What is ADHD?

ADHD is a neuro-developmental disorder that first appears in childhood and is most commonly identified in the preschool and early school years. It is thought to affect between three to five per cent of children aged six to nine years. Boys are more likely to be diagnosed with ADHD than girls. Since the symptoms of ADHD are seen in all children from time to time, it can be difficult to diagnose. Typically a diagnosis is made by the age of seven, when the symptoms are most obvious. Although the symptoms of ADHD may improve as children mature, as many as 60 per cent of those diagnosed with ADHD in childhood continue to have some symptoms in adulthood.

What would you notice in a child with ADHD?

The most striking features of ADHD in children are difficulties with paying attention, impulsive behaviour and over-activity. Children with ADHD find it hard to manage their immediate reactions and frequently act impulsively without appearing to think first. Children with impaired attention change their activities often without finishing what they are doing. They have difficulty concentrating and remembering what they are told to do. Children with hyperactivity often talk a lot and behave noisily. They seem to be always ‘on the go’ and are frequently restless in situations where they need to be calm. Children with ADHD may be careless in dangerous situations. They may constantly interrupt, intrude on others, and have difficulty taking turns in games or conversation. Older children with ADHD are often not able to plan ahead or get themselves organised.

Attention difficulties and ADHD

Attention difficulties, being over-active, and acting on impulse rather than thoughtfully are seen in all children from time to time, and may be quite common at different ages. There is no clear cut-off between those with ADHD and those without. For a diagnosis to be made, the behaviours of concern should be far more common than are expected in children of the same age, occur in more than one situation, and cause difficulties in the child’s ability to get on at home, at school or with friends. When behaviours are significantly out of step with the performance of other children, and are causing problems for a child at home, school and with friends, further investigation should be undertaken.

How does ADHD affect attention?

Children with ADHD have been shown to have minor differences in brain function compared to other children, especially with those thought processes that control attention and organise memory. These processes are known as ‘executive functions’ (referred to in the table as ‘skill areas’).

Executive functions allow us to set goals and maintain focus, screen out distractions, check our progress and regulate feelings. They are necessary for directing our own actions and controlling our emotions. They are also important for learning new things and for organising what is being learned in schoolwork. Because children with ADHD have difficulties with executive functioning, they often experience difficulty at school and in social situations. The most common difficulties are with sustaining attention and managing impulsive reactions. This pattern is referred to as hyperactive impulsive ADHD. Other children may show inattentive ADHD, where their main problems are to do with the rate at which they can take in and process information. Though difficulties with concentration and attention are central features of ADHD, they may still vary under different circumstances. For example, concentration may be good when the child is highly motivated by a video game but be much poorer when reading a book. Problems with attention mean that children with ADHD often experience learning difficulties at school. Poor attention for academic work may also be influenced by the child’s expectation that he or she cannot succeed as well as others.

Executive functions and related difficulties for children with ADHD

Skill area

Behaviours you might notice when there’s a difficulty

Initiating activities

 

Has trouble getting started (eg on homework, chores, getting ready to go out)

Planning

 

Can’t easily think through steps towards a goal (eg doesn’t work out what is needed to complete a task, doesn’t leave enough time to finish homework)

Prioritising

 

Not able to appreciate the importance of different tasks (eg may focus on small detail and lose track of a more important task)

Persisting

Finds it hard to keep going at tasks until they are completed.

Organising

Can’t easily think through tasks in a logical way (eg may lose track of important items, may approach problems in a haphazard way).

Doing complex tasks

One or two things are manageable, but if a task requires several steps the child may get stuck or mix them up.

Inhibiting

 

Easily distracted when focus is required, and may find it difficult to control inappropriate impulses (eg repeatedly speaks out of turn in class).

Monitoring

 

Doesn’t review own performance (eg doesn’t check answers, doesn’t keep track of time while getting ready for school).

Shifting

May be unsettled when moving locations or changing activities or when unforeseen circumstances arise.

Regulating emotions

May ‘wind up’ easily and have difficulty unwinding; may overreact to minor events

Children with ADHD in early childhood

Careful consideration should be made before diagnosing a child with ADHD in early childhood, as these behaviours are often developmentally appropriate (Green & Chee, 1994). For this reason, a diagnosis is made only when the frequency and severity of a child’s behaviours is out of step with their developmental stage. For example, problems of hyperactivity-impulsivity typically occur in children aged 3-4 years, while inattention often manifests later, when children are 5-7 years. The peak time for a family to seek help is often after the child starts school, as this is when children are required to sit for longer periods of time and focus their attention. We also have some information about what ADHD might look like

Children with ADHD at school

Children with ADHD can have a difficult time in school as the very areas they have difficulty with are those which assist their learning and are expected of them at school. Sitting still, listening to instructions, speaking when it is appropriate, and completing written assignments are activities that involve executive functioning, and so are more difficult for children with ADHD. Their inability to maintain attention and control impulsive behaviour can interfere with the smooth running of the classroom. Their behaviour can also interfere with the learning of other children. School staff may find it difficult to meet their particular needs. Although children with ADHD continue to learn, they often fall behind the progress of other children. As they get older, they may develop secondary problems, such as poor self-esteem and anxiety, because they do not easily fit into the regular classroom and often receive negative feedback about themselves as students. Early difficulties with attention have been shown to negatively affect achievement at school.

How is ADHD diagnosed?

A diagnosis of ADHD is not straightforward. It cannot be diagnosed by any one clinical or laboratory test. To make a diagnosis, a mental health professional needs to undertake a thorough assessment of many factors. These include the child’s progress through early development, any prior experience of trauma or ill health, family circumstances, learning and school behaviours. Parents, carers and teachers should be asked about behaviours they have observed at home and at school. Sometimes parents, carers and teachers will be given questionnaires that rate children’s behaviour to help the psychologist or doctor assess the severity of the ADHD symptoms. They will ask how much the symptoms affect the child’s capacity to cope at home, at school and with friends. All of the information gathered will be combined to help the mental health professional come to a conclusion about whether the child has ADHD or not.

ADHD and other mental health difficulties

Children with ADHD are at greater risk of developing other mental health difficulties. In particular, these include behaviour and learning disorders, such as Oppositional Defiant Disorder, Conduct Disorder, learning and/or language disorders, which may occur alongside ADHD. Children with ADHD may sometimes also experience feeling depressed or anxious, have low self-esteem and difficulties with making or keeping friends. 

What professional supports are available?

Both medical and psychological supports are available. While medical treatment prescribes medication to alter the way the brain reacts to information, psychological support emphasises teaching skills for improving attention and managing behaviours. A combination of medical and psychological treatments is often effective. Getting help early for ADHD is important to reduce the possibility of related problems of under-achievement in school and poor self-esteem.

Psychological treatments

Psychological professional support commonly involves:

  • parent and carer education about ADHD, with specific focus on skills for managing the child’s challenging behaviour 
  • school staff education about ADHD, with a focus on skills and strategies for managing the child’s challenging behaviour and assisting their learning 
  • counselling and psychological support for the child, including education and advice, and skills training to improve concentration.

Addressing issues of self-esteem, anxiety and peer relationships is also a crucial element of counselling. Learning new skills can help children with ADHD gain control over the main symptoms more quickly. All children require assistance from parents, carers and teachers to provide structures for their behaviour and learning until they have matured sufficiently to manage for themselves. It is very important to establish a plan to help the child’s learning at school. This plan should focus on ways to help the child overcome difficulties with executive functions. A coordinated approach between home and school has been shown to be of most benefit.

Medical treatment

Medication (ie psychostimulant medication such as methylphenidate and dextroamphetamine) can be prescribed to improve concentration and attention. These medications have been shown to improve brain functions related to memory. It is a short-lived improvement and not a cure. Not all children benefit from these drugs so discussion of the pros and cons with the prescribing doctor is very important. Ongoing medical monitoring should examine whether the medication is making a difference and check for possible side effects such as sleeping difficulties and decreased appetite. Medication alone is usually not sufficient treatment for ADHD. The best way to support and assist a child with ADHD is to have a coordinated approach both at home and at school. 

How to assist children with ADHD

Having a child who has ADHD has been shown to put additional stress on family members. Typically, parents and carers find that they need to change their parenting strategies for children with ADHD to take into account the particular needs and abilities of the child. Similarly, the classroom, with its demands for concentration, presents difficulties for children with ADHD, and school staff can use teaching approaches and strategies that help to prevent children under-achieving. The best way to support and assist a child with ADHD is to have a coordinated approach between home and school. ADHD is a disorder that can look different in different children, so it is important to be aware of each child’s specific strengths and areas of need.

General principles for assisting children with ADHD:

Provide structure: Children with ADHD require more routine and structure in their day than other children of a similar age. Try to ensure that rules and instructions are clear, brief and, where possible, presented in charts and lists. 

Maintain a good relationship: Relationships can become strained with children with ADHD whose behaviour is often stressful to deal with. Having fun and taking note of children’s interests are important in relationships. Trying to maintain a good relationship with children will assist with their self-esteem and help them to be more cooperative. Taking some time out where possible can also be important and can benefit everyone

Become a keen observer: Keep an eye out for the things that trigger certain behaviours in the child (eg over-stimulation at birthday parties). Noticing these things will help in managing behaviours, namely by being able to put strategies in place to manage the situation.

Provide praise and positive reinforcement: It is important to provide positive statements and praise when children are behaving well, and to focus more on this than on negative statements about challenging behaviours. This is important for all children, but particularly for children with ADHD.

See also:

What does ADHD look like?

ADHD: Suggestions for families

ADHD: Suggestions for schools and early childhood services

ADHD: Further resources