Introduction

Attention Deficit Hyperactivity Disorder is an internationally recognised medical condition. Medical practitioners in the U.K. are increasingly diagnosing it in school age children, however the cluster of problems defining A.D.H.D. constitutes one of the most complex disorders in childhood.

ADHD is a condition that is managed, not cured.

The purpose of this information site is to provide background information. The key to helping children living with ADHD is to understand the disorder. This is by no means a comprehensive guide and further means of finding out about ADHD will be covered. If you require further help or information please do not hesitate to contact the Ryegate Children’s Centre on 01 14 267 0237 or myself on 0114 271 7626.

A brief history and a working definition of ADHD

Despite several name changes over the past hundred years, the problems now defined as ADHD are not new. It is believed that George Still an eminent paediatrician was one of the first people to recognise the cluster of problems. In lectures he gave back in I902 he described a small group of children who showed ‘inhibitory volition’, aggression, defiance, lack of moral control, resistance to discipline and impaired attention. He hypothesized an underlying neurological deficiency and believed these children should be institutionalized at an early age.

In 1917, following a world outbreak of Encephalitis, studies were carried out in the USA with children who had physically recovered from the infection but it was noted they had impaired attention and impulse control, were very active and had behavioural problems. It was assumed that this was a result of the infection and the term Minimal Brain Damage was used to describe the condition.

It wasn’t until the 1960’s that the idea of brain damage began to be questioned because the core symptoms were being seen in children who had no history of infection/brain damage. Therefore the term minimal Brain Dysfunction was used, however it was soon felt that this was too vague a term and other terms were used including hyper kinetic disorder and hyperactive child. Research in the I970’s began to focus on the view that lack of attention and impulse control was the major problems for these children.

Attention Deficit Hyperactivity Disorder is the most recent diagnostic term for children presenting with significant problems with attention, impulse control, and over-activity as described in The Diagnostic and Statistical Manual of American Psychiatric Association (DSM IV). This can be viewed in the ‘assessment tool’ section of this site.

A summary statement has been taken from the British Psychological Society (1996) as a working definition;

ADHD is a changing and evolving concept, which refers to children and young persons whose behaviour appears impulsive, over-active and/or inattentive to an extent that is unwarranted for their developmental age and is a significant hindrance to their social and educational success.

Attention Deficit Hyperactivity Disorder.

The core features of ADHD are EXCESSIVE

· Impulsivity

· Inattentiveness

· Over activity

It is cause for concern when the above symptoms are more excessive than that of other children of their age and clearly causing a functional difficulty in two or more settings, for example school and home. Any learning difficulties need to be taken into account.

Impulsivity; Children with ADHD:

§ have difficulty thinking before they act.

§ have difficulty weighing the consequences of their actions before acting and do not reasonably consider the consequences of their past behaviour.

§ may well be aware of a rule and able to explain it, but they are unable to follow it.

§ have difficulty waiting for turn in groups.

§ often interrupt, intrude on others and blurt out answers to questions.

This impulsivity results in unthinking, impetuous behaviour and children who seemingly do not learn from their experiences. Parents and teachers are often frustrated and sometimes inaccurately describe the child as being oppositional and non-caring which often leads to ineffective disciplinary interventions.

Inattention; Children with ADHD:

Ø have difficulty remaining on task and focusing attention.

Ø often do not seem to listen when directly spoken to.

Ø often do not follow through on instructions and fails to finish schoolwork and set tasks.

Ø lose things necessary for tasks and activities, for example pencils, books etc...

Ø are forgetful in daily activities.

When compared to other children of their age they have difficulty remaining on task and focusing attention. It was once suspected that’ distractibility was the core problem however it is now recognised that it is the inability to invest in the task, rather than distractions, that is primarily responsible for off-task behaviour.

Hyperactivity; Children with ADHD:

q frequently fidget with hands or feet.

q run about or climb excessively in situations when it is inappropriate.

q often on the go - as if ‘driven by a motor’.

q have difficulty in controlling bodily movements, especially in situations in which they are required to sit still or stay put for long periods of time.

q are quicker to become aroused.

Children with ADHD tend to be excessively restless, overactive and easily aroused emotionally. Again compared to children of a similar age the speed and intensity in which they move within their emotions - whether happy or sad is much greater. This frequently frustrates parents and teachers because soon after an upsetting event the child forgets the event and moves onto something else. The child is then accused of lacking guilt and ‘wearing their emotions on their sleeves’.

How is ADHD diagnosed?

All of the signs can appear in any child to some degree. There is no simple blood or urine test to determine ADHD. The diagnosis is complicated which is why a number of professionals are usually involved and reaching a diagnosis may take time. There are currently no rigid national guidelines in this country therefore diagnosis and management may be approached in different ways. At Ryegate Children’s Centre diagnosis is reached through comprehensive assessment, which includes;

q An experienced Paediatrician taking a careful, thorough and detailed history from parents.

q Physical and Neurological examination of the child by the Paediatrician.

q Gathering information from other professionals involved with the child, for example School Teachers, Psychologists, School Medical Officers etc.

q Parents and Schoolteachers completing ‘Connors’ questionnaires.

q Clinical observation of the child.

Following this comprehensive assessment, which requires good liaison from all involved, a diagnosis of ADHD may be reached.

What causes ADHD?

The exact cause or causes of ADHD are not known. Evidence suggests that the disorder is genetically transmitted and is caused by a complex deficiency or imbalance of the brain chemicals. Dopamine, Norepinephrine and Serotonin, which are chemicals that help to transmit information from one brain cell to another, are believed to be involved. Research is on going.

Management at Home

It is important to remember that all children are individuals and you know your child best, but below are a few basic suggestions, which may help. ...

Show that you believe in your child’s abilities. Focus on your child’s strengths and support each attempt to succeed. Many children with ADHD feel like failures and give up before they have a chance to succeed.

Make directions brief. First, get your child’s attention, and then state what to do slowly, with simple words and short sentences. Keep your voice calm and avoid sounding sarcastic or annoyed. Ask your child to repeat what you said. Reward the child immediately with physical or verbal praise.

Positive expectations are statements we make to children about what is appropriate behaviour, the goal is teach your child what you want - not what you don’t want. For example, telling your child that dirty clothes belong in the laundry basket is more effective than telling your child to stop leaving their clothes on the floor. Telling your child with ADHD that their feet belong on the floor is easier to understand than telling them to take their feet off the table. State what you want, not what you don’t want.

Communicate clearly with eye contact. It is important to make eye contact with your child as they are much more likely to pay attention to what you are saying if you have eye contact. Remember keep verbal communication short.

Accept that your child will be absent minded. It may seem that you are always reminding your child about something, try not to get annoyed and say things like ‘if I have to tell you one more time’. Repeat things as though you were telling them for the first time.

Use lists and pictures to help your child manage things at home. Sit down and prepare an achievable list together - it could be to help your child get dressed in a morning and the order that their clothes go on, or it could be chores that need to be done in the home. Let them tick of each completed task and reward them immediately on completion.

Offer a routine and prepare your child for change in that routine. Your child probably won’t take surprises and change well. Give them plenty of notice and talk about the change with them.

Structure and organize time. Children with ADHD cope much better if they have a clear programme/timetable to follow. They can be particularly difficult at weekends and school holidays. Try and plan what they are going to do and set out a timetable in advance.

Avoid confrontations. Learn which situations are likely to trigger off difficult behaviour and whenever possible plan to avoid these situations. This should not be seen as backing down but as being in control. Do not make the mistake of thinking your child will have learned from the way you previously avoided a confrontation, they won’t.

Pay attention to good behaviour. It is important to acknowledge behaviour. Children with inattentive and impulsive behaviours often spend much of their day in trouble; as a result they can feel quite bad about themselves. Giving attention to good behaviours will help to make them feel better about themselves. Use extension of privileges as well as praise to give weight to good behaviour.

You are your child’s advocate. It is important that you are informed and act for your child. No one is better equipped than you are to do this. You must communicate information about your child and ADHD to appropriate others who have contact with your child.

Medication

If your child has been prescribed medication you must work closely with the medical team involved. It is important that you observe your child and provide feed back to the team - both positive’s and negative’s. This will assist the team in making appropriate changes perhaps to the dose or the time of doses. As you know your child is an individual and therefore his medication may not be the same as other children’s. It is also important that your child understands about the medication - be honest and allow time to talk about the use and need for medication.

Management in School.

Teachers play a vital role in the future success of children with ADHD. Like other children with disabilities, children with ADHD learn best when their teachers understand their special needs and individualize their educational programme to meet these needs.

The Code of Practice provides guidelines for the assessment and identification of special educational needs. Some children with attention difficulties and ADHD need extra support in school — this maybe met through the schools Special Needs Educational provision or for some children it may involve input from the local educational authority. Further information on education, Code of Practice and the Statementing Procedure is available in the ‘disability information pack’ available from Ryegate — please ask if you have not received a copy.

STEPS (Support Teaching and Educational Psychology Services)

Children with difficulties in attention and concentration, with or without a diagnosis of ADHD are frequently discussed with support teachers and Educational Psychologists in the STEPS service. The service is based at Bannerdale Curriculum Service on Bannerdale Road, Sheffield 7. They can be contacted on 0114 250 6800.

The service consists of a range of teams organized on an area basis. Within the service is a Learning Support Team, a Behavioural Support Team and an Early Years Support Team. Between them the team offer a wide range of expertise and specific knowledge to support pupils with learning and adjustment difficulties in mainstream schools, they work together with the school to develop policies and practices to help your child. STEPS also contribute to the planning and delivery of multi-agency training at a city wide level in order to support the development of increased understanding and approaches to children with attention difficulties.

Classroom Strategies for Teachers and Support Staff

Research has consistently shown that teachers play a vital role in the future success of students with attention and behavioural challenges. Children with ADHD can stretch you to your limits both personally and professionally. It is important that you have access to support systems e.g. someone you can talk to about your frustrations and celebrate your successes with. This may be colleagues who have worked with children with ADHD before, the STEPS service, the parents etc. It is also. vital that you have some knowledge of ADHD - it is only by understanding the nature of ADHD that you may start to anticipate the children’s problems and behaviour.

It is important to remember that all children are individuals - each and every one having their own strengths and weaknesses. Below are some ideas and strategies which you may find helpful, it is not a comprehensive list of ‘must do’s’ but more a suggestion of strategies that have been found useful.

v Children with ADHD thrive on predictability and routine. Their most disorganized behaviour is likely to occur during free time.

v A ‘getting started routine’ that is known to the child and can be used each lesson will be helpful. This may involve written or visual instructions, set procedures and may also require the help of more organized classmates. Many children with ADHD have difficulty handling ‘transition’ e.g. coming into the room at the beginning of the day or after break and then settling down can be a problem - give them something to do immediately they come in.

v Establish agreed ‘cues’ to maintain attention and provide regular reminders of on task behaviour, which can be verbal or visual. For example, “a traffic light system” - the child has three cards on view, when they are on task the green card is on top however when their concentration slips the orange card is used to reinforce a verbal prompt and if concentration resumes then praise is offered, if not then the card is turned to red and a prearranged consequence is applied.

v Maintain eye contact with the child.

v Present rules and instructions clearly and briefly, using visual means where possible. Display lists of rules in prominent locations in the classroom, use posters that are brightly decorated. Encourage the child to re-state rules or directions, particularly prior to beginning new activities. Be consistent.

v Give a five-minute warning before the end of a session for the completion of the task and putting away the equipment etc.

v Try to avoid singling out this child all the time. Some of these approaches can benefit all the class.

Strategies for structuring the learning environment

While the actual type of classroom is important to the child with ADHD, having a considerate and understanding teacher who uses consistent methods, routines and input will have a much greater impact than just the environment alone.

ü Seat the child near to your desk - as part of the classroom seating arrangement and without being perceived as punitive. Increase distance between desks if possible - this will reduce the amount of peer reinforcement the child receives for disruptive behaviour and ensure the table is away from physical distractions, for example the door, window etc. Have the child facing the front with their back to the rest of the class.

ü Try various groups to determine the situation in which the child works best. Where possible provide several tables for group projects and traditional rows for independent work. Some teachers feel that arranging desks in a horseshoe shape promotes appropriate discussion while permitting independent work. Surround the child with good role models.

ü Produce a ‘stimuli reduced study area’. All pupils will benefit from access to this area also.

Strategies for modifying instructions

q Make directions clear and concise - be consistent. Simplify complex directions and avoid multiple commands. What they perceive to be large amounts of information easily overwhelms children with ADHD.

q Make sure the child understands the instruction before beginning the task. Help the child feel comfortable - many children won’t ask, as they feel awkward when they don’t understand again! Repeat in a calm, positive manner if needed and have the child repeat the direction back to you.

q Have a checklist written and attached to the child’s desk that outlines the steps in starting and completing work.

q Use a home-school booklet for daily communications, and remember it may be necessary for you to assist the child in ‘remembering’ to bring the notebook to and from school.

Strategies for completing class work

Assignments should be brief and adjusted for the child’s attention span. For example, the child can be given fewer math’s problems or questions than the other children. This increases the likelihood that the child will complete the work.

REMEMBER - being fair does not mean treating all children the same.

q Where possible, provide children with photocopies of class notes and homework. If children with ADHD have to copy homework questions from the board you may find that they have an incomplete list. This may be because they tire of writing; also many children with ADHD find written work difficult.

q Allow additional time for certain tasks. Challenged children may work more slowly.

q Remember that variability is common, with the result that work output may vary greatly within the academic day and from day to day.

q If the child takes medication, be aware of the time of day. Just before lunch and towards the end of the school day may be problematic times for the child since the medical effectiveness may be diminished.

Strategies for behaviour and self-esteem

> Keep the classroom behaviour rules clear and simple.

> Actively reinforce desired classroom behaviour. Frequently praise for ‘on-task’ behaviour, however avoid using the words ‘good’ or ‘bad’ in describing behaviours. Try using terms such as ‘in control’ ‘appropriate’ or ‘out of control’ ‘inappropriate’.

Ø Rewards must be changed or rotated more frequently in children who have ADHD. What motivates the child today will undoubtedly lose its effectiveness - so have an alternative reward available.

Ø Have pre-established consequences for misbehaviour, and administer them immediately.

Ø Avoid using negative consequences for the whole class based on the child with ADHD’s behaviour

Ø Avoid ridicule and criticism - remember these children have difficulty staying in control. Try to avoid being too critical of children in front of their peers since peer humiliation is often one of the major detriments to self-esteem.

Ø Peer strategies, such as ‘circle of friends’ and ‘circle time’ may be a great help to children with ADHD. Circle time is a whole class approach, which promotes self-esteem, turn taking, speaking and listening skills.

Ø Adolescents with attention deficit may be particularly challenging. Careful modification in the curriculum should be made in order to reduce the strain on memory, the stress caused by lack of organizational skills etc.

Ø Children with ADHD often experience significantly less success in school than their peers. It is important that you work to ensure the child is viewed as being successful not only by the child’s peers and teachers but by the child himself. Feeling successful is of the utmost importance to turning around the learning experience of children living with ADHD.

“Nothing succeeds like success”

The Use of Medication in the Management of ADHD.

For some children, even with the above strategies in place this is not enough alone and it is appropriate to try the use of medication (whilst continuing behavioural measures). A multi-model approach should include, where appropriate, psychological intervention, education and medication. This then has the greatest chance of alleviating the multiple difficulties faced by many children living with A.D.H.D. and of enabling the child to ‘learn’ strategies whilst supported by medication. This means a child is more likely to successfully be weaned off medication at a later date. The medication most commonly used is Methylphenidate -often known as RITALIN. Methylphenidate can improve attention and social interactions, increase academic productivity but not necessarily achievement, and reduce disruptive and impulsive behaviour.

It does not stop difficult behaviour but hopefully enables the child to ‘learn’ more appropriate behaviour with time.

Medication is usually suggested as an initial six-week trial, during which time careful monitoring takes place. It is only continued if there are positive results with insignificant side effects. Children are usually commenced on 5mg (that’s 1/2 tablet) twice a day for two weeks and then increased to 10mg (that’s I tablet) twice a day. After this initial period fine-tuning of the medication may still be necessary but must only be carried out after close negotiation with the medical team involved. Despite its general effectiveness, it can have unwanted side effects, including potentially irreversible problems with Tics.

The other most commonly seen side effects include appetite suppression (this can be helped by ensuring the medication is given with or after food or if this difficult in the school day then very shortly before), tummy ache, head ache, loss of sparkle/sadness, sleep difficulties and irritability. These effects have been reported to be transitory and disappear with a reduction in dosage. It is important to understand that the effect of Ritalin varies with time after ingestion. Initially there will be a time (usually after around 20 mins) when the medication is partly ineffective, it will then have a period of full effectiveness, followed by a period where the Ritalin still has some effect but is decreasing in it’s effectiveness. Ritalin is thought to be clinically effective for between 3 to 5 hours - which is why a dose is usually given prior to school and then again at lunchtime.

The dose is also independent of body weight and is individualized, some children will be fast metabolisers and others slow. Fine tuning of dosage and timing is crucial to effective management. Therefore effective communication between the child and family, school and the medical team involved is essential (sometimes a simple questionnaire is used to monitor effect, a copy of which is available in the ‘assessment tools’ section of this site). Ritalin is a stimulant medication and is known as a controlled drug - it is therefore important that this medication is kept safe within school and home. Supervision of the child taking the medication is essential. Always keep the bottle of tablets locked away.

Although Ritalin is an effective drug treatment for the majority of children with ADHD it is not the only drug therapy available, however it is not within the scope of this information site to discuss all other options, but please feel free to discuss this with the Ryegate team.

Attention Deficit Hyperactivity Disorder Information Site

Ryegate Children’s Centre, Sheffield