to as a school psychologist or a guidance officer).

Tailored support and psychological treatment for children with ADHD

Psychologists also offer individual counselling and specific psychological treatments for children with ADHD. Counselling includes educating them about their behaviour, discussing issues related to medication, expectations about acceptable behaviour and helping the child to achieve insight and self-regulation, as well as skills training to improve concentration and decrease impulsivity. Cognitive-behavioural techniques assist children to improve their behaviour and social skills, both at school and at home. These techniques work by enabling children to think about their behaviour, develop more effective self-control strategies and to act appropriately. Addressing issues of self-esteem, anxiety and peer relationships is also a crucial element of counselling.

Treatment and intervention should be based on accurate diagnosis. Indeed, any behavioural problem that affects a child's social relations, academic skills or learning, can benefit from a carefully designed program. That program may or may not include medication. The immediate impact of medication makes it an attractive short-term solution for behavioural problems associated with ADHD. This can help the psychologist who then works with a more compliant and focussed child. However, programs must also address issues of behaviour management or problems that may return when medication ceases or is withdrawn.

Medication should generally not be regarded as sufficient in itself for treatment of ADHD. Even children with severe ADHD should have access to long-term behavioural programs, as should their families and teachers. Close collaboration and consultation between professionals involved with children with ADHD can ensure medical and psychological interventions are coordinated to maximise the benefits and outcomes for each child.

Seeking professional assistance

It is very important that children who have symptoms of inattention or hyperactivity are properly diagnosed so that appropriate treatment and management can commence. A clinical psychologist who works with children, an educational and developmental psychologist, or a clinical neuropsychologist who specialises in the diagnosis of childhood brain disorders, can make the diagnosis. Psychological assessment is usually undertaken in conjunction with a medical assessment in order to provide an accurate and comprehensive diagnosis. A clinical or educational and developmental psychologist can provide the necessary programs for the management of ADHD in the school and at home, working with teachers and parents to assist the child's social and academic development.

Your APS psychologist has at least six years of education and training to equip them to provide a professional and efficient service. You can access an APS psychologist for professional assistance in understanding and managing ADHD in children. Refer to the APS Find a Psychologist service.