12th June 2014
Kathy Morris
Consultant Clinical Psychologist
ADHD is…
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ADHD is not simple to define. There is more than one
explanation
ADHD is also called Hyperkinetic Disorder (HD).
Attention Deficit Disorder (ADD) also has features
of ADHD
However, the main features of ADHD are:
a. Inattention
b. Hyperactivity
c. Impulsivity
(From ‘Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition’ [DSM IV])
Inattention
Inattention is…
Not paying close attention to detail
b. Making careless mistakes
c. Difficulty in sustaining attention
d. Not seeming to listen when spoken to
e. Not following instructions
f. Failing to finish activities
g. Organisational difficulties (e.g. losing things)
h. Forgetful
i.
Easily distracted
a.
Hyperactivity
Hyperactivity is…
a.
b.
c.
d.
e.
f.
Fidgety
Restless
Often running around or climbing excessively
Noisy
Often ‘on the go’
Talking excessively
Impulsivity
Impulsivity is…
a.
b.
c.
Blurting out answers before questions are finished
Interrupting or intruding on others
Difficulty waiting in turns
Defining ADHD – Medical Research
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ADHD occurs in 3-9% of children with 3 times
more boys than girls being diagnosed. (Swanson et
al., 1998)
Children with ADHD have been shown to have areas
of the brain that are under-active and smaller e.g.
frontal lobes, cerebellum, basal ganglia.
(International Consensus Statement on ADHD,
2002)
ADHD has been associated with low levels of
dopamine in the brain. Dopamine is a naturally
occurring brain chemical, that acts as a signal
between brain cells. Genetic studies suggest that
a variation in the genes that regulate the dopamine
signal increases the risk for ADHD.
Prevalence
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Prevalence estimates are highly dependent on:
–
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The population sampled, methods used and diagnostic criteria
applied
US estimates higher than UK estimates
Most estimates vary between 5% and 10% for ADHD
About 0.5-1% of school age children have HKD
Taylor (1994) suggests that a point prevalence for HKD is 1:200
in the whole child population
Male to Female ratio is at least 4 to 1
What else could it be?
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Anxiety
ADHD
Sexual abuse
Social/ environmental factors
Specific Learning Difficulty/ Dyslexia
ASD
Secondary Symptoms:
co-morbidity
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Antisocial Disorders (25%-50%): CD, ODD
Affective Disorders
–
–
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25% have co-existing anxiety disorder
20% have co-existing mood disorder
Developmental Disorder (20%)
–
–
–
–
–
–
–
Dyslexia
Dyspraxia
Specific language impairment
Discalculia
Learning disability
Autism Spectrum Disorder
Tic disorder
Outcomes and co-existing problems
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Long-term outcomes are poor
Children with ADHD are 4 times more likely to have mental heath
problems in later life if not treated
Example of such mental health problems are:
- conduct disorder
- anxiety disorder
- bi-polar disorder
- depression
(Barkley, 2002)
Other problems associated with ADHD
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Poor self-esteem
Poor social skills – relationship difficulties
Mood swings
Sleep problems
Never feeling satisfied
Extreme stubbornness
Poor organisation and management of time
Underachievement at school
Lack of motivation
Problems with rules
Over-sensitivity
Vulnerability to stress
Short-term memory difficulties
Physical symptoms (e.g. headaches, stomach aches)
Assessment
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Parent and Teacher Conners’ Rating Scales
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Strengths and Difficulties Questionnaire (SDQ)
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ADHD Information Questionnaire
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Other information that will be useful for
assessing a child with suspected ADHD e.g.
observations of behaviour, sleep patterns
Treatment of ADHD –
medication how does it work?
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Medication is not a cure, but it can help improve
concentration and reduce impulsive behaviours
The National Institute for Clinical Excellence (NICE)
recommends that medication be used together with
therapies
There are different types of medication – some are ‘shortacting’ (e.g. Ritalin) and others are
‘slow-release’ (e.g.
like Concerta XL, Equasym XL)
Treatment of ADHD –
medication (continued)
Why is it important to monitor medication?
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When paediatricians and psychiatrists first prescribe
medication, they need feedback regarding the impact of the
medication upon behaviour and possible side effects.
The child’s parents may ask you to comment on any changes
in the child’s behaviour. This is to ensure that the medication
is at the right dosage; it may need to be adjusted
N.I.C.E. guidelines 2008
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Specialist teams
DSM IV or ICD 10 criteria
Consider co-existing conditions: social,
familial, educational, health, m.h. of carers
Diagnosis not on rating scales/observation
alone
Significant, pervasive, impact on life
Behaviour interventions in class: training for
teachers
N.I.C.E. guidelines 2008 (continued)
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Moderate : group parent training ? with social
skills group/CBT for child
Severe : drug treatment and group parent
training
Drug treatment always part of
comprehensive treatment plan
Take account of child/young person’s views
What should you do if you think that a
child has ADHD? Care pathways
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Discuss any concerns with other professionals who
work with the child
Discuss the child’s presentation with the parents
If in school the child may be referred to: the
Educational Psychology Service and the Core Panel
The parents may wish to discuss the child’s behaviour
with their GP, who may in turn decide to refer the
child on to a paediatrician or psychiatrist
There is a multidisciplinary team at the Phoenix
Centre
Things that can help
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Always address the child by name
Try to make eye contact wherever possible
Provide clear instructions, both in verbal and
written/pictorial form
Break big tasks into smaller ones and tell them
what the end objective is
Raise the profile of the child (e.g. running
errands, sharing successes, interests and areas of
strength)
Give the child a ‘fresh start’ once the cause of
their difficulties has been identified
Things that can help (continued)
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Work with the parents and child to enable them to tackle
associated areas of difficulty e.g. reading and peer
relationships
Assist
in
monitoring
medication
and
behavioural
interventions if asked to do so
Encourage the child to participate in activities that will help
to develop self-confidence and social skills
Ensure clear communication with parents and other
professionals, so action can be taken promptly before things
get out of control
Learn best from activities that are:
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Hands on, practical
Novel
Have a range of different elements
Short
Frequently changing
An opportunity to be in the limelight
In a distraction-free place for written work
Enabling physical movement in a group or
class
Learn least from activities that:
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Require passive listening or watching
Are routine and predictable
Demand high attention to detail
Require staying still for long periods
Demand high level of repetition/ practice
Dealing with inattention
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Provide children with a brief outline of the task to be
completed
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Break instructions and activities down into manageable
chunks
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Have realistic expectations about what is achievable
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Keep targets to one or two activities
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Use special cue phrases when attention appears to be
waning e.g. ‘Wait for it’, ‘Now for the interesting bit’, ‘The
next bit is amazing!’
Dealing with hyperactivity
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Give restless and fidgety children opportunities
to move e.g. in seat :squeezable balls, doodle book,
tangle toys, blue tac or small building blocks that
do not make a noise
Try to keep children busy e.g. give them a job or
task that allows them to be active in a controlled
and positive way e.g. handing out books,
equipment, delivering a message
Dealing with impulsivity
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This can be difficult and frustrating to manage
but not impossible!
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Children with ADHD act first and think later.
We need to reverse this process
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a.
b.
c.
Encourage the child to do things in 3 stages:
Stop and listen
Look and think
Decide what to do
Praise
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Using praise improves concentration and self-esteem
When praising focus on the particular behaviour that you
are wanting to encourage
If the child has behaved well during a specific task – praise
them
Rewards
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Children with ADHD respond very well to rewards related
to short-term targets
Agree specific achievable targets e.g. sitting still for 10
minutes
Negotiate rewards with the child and vary them regularly
to maintain interest
Build on success e.g. activities that the child does well.
Nothing succeeds like success!
Little things mean a lot
Identify small ways of complimenting the child for
positive behaviour
e.g. ‘Well done, Peter, you…
…asked a good question
…solved a problem
…encouraged someone
…listened well’
(From ‘Practical Ideas that Really Work with Students with ADHD’
McConnell & Ryser)
How to deal with challenging behaviour
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Be specific and realistic about the behaviour you are
expecting from the child
Do not try to address all behaviours at once
Address the behaviour and not the child e.g. ‘I like it when
you put your hand up to answer questions’
Clearly state what behaviour is unacceptable and the
consequences of such behaviour e.g. ‘If you continue to push
Ryan you will have time out. Please take a step away from
him’
How to deal with challenging behaviour
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Children with ADHD may not be doing what you’ve
asked because they have forgotten the task.
Instead of saying ‘please get on with it’, remind
them of the actual task and be specific
Children with ADHD can have explosive outbursts
due to feelings of extreme frustration with
themselves but take it out on those around them
Try to remain calm and emotionally neutral. Show
the child that you are in charge of the situation
Think Positive!
Many negative characteristics of ADHD can have a positive side
Impulsive
Decisive and enthusiastic
Distractible
Creative and open-minded
Restless
Energetic and lively
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Although it may not always be easy to see a situation in this way it
will help to maintain a positive relationship with the child
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Although you may feel frustrated at times, the way you react to
any child can strongly affect the way others behave towards them.
Further information
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ADDISS (Attention Deficit Disorder Information and
Support Service) via www.addiss.co.uk /
020
8906 9068
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Google Scholar – recent articles
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ADDERS UK via www.adders.org
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‘123 Magic’ by Thomas W Phelan
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‘Understanding ADHD’ by Christopher Green & K Chee