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Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder which can cause two broad types of behavioural difficulties: inattentiveness, and hyperactivity and impulsiveness. Most people with ADHD have symptoms of both inattentiveness and hyperactivity/impulsiveness, but this is not always the case. Children who have predominantly inattentive behavioural difficulties without significant hyperactive or impulsive behaviour may be described as having Attention Deficit Disorder (ADD), and they can sometimes go unnoticed as the symptoms are less disruptive to others. Both ADHD and ADD can impact on a child’s social relationships, academic attainment, self-esteem and family life.

Top Tip

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Support social situations – keep them short and try to avoid new or demanding social tasks when the child might be tired, hungry or otherwise not at their best.

Often symptoms of ADHD are noticed in early childhood, however the difficulties tend to become more obvious when the child starts school and the demands placed on them increase. Most cases of ADHD are diagnosed between 6 and 12 years old and in the UK it is unusual for a diagnosis of ADHD to be considered before 6 years old. This is because many typically developing children go through a period of highly active behaviour, restlessness and inattentiveness, and this is nothing to worry about. Parents and professionals should only be concerned if a child’s behaviour appears to be markedly different from that of their classmates.

The cause of ADHD is not known, although it has been observed to run in families so there are thought to be both genetic and environmental factors which contribute. Differences in brain structure and brain chemistry have been observed between people with and without ADHD but work to understand these differences is ongoing. Babies who are born prematurely or with a low birth weight have an elevated risk of developing ADHD, as are children who suffered from a brain injury prenatally or after birth. Smoking, drinking and drug misuse during pregnancy are also risk factors for a child developing ADHD.

If there are concerns regarding possible symptoms of ADHD a child could be referred to a number of different healthcare professionals with specialist knowledge of ADHD, including a child psychiatrist or paediatrician. In order for a diagnosis of ADHD to be made, children must experience symptoms of inattentiveness and/or hyperactivity and impulsiveness for at least 6 months, with symptoms displayed in at least two settings (e.g. at school and at home), and appearing before the age of 12. Symptoms should have a significant, detrimental impact on the child’s academic, social or occupational functioning and must not be better explained by another condition. ADHD cannot be cured but can be treated by therapies and/or medication.

Checklist

Child displays symptoms of inattentiveness and/or hyperactivity
Symptoms have been present continuously for at least 6 months
Symptoms are displayed in at least 2 settings
Symptoms started before the age of 12
Symptoms have a significant (negative) impact on the child’s social/academic/occupational functioning
Symptoms are not better explained by another condition
The symptoms experienced by a child with ADHD are likely to change throughout their childhood and adolescence. For some children, their symptoms might decrease as they get older, or they may become less obvious to others as they learn to manage their difficulties, but for others their difficulties will persist into adulthood.

ADHD is thought to be ultimately related to a deficit in executive function; the cognitive processes which plan, organise, monitor, evaluate and, if necessary, inhibit our behaviour. If executive function is the overarching impairment, we can see that any aspect of behaviour that requires planning and coordinating can be more difficult for a child with ADHD, including language and communication skills. Indeed, children with ADHD are at higher risk for experiencing language and communication difficulties, with research suggesting that between 50-80% of children with a diagnosis of ADHD also have a language difficulty or social communication difficulty.

Prevalence

Approximately 3-5% of school-aged children are affected by ADHD – that’s roughly one in every class of 30 children. ADHD is more commonly diagnosed in boys than in girls, however girls are thought to be less likely to be identified.

What to look for

Children with ADHD who have symptoms of hyperactivity and impulsiveness are often the easiest to identify. Usually, children with this presentation will be highly active and they might be described as “a bull in a china shop” because their actions can be impulsive and appear careless. These children will likely have difficulty sitting still in the classroom and will have difficulty paying attention to teaching and staying on task.

Children who predominantly have symptoms of inattentiveness without hyperactivity and impulsiveness can be more difficult to identify as their behaviour is less disruptive. These children are likely to have difficulty concentrating on tasks and might be visibly inattentive to spoken language. They can be easily distracted and will often have difficulty getting started, as well as sticking to tasks, and they might constantly switch activities. These children often have significant difficulty planning how to complete a task independently and can appear to be disorganised and forgetful.

Difficulties

Short attention span and high distractibility. Children will have difficulty maintaining concentration on lengthy tasks and tasks which are not of interest to them.
Frequently making careless mistakes.
Forgetfulness and losing things often.
Difficulty listening to spoken information and instructions. Because of this, they can have difficulty following instructions and may miss details in stories and conversations.
Frequently flitting between different activities.
Difficulty planning tasks, organising themselves and equipment.
Excessively active, ‘fidgety’ and have difficulty sitting still.
Poor turn taking. Children may have difficulty waiting for their turn, even when they understand the rules, and they may frequently interrupt other people talking.
Talking excessively and dominating conversations.
Impulsiveness – acting without thinking first and having a reduced sense of danger or the consequences of their actions.
Poor sense of time.
Poor conversation skills. They might have difficulty introducing or maintaining a topic of conversation, difficulty paying attention to conversations and may miss details,
which makes it difficult for them to respond appropriately. They can also have difficulty monitoring and adapting their style of communication to their environment. Impulsivity and miscommunications can cause children to ask inappropriate questions at times.
Weak narrative skills. Children can struggle to tell coherent stories as they may have trouble sequencing events and ideas.

Myth Busting

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Are all children with ADHD hyperactive?

There is more than one kind of ADHD, one of which is a predominantly inattentive type which is sometimes known simply as Attention Deficit Disorder (ADD). These children present only (or mostly) with symptoms of inattentiveness and it does not impact on activity levels. Children with predominantly inattentive symptoms may be described as ‘day-dreamers’. It is more common for girls to be diagnosed with this type of ADHD, but it can occur in boys too.

Do children with ADHD jut need to try harder to pay attention and focus on activities?

ADHD is nothing to do with laziness and not a sign that a child is necessarily unmotivated to engage. Studies show that there are brain differences in children with ADHD which means that telling them to “concentrate harder” is just as ineffectual as telling a person with a hearing impairment to “listen harder”.

Does having ADHD mean that a child cannot focus on any activity?

Some children with ADHD can actually become ‘hyper-focused’ on activities which they really enjoy and find it hard to tear themselves away. So while a child with ADHD might find it difficult to concentrate on their classwork, you might find that they are able to play their favourite game for hours and they might have difficulty shifting their attention, e.g. if you call their name.

Is ADHD caused by bad parenting and a lack of discipline or boundaries at home?

Many of the difficulties associated with ADHD – particularly impulsive and hyperactive behaviour – can cause problems in public settings, especially those in which other people have expectations of certain behaviours, e.g. supermarkets, waiting rooms, and public transport. A child with ADHD may exhibit behaviours which are not appropriate, and parents very often feel judged by others for seemingly not being able to ‘control’ their child who is not conforming to public expectations. The reality is that, for children with ADHD, these behaviours are not always under the control of the child or parents. In fact, while children with ADHD usually benefit from structure and routines, overly disciplinary parenting, which continually punishes a child for behaviours which they are not able to control, can be significantly detrimental in the long run and particularly damaging to the child’s mental health and wellbeing.

Is having ADHD really a serious problem?

ADHD is not a life-threatening medical condition, but it can be life-altering and there should be no doubt that it is possible for ADHD to have a significant detrimental impact on a person’s quality of life, if their symptoms are not addressed. People with ADHD, especially those who have not received any treatment, are at higher risk for developing emotional difficulties, engaging in antisocial behaviour and substance misuse, and the disadvantages experienced with regard to their education can have a lasting impact on employment prospects.

Strategies

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Children with ADHD benefit from a structured environment with familiar routines. This helps them to learn the expectations and consequences of their behaviour because the environment is predictable.
Clear boundaries will help children to manage impulsivity.
Give specific positive praise rather than general feedback, e.g. instead of saying “well done!” say “You did really good sitting and I liked that you showed me that you were listening by looking at me”.
Make sure instructions are short and specific so that the child knows exactly what he/she needs to do.
Many children with ADHD respond well to reward charts or similar strategies which allow them to earn rewards because these reinforce and incentivise positive behaviours.
Encourage the child to get lots of physical activity during the day. Do not expect the child to sit still for extended periods and provide lots of opportunities for movement breaks – you could invite the child to be your assistant so that they have a reason to stand up and move around the classroom.
Limit distractions. It’s often better to have the child sitting at the front of the room away from windows and doors, and they may do better with an individual desk or paired with a less distractible peer than sitting with a group.
Task management boards and checklists for older pupils can help students to plan activities and remain on task.
Be aware that children may need to fidget to be able to process information and this is not necessarily a sign that they aren’t listening. Try to find an outlet for this that you can accommodate in your classroom.

Role of SaLT

Children with ADHD may or may not require support from SaLT. Using the Language Link assessment can help you to identify whether a particular child requires intervention to support their language development or whether they require further assessment from a SaLT. Social skills interventions might also be appropriate and these might be led by school staff or by a SaLT depending on your local circumstances.

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Focus on - Attention Deficit Hyperactivity Disorder