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When they say ADHD…
 By
Loi Eberle, M.A.,
Educational Consultant
Editor of Woodbury Reports, Inc.
loi@woodbury.com
208-267-5550
Most people have heard the terms ADD or ADHD. Either a family member
or a friend’s child has received the diagnosis, or they have heard it frequently mentioned in the media, due to the increasing number
of people who are affected in one way or another by this behavior. In fact, when they hear the definition, many people feel they probably
would have received that diagnosis themselves, if the questionnaires and rating scales had existed when they were in school. Yet, although
the term is familiar, there seems to be less clarity about what exactly it is, and even more confusion about what to do about it.
Definition & Diagnosis
ADHD is not so much a single condition, but one that can “include a loosely defined set of common childhood problem behaviors…noncompliance,
academic difficulties, social skills deficits, aggression, overactivity and attentional defects.” These behaviors can be caused by a
variety of factors, so there has been a great deal of effort placed on developing a better understanding of this behavior when it occurs.
Other causes of ADD/HD types of behavior, such as structural and/or physiological deficits of the central nervous system due to prenatal,
natal and postnatal trauma, or metabolic and seizure disorders, need to be ruled out, for example. Efforts are made to isolate a “pure
ADD/HD group” by evaluating each child according to psychiatric, neurological, cognitive, educational, and social parameters.
There are actually three ways it is categorized: ADD refers primarily to inattention (attention deficit disorder); ADD/HD refers to
predominately hyperactivity; and ADHD refers to a combination of inattentive and hyperactive behaviors (attention deficit hyperactivity
disorder). The symptoms of inattention and impulsivity are difficult to define; it is not easy to measure them. ADHD symptoms which
usually are present in a child might not be observed in a highly structured or novel setting with interesting tasks or one-to-one attention;
it may require observations in a variety of settings. Merely describing hyperactivity is “not meaningful without referring to the situation
in which these behaviors occur.”
ADHD symptoms are assessed through questionnaires completed by parents, teachers, peers, and even the children themselves. It is a diagnosis
that is determined with a checklist of symptoms, with 6 out of 9 symptoms on one rating scale needing to be present to receive a diagnosis
of inattention, and 6 of nine symptoms on another rating scale being necessary to be diagnosed with hyperactivity. The symptoms not
only need to be present, they also must have occurred for at least 6 months, at a level that has caused adjustment problems beyond what
would be considered normal for their age and are clearly having an adverse affect on their social, academic, or occupational functioning.
More recently, other diagnostic tools are being explored. For example, neuroimaging and functional imaging studies have found differences
in metabolism and in the shape of the brain among those with ADHD. There is also some indication of a genetic predisposition for ADHD.
Studies done on twins show that hyperactivity and inattention can be inherited separately. Some research also indicates that possibly
a deficit in a combination of neurotransmitters might be involved with ADD/HD behaviors.
Because behaviors that are broadly defined as ADHD may be the result of a variety of causes, understanding why they are occurring will
give insight about the best way to help. If the child’s behavior is determined to be the result of pervasive developmental disorders,
autism, anxiety, or personality disorders, then these children should work with mental health professionals who have experience in these
areas. On the other hand, “if clinical findings indicate that the symptoms of inattention and/or impulsiveness are due to developmental
disorders, structural defects of the central nervous system, or inappropriate or inadequate stimulation at critical ages, then…a diagnosis
of ADHD can be considered.”
Even if the child’s behavior truly fits within the set of behaviors given the ADD or ADHD diagnosis, the issue remains, what to do about
it??
Parenting Skills
The literature certainly indicates that most children with ADHD also develop other dysfunctional patterns such as depression, anxiety,
oppositional defiant disorder, and even conduct disorders, that co-exist with their ADHD. In some cases parents contribute to conduct
problems by their inconsistent and impotent responses to their child’s rages. Behavioral management skills can help families work with
their child in more helpful ways, so that the child can become more self-reliant and less anxious. Since rage reactions can be triggered
by anxiety, if the anxiety is reduced, it can result in less raging behavior. Although sometimes medications can help a child gain some
control over moods and behaviors, even in those cases, it is still important for parents to develop good parenting skills.
Family Therapy
It also is helpful for parents to fortify their relationship with each other, when they are dealing with their ADHD child. The parent’s
marital boundaries, which are sorely needed to protect their own relationship, are often weak and diffuse in ADHD families. These boundaries
need to be strengthened and the parents need to be supported to help them let go of their excessive focus on parenting their ADHD child.
These families can greatly benefit from family systems therapy, where the family itself is the focus of treatment, helping them to create
a safer, more relaxed environment for their ADHD child. Extended, long-term therapy with ADHD children is usually unnecessary if the
families are in therapy to work on their entire family system. The ADHD child will be benefit far more by the parents working to solidify
their own relationship through enhanced intimacy and communication Long-term therapy with the ADHD child only serves to reinforce the
child’s self-perception of being “damaged”. Short-term therapy for the ADHD child should consist of family sessions designed to educate
parents with knowledge and skills that will enable them to become advocates for their ADHD child and help them to create a healthier
family environment for all of their children.
Medication & Diet
Research has shown that stimulant medication will relieve inattention and restless behavior in approximately 75% of hyperkinetic children,
however, “most studies do not find clear evidence of improvement in academic learning.” Particularly when central nervous system dysfunction
is involved, stimulants have no clear role to play in relation to learning disabilities. While most side effects of stimulant medication
are more annoying than dangerous, the emergence of Tourette’s syndrome has been reported and there is evidence of growth suppression
with prolonged use of stimulants. Response to stimulant drugs cannot be used as a confirmation of the diagnosis of ADHD, since children
who did not demonstrate symptoms of ADD or ADHD responded in the same way to stimulants.
Dr. Feingold, Emeritus chief of the Department of Allergy at the Kaiser-Permanente Medical Care Program in San Francisco, specifically
indicated that salicylates, food colorings, preservatives, and additives trigger allergies that are a precipitating factor in what he
called the Hyperkinetic Learning Disability syndrome. The use of the Feingold or the Kaiser- Permanente diet has not received scientific
confirmation, and “no objective challenge study of the effect of sugar on hyperactivity has been done to date,” although there are many
anecdotal reports of the diet’s success.
How Should They Be Taught?
It is important to provide these children and adolescents with “persistent, patient instruction in systematic ways.” They need help
in “organizing assignments and learning materials…Teachers need to give clear directions in classes and to provide organized media for
communicating assignments and require organized notebooks and assignments books, with time provided for their consistent use. Teachers
should also stockpile a few extra copies of assignment schedules, textbooks, and other materials to avoid the inevitable confrontations
that occur when the student forgets them elsewhere. Teachers should understand that at home, parents of children with ADHD have organizational
problems of their own to deal with. Expecting them to manage their children’s work at school by remote control is unrealistic.”
Teachers who are successful teaching students with ADD or ADHD, consider these students as a challenge, not a burden. They recognize
that their role not only includes imparting knowledge, they need to teach skills in socialization as well. These teachers are not annoyed
by these student’s behaviors, and respect them as human beings. It is important to convey acceptance and support for the students with
ADD/ADHD who may be less popular with their classmates because they are impatient and talkative. “Students with ADHD are easy targets
for scapegoating or being made the object of mirth in the classroom…In the final analysis, no specific kind of class placement, no single
set of curriculum objectives, no special list of teaching techniques exist for teaching students with ADHD.”
Prognosis
Studies have “estimated that more than 70% of hyperactive children continue to meet criteria of ADHD in adolescence and up to 65% as
adults.” “At the 5-year followup with children 11 to 16 years old, the initial symptoms of hyperactivity, distractibility, impulsive
behavior, and aggression were generally decreased but still were greater than in the normal controls. Further, the hyperactive children,
now young adolescents, were considered immature, had difficulty maintaining goals, failed more grades in school, and had lower academic
achievement than their matched controls. Twenty-five percent of them were considered antisocial. “While few hyperactive children become
grossly disturbed or chronic breakers of the law and none were diagnosed as being psychotic or schizophrenic, the majority continue
as young adults to have…continued symptoms of the hyperactive child syndrome…lower educational achievement, poorer social skills, lower
self- esteem…continued impulsivity and restlessness.”
Later studies indicated “core symptoms of inappropriate restlessness, attention difficulties, and impulsivity were still present in
adolescence, though somewhat muted. Poor school performance, social deviance, and difficulties in relationships with peers and with
adults were prominent, with 10% to 50% of the ADHD group having a history of anti-social behavior, although approximately 50% were indistinguishable
from normal peers. However, the remaining 50% had a history of antisocial behavior, used alcohol and marijuana, and 20% had a DSM-III
diagnosis of Antisocial Personality Disorder. Drugs that were so effective in the short term to reverse the core symptoms of ADHD were
not effective in the long term with adolescents, who were still failing in school, having behavior problems and poor self-esteem, still
at high risk for academic and social difficulty.”
Can Emotional Growth Programs Benefit ADHD?
To date, all the followup studies have focused on traditional approaches to education and medication. The data from these studies has
shown the long-term outcome for children with ADHD has generally been disappointing, with half of the children studied showing continued
symptoms of decreased impulse control, lower educational achievement, poorer social skills, and low self-esteem These studies did not
include data on students who are being educated in emotional growth settings that focus on developing skills in the areas self-esteem,
impulse control, and social skills. Anecdotal evidence indicates that students who improve in these areas also improve their ability
to achieve academically, and they are able to develop the skills that will enable them to find successful employment and develop healthy
relationships. Given that the problems associated with ADD/HD are becoming more familiar to a greater number of people, hopefully more
research will be directed towards alternative forms of educational programs. This would serve to validate anecdotal evidence which shows
greater success with ADHD students when the education includes: a strong emotional growth component, a structured environment that enhances
self-esteem based on true achievement, offers needs-based instruction in academics, and helps students to develop skills in self-monitoring
and self-regulation.
Ostrom, N.N. & Jensen, W.R. (1988). Assessment of attention deficits in children. Professional
School Psychology, 3, 254-269.
Practice Parameters, attention deficit/hyperactivity disorders. (1997). Journal of the Academy of Child and Adolesccent Psychiatry,
36 (Suppl.), 85S-121S.
Porges, S.W., & Smith, K.M. (1980). Defining hyperactivity: Physiological and behavioral strategies.
In C.K. Whalen & B. Henker (Eds.), Hyperactive children: The social ecology of identification and treatment (pp.75-104.) New York:
Academy Press. (reduced glucose utilization bilaterally with significant reduction in superior frontal and premotor cortices and reduced
anterior frontal width and smaller volume of left caudate, frontal interior bilateral retrocallosal.).
(dopamine, norephinephrine, or serotonin systems may be involved)
Disorders of Learning in Childhood, A. Silver & R. Hagin, (2002 Wiley & Sons, Inc.) Ibid.
C.A. Everett & S. Volgy Everett, Family Therapy for ADHD, (1999 Guildford Press).
A. Silver & R. Hagin, op cit.
Ibid.
Ibid.
Ibid.
Barkley, R.A. (1996). Critical issues in research on attention. In G.R. Lyon & N.A. Krasnegor (Eds.), Attention, memory and executive
functions ) pp.45-56. Baltimore: Brookes; and Goldman, L.S., Genel, M., Bezman, R.J./, & Slanetz, P.J. (1998). Diagnosis and treatment
of attention-deficit/hyperactivity disorder in children and adolescents. Journal of the American Medical Association, 279, 1100-1107.
Weiss, G. (1983). Long-term outcomes: Findings, concepts and practical implications. In M. Rutter (Ed.), Developmental neuropsychiatry
(pp.422-436). New York: Guilford Press.
A. Silver & R. Hagin, op cit.
A. Silver & R. Hagin, op cit.
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