Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD)

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Attention Deficit Hyperactivity Disorder

Attention-deficit hyperactivity disorder (ADHD), which is often referred to as childhood hyperactivity, is a severe and chronic disorder for children. It is one of the most prevalent childhood disorders, and affects 3% to 5% of the school-age population. Boys outnumber girls three or more to one. Children with ADHD can experience many behavioral difficulties that often manifest in the form of inattention, being easily distracted, being impulsive, and hyperactivity. As a result, children with ADHD may develop emotional, social, developmental, academic, and family problems because of the frustrations and problems they are constantly experiencing.

Families who have children with ADHD often experience much higher anxiety and stress levels. A large number of children, almost half, will exhibit signs of ADHD by the age of four. However, most children are not diagnosed until he or she reaches elementary school.
The behaviors that are associated with ADHD in children put them at risk for a host of other problems and complications such as completing their education, alcohol and other drug abuse, and an increased risk for delinquency. There has been much research on ADHD in recent years and many different types of medications and interventions have proven to be quite helpful. With the proper diagnosis and treatment, children with ADHD can learn to cope with the daily demands of the classroom, social situations, family interactions, and life in general.

Therefore, it is imperative that teachers, administrators, and school counselors become familiar with the characteristics of children with ADHD. It is also vital that they know how to properly assess for diagnosing ADHD, and that they learn the intervention strategies for children, along with their families. The child needs to have a ?team? of caring individuals working with them to help them overcome and deal with the ?hurdles? that living with ADHD can bring.

This paper will address four key areas of ADHD. They include: The causes of ADHD, the characteristics of ADHD, classroom intervention, and parental intervention. We will also discuss key medications that are being used to treat ADHD.

Causes of ADHD

When parents are told that their child has ADHD, it is only natural that their first response is to want to know what caused this disorder. Unfortunately, there is no simple answer. For years researchers have been trying to find the underlying cause of ADHD, but have yet to come up with a definitive explanation.

Although there are several theories to try to explain the causes of ADHD, most experts agree that it is most likely not any single cause, but instead a combination of factors that causes ADHD.

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These factors may include brain damage, poor or inadequate prenatal nutrition and care, maternal alcohol or drug use during pregnancy, malnutrition, abusive home environments, genetic factors, high levels of stress, food additives or allergies, and physical, neurological, or psychiatric conditions (Schwiebert).

There are some indications that the maternal lifestyle during pregnancy, such as the use of drugs, smoking, and stress, may contribute to symptoms of ADHD in children. One study investigated to what extent the mother?s lifestyle might impact her child with regard to ADHD. The study found that prenatal nicotine exposure brought about structural changes and compromised the neuronal maturation. What is more important is that these initial changes profoundly influenced the development of cells that emerged later on during postnatal life. The nicotine had been found to cause dysfunction of the dopaminergic system, which has also been observed in children with ADHD. Therefore, the evidence to date points to plausible biological mechanisms that could account for the ADHD-prenatal nicotine exposure link (Rodriquez). It is also noteworthy to say that the study showed a greater number of associations between prenatal exposure and behavior for boys than for girls.

It is a known fact that a growing number of both children and adults consume junk foods high in toxins and depleted of nutrients. There are concerns that this drastic change in our diets may very well be contributing to the rising numbers of children diagnosed with ADHD. One study that looked at nutrition in the treatment of ADHD found that there is indeed a possible link between diet and ADHD. It showed that, although there is much controversy surrounding this issue, there is increasing evidence that there is a subset of children with behavioral problems who are sensitive to one or more food components that may contribute to their hyperactive behavior (Schnoll). Possible culprits may include: food colorings, flavor enhancers, artificial flavorings, preservatives and salicylates. Some believe that nutritional deficiencies such as low iron (anemia), hypoglycemia (low blood sugar), vitamin and mineral deficiencies and other excesses such as fatty diets could contribute to the problem. The report makes it clear, however, that it would be futile to try to identify a specific food or substance that causes negative behavior in all hyperactive children. Clearly all children are different and each child will need to be looked at as an individual with regard to their specific diet and lifestyles.

     Although experts have not been able to pinpoint the exact causes of ADHD, it does seem fair to say that most agree that genetics play a major role in this disorder. One study showed that ADHD has a strong genetic component. The study showed that ?the disorder tends to cluster in families? (Durston). Between 10-35% of children with ADHD have a first-degree relative with past or present ADHD. Approximately half of parents, who have been diagnosed with ADHD themselves, will have a child with the disorder. A large number of twin studies also suggest a genetic element to ADHD. If it is present in one twin, it is much more likely to be present in an identical twin than in a fraternal twin, even when the twins have been raised separately (Durston). Although there is compelling evidence that ADHD has a genetic basis, it remains unclear which genes are responsible.

Since it has been considered that approximately 50% of ADHD cases can be explained by genetics, it still leaves many cases in which other agents must be at work. Some believe that the problem may lie within our environment. There are many possible toxins that have been looked at as possible links to ADHD. They include: exposure to lead and mercury, carbon monoxide, air pollutants, pesticides, and radiation.

There are a host of medical problems that may also play a part in ADHD related symptoms. They range from minor to major ailments and diseases and may include such problems as infections, stomach problems, poor hearing and eyesight, cerebral vascular accident, brain tumor, kidney disease, hormonal disorders, physical disabilities, neurological disorders, learning difficulties, head injuries, and problems in utero and birth complications.

As you can see there are many theories and factors that are being studied to determine what the actual cause of ADHD is. The most current information leads us to believe that a good number of cases are genetic. The rest of the cases could be one, or most likely, a combination of any of the other factors we have discussed.

Characteristics and Diagnosis

Since it is so important to make a correct diagnosis when dealing with ADHD, it is very important to know what to look for. Therefore, being able to recognize the characteristics of ADHD is vital. Attention Deficit Hyperactivity Disorder (ADHD), a commonly diagnosed disorder in children, is characterized by inattention, hyperactivity, and or impulsivity. The DSM-IV states that in order to diagnose a child with Attention Deficit Hyperactivity Disorder, the child must exhibit six or more of the nine characteristics in the category of inattention, or six or more of the nine characteristics in the category of hyperactivity-impulsivity. These characteristics must persist for at least six months before the age of seven and they must have a negative affect or impairment in at least two areas of the child?s daily life, either work, school, and or home (65).

According to the Diagnostic Criteria from DSM-IV-TR, the primary characteristics of inattention include difficulty paying attention to details or activities, the inability to listen, the inability to follow through on or finish tasks, difficulty in organizational skills, lack of involvement in tasks involving mental effort, and distractibility and forgetfulness (65). The primary characteristics of hyperactivity consist of fidgeting, squirming, excessive leaving of seats, running or climbing around in inappropriate situations, feeling of restlessness, the inability to participate in quiet activities, constant on the go attitude, and talking too much (66). Impulsivity characteristics include constant blurting out, interrupting of others, and the inability to wait one?s turn (66).

If a child is diagnosed with Attention Deficit Hyperactivity Disorder, he or she will exhibit these primary characteristics consistently, regardless of where he or she is, or with whom he or she is interacting with. There are secondary characteristics, especially regarding peer relations, which result in the consequences of the primary characteristics. Mrug, Hoza, and Gerdes state that children with Attention Deficit Hyperactivity Disorder have more difficulties expressing non-verbal behaviors in an impartial manner such as attending to others or playing a game. They also have difficulties showing positive and neutral verbal and non-verbal behaviors such as giving praise, holding a conversation, or patting another person on the back (53). This study also showed that children with Attention Deficit Hyperactivity Disorder children exhibited characteristics of high intensity, unacceptable, inadaptable behaviors and ?insensitivity to social expectations for example, yelling, running around, or talking at inappropriate times? (53). Children with Attention Deficit Hyperactivity Disorder, according to Mrug, Hoza, and Gerdes, display verbal, and physical behaviors that are controlling, aggressive, and negative. They tend to command, tease, hit, become off-task, and be disobedient/ disruptive. The study also showed they tend to be noisier than other children, cause more trouble, become angry or mad when things are not going his or her way, display more rudeness and cruelty to others and tend to make fun of others. These characteristics also tended to flourish in frequency when all adults would exit the room (54).

     Mrug, Hoza, and Gerdes state that one of the most persistent social characteristics of children with Attention Deficit Hyperactivity Disorder is the development of aggression (54). Carlson, Shin, and Booth have found that the early development of aggressive behavior is a leading predictor of the child with Attention Deficit Hyperactivity Disorder behavioral outcomes. The researchers indicate that although hyperactivity and aggression have common characteristics and tend to overlap, they are recognized as separate behavioral dimensions (200). Research has found that children with Attention Deficit Hyperactivity Disorder were more likely to be aggressive for no purpose except to inflict harm on someone else such as being hostile, and these children were more likely to be aggressive to gain something of instrumental value such as to win a game (201). Cruce, Aldridge, Langford, Sporer, and Stinnett found that children with Attention Deficit Hyperactivity Disorder exhibit more characteristics of being unable to stay on task, troublesome, help seeking, defiant, and less able to show self-control (223).

     With all of these characteristics in mind, a trained professional must diagnose the child based on these certain characteristics and follow the criteria to correctly identify the characteristics. It is also important to rule out any disorders from axis II such as developmental disorders, personality disorders, or mental retardation, as well as schizophrenia, or other psychotic developmental disorders (DSM IV, 66).

     An interesting aspect of children with Attention Deficit Hyperactivity Disorder is to evaluate what they believe their perception of their own behaviors and characteristics entails. Research from Cruce, Aldridge, Langford, Sporer, and Stinnett found that children with Attention Deficit Hyperactivity Disorder thought that they just had more energy than their peers; that they definitely had more over talkativeness, and that they believed they were more quick tempered than most of the non Attention Deficit Hyperactivity Disorder children (231). It also appears that the children with Attention Deficit Hyperactivity Disorder thought that they had more silliness within them and that they were more reckless; they also thought that they believed that their peers liked them despite these characteristics.

ADD/ADHD in the Classroom

Due to the fact that ADD/ADHD children ?do? tend to be a bit different then that of their peers, special classroom intervention practices should be considered. Children affected by attention deficit disorders are increasing demand in schools. Schools use school based screening to help diagnose and recognize students with ADD/ADHD; this includes educational testing, an observation by the school psychologist, standardized parent and teacher behavior rating scales, and a medical history questionnaire (Shea,2:1168).
?According to Silver (1995), as many as 10 to 20 % of children and adolescents have learning disabilities, and about 20 to 25% of them also have ADD/ADHD. Many of these students receive special education services, but increasing numbers of them are being placed in general education settings and need to acquire independent learning skills and strategies?(Prater,22:397).

How do you deal with, and help a child with ADD/ADHD in a classroom environment? How do you help the child reach his/her potential so that they feel a since of accomplishment? Many teachers ask themselves these questions everyday. What can one teacher do to help a handful of ADD/ADHD students in a classroom of 25 or more? There are simple interventions that a teacher can do to help make a difference in the child?s learning experience. I will discuss four areas.

     First, you need to set up your classroom for the ADD/ADHD children. You can do this by moving your ADD/ADHD students closer to the center of instruction. This will help you better monitor, as well as encourage these exceptional students. You will be able to prompt and redirect the child when needed. If the child is very auditorally distractible and constantly looks around to see where the noise is coming from, then move the student?s desk near the back of the classroom. If the child is visually distracted, move his or her desk near the front. You can also move the ADD/ADHD children near others who are well focused and organized. Developing a buddy system between a well-organized child and the ADD/ADHD child can help the exceptional one to stay on task and learn organization habits.

     Perhaps it would be wise to keep your classroom desks in rows, instead of group tables. Groups seem to be too distracting for the ADD/ADHD child. Once in a while arrange the students? desks in a horseshoe shape for discussions, but they will still be able to work independently. It is important for the teacher to be able to move about the classroom; the more teacher student interaction, the better. Keep the ADD/ADHD student?s desk away from windows and hallways. This could prevent major distractions. Providing an area free from bright and loud posters where students can comfortably read could be an effective strategy. Perhaps you could have a CD player in this area for soft and soothing music.     

     Second, you need to help your ADD/ADHD child become organized. You can do this by using folders or dividers in the child?s desk to keep their papers organized so they can find them later. The child can also keep a binder for his/her homework or graded class work to be sent home daily to help minimize forgetfulness. Keep the binder at school every Friday so that the student doesn?t have to remember it over the weekend.

     During math time you can help the ADD/ADHD child become organized with rows and numbers by allowing them to use graph paper. This will also show him or her how much neater their work can be. During independent class work, allow the student to do every other or third problem. Exceptional students often need confidence building. This way the child doesn?t get overwhelmed or distracted from too many problems at once.

     The most important thing a teacher can do to help organize the special student is to keep a visual schedule at her or his desk. This schedule can show the order of each project or subject, how many worksheets are to be done, and when he/she can have a break if work is completed. Allowing extra breaks to the restroom or to do errands can keep an ADD/ADHD child from being bored.

     Allow at least five minutes out of each day for the students to clean and organize their desks and classroom. You can reinforce this organization by having a ?desk fairy? that gives an award to the most clean or organized rows. A reward can be a homework coupon.

     You can use a color code for covers on textbooks to match the folders or workbooks. If the teacher is able to, allow an extra set of textbooks to stay at home so that there is no excuse for forgetting homework. Most ADD/ADHD students actually do their homework and forget to turn it in when they are asked, because they are not paying attention. Give that extra reminder and make sure you establish eye contact when asking for it.

     Third, the methods you use in delivering your lessons are vital to ADD/ADHD students. Inserting a variety of activities within your lesson could keep the exceptional student focused and on task. Such activities could include, word search, dictionary scavenger hunt, making a collage, or even role-playing. Be creative and be excited about the subject matter. There are many additional ideas to modify lessons for the exceptional student. Some of the ideas include, peer tutoring, the use multiple colors on the marker-board, illustrations, and step-by-step clear instruction. Have the student paraphrase directions so that you know if he/she has an understanding of what you are asking them to do. A cueing system is always helpful during a lesson to make sure the student is paying attention. You can do this by a tug of an ear, or a phrase such as, ?I?m looking for good listeners,? etc. Your ADD/ADHD child may want to always be the first one done on tests or class work, so instead of the students handing in their work as soon as they are done, just collect the work as a whole.

     The fourth area of discussion concerning making a difference in the exceptional child?s learning experience deals with classroom compliance. The following ideas are indeed ways to help your ADD/ ADHD student better comply with classroom management. Never belittle any student in front of a classmate. Don?t confront the child for every little thing. Give him/her a break because it is hard for a student to control him/her self all the time. Instead of pointing out bad behaviors, point out alternative behaviors. Build off the areas of strength that the ADD/ADHD child has to improve, such as self-esteem. A simple nod, wink, touch on the shoulder or even a smile can be a powerful reinforcement.

Parent intervention for ADD/ADHD

     Classroom compliance begins with parental involvement. Parents with a child that has ADD or ADHD face a difficult but possible task ahead. In order for this child to achieve his or her full potential, (s)he needs the parent?s help, along with psychiatrists, psychologists, family physicians, guidance counselors, and the education system. A professional diagnosis is the first step.

     Symptoms a parent might encounter in a suspected ADD/ADHD child are inattention, hyperactivity, and impulsivity. These symptoms may appear over a time of many months. The impulsiveness behavior as well as the hyperactivity will be noticed before the inattention. Hyperactive children seem to be always on the go or constantly moving about whether they are sitting or not. They constantly move around, touch things, play with whatever is in sight, and talk excessively. Hyperactive children have difficulty sitting at the table without tapping, kicking, or wiggling. Impulsive children are unable to control their immediate actions or think before they act upon something. One example of this would be to blurt out something inappropriate and display emotions without restraint. They have difficulty waiting in games. The chance to be first is an important concept to them. Impulsive children have no concept of time, always thinking that any task is going to take too long. Children displaying signs of inattention have a hard time keeping focused, and may get bored easily. These children may have their disorder accompanied by a learning disability; therefore the tasks might not be boring, but too difficult to comprehend.

When the parent(s) of these children notice different symptoms of ADD or ADHD over a period of time, a professional should be consulted. First, the parent should take his or her child to the family physician. Some pediatricians or family physicians can do the assessment themselves, but will often refer the parent to a psychiatrist or a psychologist. The parent(s) will need to decide what type of professional services best meet the family needs. It is vital for the parent(s) to play a major role in virtually every aspect of each applicable service. Psychiatrists specialize in diagnosing and treating childhood behavioral and mental disorders. Psychiatrists can also provide therapy and prescribe any needed medication. Psychologists can also diagnose, treat, and provide therapy for the family to deal with the disorder. The psychologists must rely on the family physician or the psychiatrist to do the medical exam and prescribe medication.
Clinical social workers are also able to potentially diagnose the disorder, as well as the child?s teacher. The teacher can be asked to record observations of the child?s behavior on evaluation forms. This is done with the parent?s consent. Teachers know so many children that their comparison of a child to others is usually a reliable and valid measure. Sometimes the teacher or the healthcare professional may notice other symptoms that may accompany ADD or ADHD (Coyle.JT.Journal of the American Medical Association.)
The disorders that sometimes accompany ADD or ADHD are learning disabilities, Tourette syndrome, oppositional defiant disorder, conduct disorder, anxiety and depression, and bipolar disorder. If the child displays these symptoms, there will be additional medications prescribed along with the medications for ADD or ADHD. The following chart depicts some common medications prescribed to ADD and ADHD children:

Adderall     2mg, 5mg, 10mg, 20mg     3yrs and older
Concerta     2mg, 5mg, 10mg, 20mg     6yrs and older
Dexadrine     2mg, 5mg, 10mg, 20mg      3yrs and older
Ritalin     2mg, 5mg, 10 mg, 20mg     6yrs and older

The next three charts depict some of the medication that is prescribed with disorders that ?accompany? ADD/ADHD. The doses in milligrams are based on the child?s age and weight. The parent will be asked to observe the child for a two-week period to see if the prescribed medication is making any change in the targeted behavior. In order to get the right medication, the parent will go through a trial and error period. Once the right medication is found, it may change due to tolerance level or growth.

Antidepressants and Antianxiety

Effexor     2mg, 5mg, 10mg, 20mg     18yrs and older
Prozac     2mg, 5mg, 10mg, 20mg     18yrs and older
Wellbutrin     2mg, 5mg, 10mg, 20mg     18yrs and older
Zoloft     2mg, 5mg, 10mg, 20mg      12 and older (for OCD)

Risperadol     2mg, 5mg, 10mg, 20mg     18yrs and older
Zyprexa     2mg, 5mg, 10mg, 20mg     18yrs and older
Haldol     2mg, 5mg, 10mg, 20mg     3yrs and older
Orap     2mg, 5mg, 10mg, 20mg     12yrs and older ( tourettes)

Mood Stabling- Bipolar
Depakote     2mg, 5mg, 10mg, 20mg     2yrs and older (seizures)
Tegretol     2mg, 5mg, 10mg, 20mg     Any age (seizures)
Lithium     2mg, 5mg, 10mg, 20mg     6yrs and older

The prescribing physician will start the child on a very small dose, and keep accurate records in conjunction with parental observations. Again, the role of the parent(s) is vital. There are some side effects of the stimulant medication; it is usually minimal. Once the child is on the medication for a period of time and it seems to be working, the parent should follow through with other interventions to assist the child and family. Behavior Therapy (BT), Social Skills Training, Support Groups, and Parent Skills Training, are several common services that would prove beneficial.

Behavioral Therapy helps the child develop ways that are effective to work on immediate issues. ?Rather than helping the child understand his or her feelings and actions, it helps directly in changing their thinking, and coping and thus may lead to changes in behavior? (nimh). A support system in the Special Education class might be an Anger-Coping group which deals with these types of strategies in the classroom. This must be approved by the parent.

Social skills training can help children learn new behaviors by the therapists discussing and modeling appropriate behaviors in social relationships. Some of these skills could be like sharing toys, asking for help, responding to teasing, and waiting for a turn. Social skills will help the child with ways to work and play with other children. This can be reinforced by the parents in social outings outside the home as well as in the home.
Support Groups assist parents in meeting with other parents who have similar problems and concerns. These groups usually meet on a monthly basis and share frustrations and successes. Support groups will often refer parents to qualified professionals and share information that works.

Parenting skills training is often offered by the therapists. This gives parents tools and techniques for managing their child?s behavior. One such technique is the use of the token or point system for immediately rewarding good work or behavior. Another technique is the ?Time Out,? when the child becomes too unruly or out of control. Sometimes isolation works better in this situation. This entails placing the child in a room by him or herself. Another alternative is to have the child sit in a corner for a short period of time. The therapist will suggest that the parent keep the child on a schedule. This schedule should consist of daily routines from morning until bedtime.

Here are some simple behavior interventions for the parent:

Schedule: Have the same routine everyday. This should include breakfast, school, homework, playtime, dinner, a bath, and bedtime. This schedule should be posted on a bulletin board or the refrigerator and the parent should check off each completed time.
Organize items: Have a place for everything and keep everything in its place.
Homework: Help the child to pack his or her backpack, and stress the importance of writing down assignments and bringing home needed material.    
There is much more for the parent to learn in the parent skills training, but the first step is to get the child diagnosed. After the diagnosis, following the prescribed directions and medications from the physician and psychiatrist is extremely important. Furthermore, the parent needs to be consistent with the medication, therapist meetings, behavioral groups, and parent-child support groups. It is the parent?s role and responsibility to see their child grow healthy and happy with success into adulthood.
Many children continue to be diagnosed with ADD/ ADHD. These children face potentially serious behavioral difficulties, and could develop emotional, social, developmental, and family problems. Over course of this essay, we have looked at possible causes, characteristics and diagnosis, classroom interventions and the parent?s role of these exceptional children.

The causes of ADD/ADHD seem to be a gray area. Studies have shown that the causes could be a combination of reasons. Some of the reasons range from genetics, to a lack of pre-natal care or abuse.

Some of the characteristics, include, inattention, impulsiveness, and hyperactivity. Some children with ADD/ADHD are aggressive, controlling, insensitive, defiant, and even cruel when annoyed. Proper diagnosis, and treatment is extremely vital.

Classroom intervention is necessary for the ADD/ADHD student to succeed. ?Some? classroom interventions are essential so that this exceptional student does not infringe on the education of others in the class. Different areas of classroom intervention include, classroom set-up, teaching organizational skills, the modification of lessons/activities, and classroom management.

The parent?s role is absolutely vital. The role of the parent begins with a proper diagnosis. After the diagnosis, following the professional?s directions is a must. This may include, being consistent with the prescribed medication, follow-up therapy sessions, various training, and support groups. When the parents of a child with ADD/ADHD follow through with all of their responsibilities, to include heavy involvement in the school, there is no reason that the child cannot grow up into a healthy, happy, and successful adult.

Work Cited

Durston, Sarah. ?A Review of the Biological Bases of ADHD: What Have We Learned
from Imaging Studies?? Mental Retardation and Developmental Disabilities Research Reviews 9 (2003): 184-185.

Rodriguez, Alina, and Bohlin, Gunilla. ?Are Maternal Smoking and Stress during
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