Why is early detection important?

Research has demonstrated that appropriate early intervention can make significant differences to outcomes for individuals with Attention Deficit Hyperactivity Disorder (ADHD). The earlier ADHD is detected and diagnosed, the earlier intervention can begin, and help prevent more severe symptoms developing. Early intervention can mean more time to teach skills that will support a child to reach their full potential. Health and community professionals play a significant part in assisting families, early childhood services and schools with training on the signs of ADHD and appropriate referral pathways. The diagnostic process itself can provide opportunities to gain comprehensive information into how to best provide instruction, structure, positive relationships, behavioural modification and reinforcement to assist the child with ADHD. It also ensures the most appropriate intervention can be implemented based on that child’s specific needs.

ADHD diagnosis is typically made by the age of seven, when the symptoms become most obvious. Although the symptoms of ADHD may improve as children mature, as many as 60 per cent of those diagnosed in childhood continue to have symptoms in adulthood. Compounding this, children with ADHD are at greater risk of developing other mental health difficulties, particularly behaviour and learning disorders such as Oppositional Defiant Disorder, Conduct Disorder, and learning and language disorders. Early intervention therefore provides vital opportunities to prevent future symptoms, particularly difficulties with executive functions (e.g., initiating activities, planning, prioritising, persisting, organising, doing complex tasks, inhibiting, monitoring, shifting and regulating emotions).

Changes to DSM-V criteria

The Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) provides the diagnostic criteria for ADHD for the vast majority of health and community professionals. In 2013, the fifth edition of the manual was released and, with it, came changes to the ADHD category. Changes that relate to ADHD in children included:

  • Moving ADHD to the Neurodevelopment Disorders chapter to reflect the brain development correlations with ADHD
  • A co-morbid diagnosis with autism spectrum disorder is now allowed
  • Examples have been added to the criteria to facilitate application across the life span
  • The cross-situational requirement has been strengthened to “several” symptoms in each setting
  • Subtypes have been replaced with presentation specifiers that map directly to the prior subtypes
  • The onset criterion has been changed from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”

The same primary 18 symptoms used for ADHD diagnosis remain in the DSM-V. They also continue to be divided into the two major symptom domains, inattention and hyperactivity/impulsivity, and six symptoms in one domain are still required for an ADHD diagnosis. 

Evidence-based tools for diagnosing children with ADHD

ADHD diagnosis is not straightforward and requires thorough assessment by mental health professionals. Diagnosis is based on the DSM-V criteria and requires a holistic and comprehensive assessment of many different factors. Initial assessment can include medical, developmental, behavioural, cognitive and mental health assessment tools. These assessments include factors that focus on the child’s progress through early development, any experience of trauma or ill health, family circumstances, learning and school behaviours. Parents, carers and teachers should be asked about behaviours at home and at school. This can be completed through rating scales, questionnaires, structured interviews and global assessment measures and focus on behavioural, emotional and cognitive symptoms and their impacts. These are based on the DSM-V and can help assess the severity of the child’s ADHD symptoms and the impact regarding the child’s capacity to cope at home, school and socially. It is also important, in addition to assessment of individual, mental, physical, family and educational factors, to understand the child’s level of functioning relative to their usual social and cultural environment. Through utilising a comprehensive assessment approach, not only can ADHD symptoms be diagnosed, but other issues/diagnoses can be ruled out or highlighted and comorbid diagnoses can be developed. 

Evidence-based interventions for children with ADHD used by professionals

Interventions for ADHD require a coordinated approach at both home and school and can comprise both psychological and pharmacological treatments.

Psychological treatments

There are numerous psychological treatments for ADHD, which focus on the areas of parent, carer and education staff psychoeducation and training and individual/family therapy (e.g., cognitive behaviour therapy, behavioural modification and counselling).

Psychoeducation and training for parents and carers focuses on helping them understand the symptoms, prognosis, treatment and strategies to use at home. This can help parents and carers understand how ADHD affects them and their child. It also helps families by using strategies, such as setting clear expectations and routines, discipline strategies, giving clear instructions and prompt feedback, to help them cope with the condition and have consistent strategies in place until the child’s self-management has been developed. Group and individual training can also provide information and strategies for behavioural modification such as having natural consequences , time-outs for cooling down/reflecting and supporting/rewarding desired behaviour. Furthermore, education, training and building on the skills and strengths of children can help them gain more understanding and control as well as building resilience.

Psychoeducation and training for education staff at early childhood services and schools aims to assist educators to understand ADHD, its impact on learning and areas where support is needed. Strategies for school staff and early childhood services involve support with self-management and organisation that focus on the different areas of executive function (initiating, planning, prioritising, persisting, organising, doing complex tasks, inhibiting, monitoring, shifting and regulating emotions). Tips such as giving clear instructions, breaking tasks down, ensuring understanding and individual tutoring not only help the individual child to learn and develop but also facilitates the learning of others. This training can help the child’s functioning in both the classroom and playground.

Individual and family therapy provides psychological support for children, advice and education for families, and skills training for children with ADHD. Behaviour modification can be an important component, which can use a system of rewards to encourage control from the child with ADHD and can facilitate the process of developing self-management. Cognitive behaviour therapy can assist in changing thinking and behaviour patterns, which compliments the behavioural therapy. General therapy/counselling can also address issues of self-esteem, anxiety and peer relationships for children with ADHD. Therapy can be completed in coordination with both parents, carers and education staff, which has been shown to be most beneficial.

Other interventions regarding diet and supplementation can sometimes be recommended but remain controversial and are not necessarily supported by evidence. They therefore shouldn’t be attempted without medical advice.

Pharmacological treatments

Psychostimulant medications (such as methylphenudate, dextroamphetamine and lisdexamfetamine) aim to improve attention and concentration. These medications have been shown to improve brain functions related to memory and some are required every day and some can be taken just on school days. They can offer improvements in concentration, impulsivity, attention, help the child feel calmer and give an opportunity to learn and practise new skills. Not all children benefit from these drugs and each has their pros and cons, so discussion with the prescribing doctor is important for parents and carers. Ongoing medical monitoring is needed to assess the efficacy of the medication and to check for possible side effects such as sleeping difficulties, decreased appetite, increased blood pressure and heart rate. Treatment breaks can be recommended to assess whether the medication is still needed. Medications are not a permanent cure for ADHD and nonpharmacological treatments need to take priority for sustainable long-term results. It is important to note that medication alone is usually not sufficient for ADHD treatment.

How can health and community professionals assist schools and early childhood services with children with ADHD?

Health and community professionals are well placed to provide information, planning, training and ongoing support in both early childhood service and school settings. As effective interventions for ADHD require the collaboration between parents, carers, educators and professionals involved, the relationship between all stakeholders is essential. Health and community professionals can help create open, collaborative relationships where information is shared in an efficient manner so that everyone involved is undertaking a coordinated approach to management and treatment. Specific information regarding the individual child’s condition, needs and treatment plan can then be shared with all stakeholders who can then tailor strategies for an individual, rather than applying general ADHD information and strategies. Health and community professionals are also well equipped to assist families, early childhood services and schools in understanding and using the appropriate referral pathways, understanding service locations and maintaining relationships with other professionals. This also provides more opportunities for connecting families and education staff with further training, resources and support. Using this coordinated and holistic support model, families, early childhood services and schools can be well trained and resourced, supported and connected to best assist children with ADHD together.

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Barkley, R. A. (2014). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment (4th ed.). New York: Guilford Press.

Ghosh, M., Fisher, C., Preen, D. B., D’Arcy, C., & Holman, J. (2016). “It has to be fixed”: A qualitative inquiry into perceived ADHD behaviour among affected individuals and parents in Western Australia. BMC Health Services Research, 16(141), 1-12.

Hamilton, N. J,. & Astramovich, R. L. (2016). Teaching strategies for students with ADHD: findings from the field. Education, 136(4), 451-460.

National Health and Medical Research Council. (2012). Clinical practice points on the diagnosis, assessment and management of attention deficit hyperactivity disorder in children and adolescents. Retrieved from https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh26_adhd_cpp_2012_120903.pdf

Rajeh, A., Amanullah, S., Shivakumar, K., & Cole, J. (2017). Intervention in ADHD: A comparative review of stimulant medications and behavioural therapies. Asian Journal of Psychiatry, 25, 131-135.

Said, Z., Huzair, H., Helal, M. N., & Mushtaq, I. (2015). Attention deficit hyperactivity disorder in children and adolescents. Neurology and Psychiatry, 19(3), 16-23.

Smith, E., Koerting, J., Latter, S., Knowles, M. M., McCann, D. C., Thompson, M., & Sonuga-Barke, E. J. (2014). Overcoming barriers to effective early parenting interventions for attention-deficit hyperactivity disorder (ADHD): Parent and practitioner views. Child: Care Health and Development, 41(1), 93-102.

Sonuga-Barke, E. J. S., & Halperin, J. M. (2010). Developmental phenotypes and causal pathways in attention deficit/hyperactivity disorder: Potential targets for early intervention. Journal of child Psychology and Psychiatry, 51(4), 368-389.