Published January 11, 2024

Attention-Deficit Hyperactivity Disorder

What is ADDHD? From time to time, we hear stories of children who are classified as either hyperactive or have conduct disorders. Or hear of parents reporting how hyperactive and disruptive their child has behaved either at home or in a public place. The parents often are not able to control the child because they are not aware of the condition or symptoms. Some parents attribute the behaviors as a normal part of growing up, but as the behaviors become more and more disruptive they become aware that this is a disorder that is interfering with the child’s daily living and coping skills. 

During my years of working as a case manager in a homeless shelter with many families with children, I often heard the parents state “my child never stays still, he does whatever he wants,” “he does not listen to me,” “he got expelled again” “the teacher says that he talks back to her,” or “he throws things around the classroom.” Many parents came to me frustrated, angry and unable to cope with their children’s behavior. They were often at their wits end and some resolved to hit the child or extreme punishment which at times made the child act out even more. Many parents did not have any knowledge that their children’s behavior had a name and that there is an available treatment that can help alleviate the display of those misbehaviors. It would often be like night to day a drastic change; the child once on therapy and medication would exhibit a cooperative response to the parents.

An important factor to know is that the children’s ages ranged from approximately 2 years to 18 years old. How did I handle these type of situation? How was I able to establish what was necessary for these families. What will be the best referral for them? That will ensure that they obtain the best possible treatment and services in the community as well as onsite. This whole process required a thorough evaluation in order to be able to complete the proper referral to the appropriate service agency and other supports.

First, it is important to know the child’s history and come to find out some children have already come into the shelter already diagnosed with the disorder, but the parents had stop both therapy and medication treatment. As a result, causing the children to start acting up again. Some of the behaviors that the children often displayed were constantly getting into trouble at the Boys & Girls club often being expelled. Some of the children often fought with other children or exhibited extreme hyperactivity; failure to listen to their parents and often receiving infractions for their behaviors often getting their parents in trouble. In addition, some of the children ended up being suspended or expelled from school due to their ongoing behaviors.

As a case Manager, I had to not only address the infractions but also I had to be clear that their behaviors were not just caused by the family being homeless in a shelter or other familial dysfunctions. I had to obtain a thorough family history to rule out any mental illness and physical, emotional, or sexual abuse. I start by first scheduling a meeting with the parents to conduct a mini assessment, which will then be submitted to the onsite psychologist for review. The Psychologist will then meet with the parents and then with the child to conduct a mental health assessment and psychosocial to determine the appropriate counseling, group and school intervention if necessary. As a case manager, I have to maintain an active role and meet with the psychologist to discuss the treatment recommended and to determine other causes or family dynamics and history as well as be involved with the behaviorist therapist and school supports. Why is it important to know what ADHD is and how it affects the youth and children? Below are some examples of recent statistics on the numbers of ADHD affected children worldwide.

Statistics

Recent data suggest that 5-7 % of school age children worldwide have ADHD. That is approximately 63 million children and adolescent who are living with ADHD. In united states alone 6.1 million children who suffer from ADHD, and it is persists into adulthood which 366 million adults worldwide have ADHD. Adults living with this condition experience many challenges with time management, organization, focusing and multitasking. (1)

The U.S. Department of Education determined that Students with ADHD would be eligible for special education under the category other health impaired (OHI) Students with ADHD can also qualify for especial accommodations under another law section (504). However, Because ADHD is not recognized as separate category of special education by the U.S. Department of Education, it is difficult to estimate how many students with ADHD are served in special Education. This is why is important for the parents need to know what supports are offered under section 504 to be able to be proactive during school intervention meetings and advocating for services through the board of education. If the parents are not aware of the supports available, most often their child will not qualify or receive the supports they need to ensure a successful school year. (2)

ADHD Case Study

A large percentage of Doctors, psychiatrist and school psychologist diagnose a large number of children in the educational system with ADDHD each year. These children are often either overly medicated or falling through the cracks and often classified in the school systems as having a conduct disorder or behavioral problems. Many are expel from school on a regular basis; some children even go as far as getting into criminal activity or using drugs. Many are labelled as troubled children or sent to a special needs classroom which does not help them address the problem and in most cases makes it worse because they become exposed to deviant youth or children.

The Life of a Child with ADHD:

I am including a case illustration to give the readers a better understanding of what a child with ADHD goes through and what to look for, the child was a 12-year-old, Hispanic, male with a history tapping on the desk at all times, exhibiting distraction and showed lack of focus, frustration and lack of attention. The child started to become more disruptive in the class but not aggressive. The child had a history of hyperactivity at age 6 years old. The child was constantly running around and often having accidents which sometimes resulted in injuries due to his hyperactivity. The child received occupational therapy as a child because he often missed school due to really bad asthma and sinus issues which caused some gross motor skills delays. The hyperactivity displayed as a child was being associated to the side effects of the asthma medication. Although the occupational and speech therapy assisted the child in learning how to manage some behaviors in 1st grade, but not all. However, the intervention helped the child learn some new skills. 

At age 12, the youth started to exhibit the behaviors again in the classroom and was failing his grade. The teacher spoke with the parent and referred the child to the consultation center which was a facility of the board of education assessment center. The facility had onsite child psychologist, behaviorist, occupational, speech and physical therapist, nurse and parents. The child history from pregnancy to birth to actual age was evaluated thoroughly to rule out any medical, motor skills or neurological conditions. The child was then referred to the child guidance clinic for a psychiatrist evaluation for medication and psychologist evaluation to rule out any intellectual disabilities. The child was place on a low dose of Ritalin to offset some of the behavior. 

The team developed an intensive Individualized Educational plan along with all medical treatment recommendation. The treatment plan included all parties with assigned task, therapy, schedule and intervention support for the child to help manage his newly diagnosed ADHD disorder. The parents were given several referrals to community resources to also assist the child with boundaries and coping skills. Within a span of 2 years the child was able to learn how to manage and control his behavior by 14 years old and was able to graduate 8thgrade with honors. The child medication treatment allowed him to stay focused, and as a result he involved himself in many school activities, band and other sports activities. The child is now a successful college graduate in a leadership position at his job. With the proper intervention and school support along with the board of education the team was able to get the right supports, which helped this child thrive with ADHD and learn how to manage the symptoms and the disorder.

What is ADHD?

ADDHD is a disorder displayed by hyperactivity, short attention span, and impulsivity that is developmentally inappropriate and endures at least six months. Typically, this condition is recognized before or during early elementary school, although it can manifest from birth and perhaps before (some mothers report that their ADHD child was a non-stop womb kicker). Because younger children naturally have more ADHD features, kids diagnosed at age four are more likely to be ‘the little terrors” that wear their parents out. ADHD was known in the past as “minimal brain dysfunction,” “hyperactive syndrome,” and “minor cerebral dysfunction.” The new name has been chosen because attention difficulties are prominent and virtually always present among children with these diagnoses. 2 Daniel P. Hallahan & James M. Kauffman, Exceptional Learners, Introduction to Special Education, Ninth Edition, page 186-197

According to the DSM-V there are currently 3 types of ADHD.

1.ADD, inattentive type of ADHD characterized by a lack of attention and distractibility with no signs of hyperactive behavior. Some of the symptoms are daydreaming, inability to pay attention in school, weak working memory and frequent loss of things. Girls are the highest percent of this type.

2. ADHD, this type is marked by Hyperactivity, impulsive behavior with no inattentive behavior. Symptoms they interrupt others, constantly talking at school, blurt answers and struggle with self-control. Boys tend to be diagnosed with this type.

3. Combined ADHD both hyperactivity, impulsive behaviors and inattentive distracted behavior. (2)

What are the symptoms?

ADHD children may exhibit a depressed mood with or without chronic:" body anxiety,” the constantly tapping foot is not driven by anxiety but rather by over activity itself. In the case of the case study child, he was constantly tapping with his knuckles to the point of having visible callouses. If you ask the child why he does that and he might say, “I don’t know-my legs just got to move: Many children with ADHD also demonstrate social immaturity and/or impairments in motor, math, or reading skills.

When ADHD arises during infancy, symptoms most commonly include over activity to stimuli (noise, light, and temperature), crying constantly, and staying awake and frequent agitation. However, a minority is exhausted, weak, oversleep, and develop more slowly for the first few months. Half of the youngsters with ADHD present symptoms before age four, while the rest do so in early elementary school. Gross agitation is more frequent in preschool children, finer degrees of restlessness, later on.

Diagnosis

According to Daniel P. Hallahan & James M. Kauffman, ADHD is widely recognized as one of the most frequent reasons, if not the most frequent reason, why children are referred for behavioral problems to guidance clinics. From one-third to one-half of cases referred to guidance clinics are for ADHD. Most authority’s estimate that forms 3 to 5% of the school age population has ADHD. It is of outmost important that the proper assessment and diagnosis be made ruling out many medical, neurological and learning disabilities.

The first recommendation is a medical examination to rule any medical conditions that can mimic the same symptoms as ADHD. A medical examination can assist in determining conditions such as; brain tumors, thyroid problems, or seizure disorders as the cause of the inattention. Second, a clinical interview with a professional experienced psychologist or psychiatrist to rule out any mental illness or disorder that can also produce the same symptoms. The clinical assessment provides a historical overview of the child developmental, physical and psychological characteristics, as well as family dynamics and the child’s socialization with his peers. It is believed that there are hereditary basis for ADHD.

According to studies if a sibling has ADHD there is a 32% chance that another if the sibling has ADHD also. Some studies referred that parents who abuse alcohol, tobacco, drugs have a greater chance of developing a child with ADHD. Possible fetal and prenatal causes of ADHD include poor maternal nutrition, maternal substance abuse, viral infections, and exposure to toxin such as lead.

Third, teacher conference and school psychologist conference this helps in evaluating the child’s behavior problems in school to rule out any learning disabilities or delays and confirm medical, psychological and educational collaborate with diagnosis.

The parent’s family dynamics and history is needed to determine any type of emotional, physical or sexual abuse. Chaotic families and child abuse worsen ADHD. Some experts claim that food additives and sugar cause ADHD however not completely confirmed by studies.

What kind of treatment is available for children?

Medication: In many cases, medication is necessary and recommended to treat ADHD, some of the medications use to treat ADHD Examples include methylphenidate, Ritalin, dextroamphetamine, Strattera and pemoline. While these drugs have a stimulating effect in most people, they have a calming effect in children and adults with ADHD. These medications do not facilitate learning but help improve the attention span and self-esteem of the child. Most medication work in a period of two days or some make take longer.

Behavioral:

What constitute the best treatment for a child with ADHD? A treatment of medication, in combination with individual tutoring, family counseling, behavior therapy and educational training are all critical. ADHD children should understand that drug taking does not mean they are crazy, that some impaired behavior does not permit all poor behavior that “unstructured permissiveness” is not good for them, and that genuine praise actually arises from jobs well done. Everyone involved should be consistent, supportive, and moderately structured environment. It is important for parents to protect the child’s dignity by making sure that their child is not labeled in school or bullied because he has to go to the nurse to take his medication.

History of ADHD

Defining ADHD has long been challenging to physicians. Previously characterized for decades as a disorder of inattention with episodes of hyperactivity and impulsivity caused by poor parenting, ADHD is currently believed to be a central nervous system (CNS) disorder. The timeline below illustrates important milestones in the understanding and treatment of ADHD.

1902: Morbid defect of Moral Control

1908: High-Grade-Feeble-Minded

1922: Post-encephalitic behavioral disorder in children

1937: Benzedrine/ Amphetamines introduced to treat hyperactive children

1956: Thorazine Chlorpromazine was introduced for Hyperkinetic emotionally disturbed children

1957: The term Hyperkinetic impulse disorder was used to described ADHD

1960: Minimal brain dysfunction

1963: C. Keith Conners publishes a studies on the effects of Ritalin (Methylphenidate) in emotional disturbed children

1966: Minimal Brain Dysfunction Syndrome became the popular term for ADHD

1967-1968: National Institute of Mental Health Institute (NIMH) awards several grants for the study of medication for ADHD children

1968: Diagnostic and Statistical Manual of Mental Disorders DSM-II includes Hyperkinetic reaction of childhood or adolescence and organic brain syndrome for ADHD diagnosis

1968: Hyperkinetic Reaction of Childhood (DSM-11)

1969: Keith C. Conners developed an assessment tool to diagnosed ADHD

1970: Controversial article published around the diagnosis implying too many parents were being coerced to medicate their children.

1970-1971: The comprehensive Drug Abuse Prevention and Control Act of 1970 makes Ritalin medication schedule III then in 1971 schedule II

1973: Section 504 of the Rehabilitation Act of 1973 Allowed students with ADHD to get additional assistance and services at school.

1975: Anti Ritalin movement debating that ADHD was not a diagnosis and that pharmaceutical companies created it

1975: American Academy of Pediatrics (AAP) published an article about ADHD, and medication

1980: Attention Deficit Disorder +/- Hyperactivity (DSM-III)

1981: 17 books were written on ADHD Hyperactive children by Russell A. Barkley, Ph.Ds.

1987: The DSM-III Revised edition change the name of the condition to Attention Deficit Hyperactivity disorder /The APP publishes a report regarding medication for ADHD children drugs mentioned Ritalin, Dexedrine, Cylert, and other medication including tricyclic antidepressant

1993: Dr. Barkley begins publishing “The ADHD Report Newsletter”

1994: Attention Deficit/Hyperactivity Disorder (DSM-IV)

1995: Joseph Biderman, MD. Publishes several hundred studies about children with ADHD

1996: An updated AAP report was issued stressing that medication therapy along with management of child’s environment and curriculum.

2000: APP publishes a guideline for diagnosis and evaluation of ADHD for Pediatricians and parents on proper assessment of ADHD

2002: Strattera FDA Approved

2007: Warning labels on ADHD medication warning of side effects

2013: The Diagnostical and Statistical Manual of Mental Disorders, 5th edition changes the age of ADHD onset criterion raising the age of the onset of symptoms and eliminating requirements that the symptoms cause impairment. (4)

Educational

In order to meet the needs of children with ADHD the classroom becomes an area to enforce some organizational, time management and educational learning skills. The teacher or instructor will need to provide the student with skills needed to transition from one activity to another. To help you follow instructions:

Simplify instructions down to a basic one or two and build from there. Verify these with your teacher or ask your teacher to break down assignments into steps for you to follow. First to help follow instructions: A student can verify the instructions with the teacher or instructor or ask the teacher to breakdown the assignment into steps. Second, to avoid interrupting or answering out of turn, during classroom a student can write down the questions he wants to ask. To take good notes bring a tape recorder to class if allowed study with a classmate. Third homework to help you concentrate find a quiet place in your home, avoid distractions such movement and noise in the family, pets, TV, telephones, music etc. To help with details review your homework with your parents, a class mate or tutor. Before going to school, organize your schoolwork in the same way each day. Have someone help you begin to establish this pattern. Keep your assignments in the same packet of your backpack. Keep a list of things to remember in the pocket of your backpack.

Teaching an ADHD Child To get Organize

Time management: ADHD children have difficulties with time management, patience and waiting for their turn in order for them to stay focused, they need to learn time management skills. Providing a calendar, journal or assignment book can help the child keep track of deadlines, and instructions. The same technique can work at home to teach the ADHD child how to manage their time better there as well. ADHD children need assistance monitoring their behavior and performance, which encourages them to maintain appropriate behavior at school. A teacher must keep a consequences board or poster to encourage self-monitoring of behavior and consequences of negative behavior. As well as a positive board or poster that monitors positive behavior, that encourages attention to task and appropriate behavior. Positive reinforcement is crucial when dealing with ADHD children in the form of social praise or privileges or recording it in a sheet.

Non-Medication Treatment:
Cognitive Behavioral Therapy/ CBT:

CBT can help teach to recognize which thoughts cause unwelcome actions and feelings, and how to replace them with better serving ones. CBT is effective in treating ADHD because it teaches coping skills to self-regulate more successfully. It also can help with managing emotions, reduce anxiety, and teach how to remember things. (5)

DBT Dialectical Behavioral Therapy:

DBT Dialectical Behavioral Therapy focuses on the social and emotional challenges the person has and can be instrumental in teaching self-regulation skills to manage behavior. DBT has been adapted to treat adult ADHD. This therapy teaches how to manage the uncomfortable emotions rather than changing them. It teaches a balance of acceptance and change. DBT focuses on mindfulness, distress tolerance and interpersonal effectiveness skills and emotion regulation. (6)

Occupational therapy:

Occupational therapy helps individuals with ADHD in several ways; it helps identify barriers to success, develop strategies for tackling those barriers, practice new skills or refine the old ones, and skills to brainstorm when things don’t work out.

In short, every parent with school age children, should become informed of the disorder, its symptoms, and what support the school or board of education offers a child who is exhibiting ADHD behaviors to get evaluated and receive the supports needed that will help his learning journey not be disruptive but allow him/her to thrive and learn.

Claribel Coreano, Transformational Life Coach

Images:

https://www.freepik.com

Resources:

1. https://www.medicalnewstoday.com

2. https://www.psychcom.net

3. https://www.psychcom.net

4. https://www.verywellmind.com

5. https://www.psychcentral.com

6. https://www.additudemag.com

7. Jerrold S. Maxmen and Nicholas G. Ward. “Essential Psychopathology and its Treatment, Second Edition, Revised for DSM-IV, Page 440-414

8. Daniel P. Hallahan & James M. Kauffman, Exceptional Learners, Introduction to Special Education, Ninth Edition, page 186-197

9. American Psychiatric Association. (1987). The diagnostic and Statistical manual of Mental disorders (3rd ed.) Washington, D.C. DSM-IV, pp. 83-85.

10. Kaplan, H.I., Sadock, B.J. (1991). Synopsis of psychiatry: Behavioral Sciences and Clinical Psychiatry (6th ed.) (pp.699-704). Baltimore: Williams & Williams