Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention Deficit/Hyperactivity Disorder (ADHD) is a disorder that is diagnosed based on behavioral presentation. Inattention, hyperactivity and impulsivity may have a variety of underlying causes that are neurodevelopmental. People with ADHD struggle to pay attention and to inhibit their impulses. They may struggle with emotion regulation and hyperactivity. ADHD has the following three sub-types: 1) inattentive type, 2) hyperactive/impulsive type, and 3) combined type. Individuals with ADHD might have challenges with schoolwork, with homework, or with interacting with others. It is considered the most common disorder of childhood. Behavior problems associated with the disorder present significant challenges to schools and parents. For example, not handing homework in, having incomplete work, and missing directions are common teacher and parents complaints of children with ADHD. These challenges continue into adulthood, with many adults with ADHD experiencing challenges with attention at work.

Children who have significant problems in this area may have any of the following potential disability. *Note, this does not serve as a diagnosis in any way. See Where to Go for Help With ADHD for professionals who can diagnose or provide a referral.

Attention-Deficit/Hyperactivity Disorder (ADHD) is a highly prevalent neurobehavioral disorder. It is marked by pervasive inattention, hyperactivity and impulsivity that often result in significant impairments in both school and social settings. Common symptoms in school-aged children include distractibility, variable attention, unable to complete tasks and assignments, chronic fidgeting and more. The current Diagnostic and Statistical Manual (DSM-5) reports a 5% population prevalence rate for children and identifies the following three subtypes of ADHD: predominantly inattentive type, and predominantly hyperactive/impulsive type and combined type. ADHD is more often diagnosed in males than in females; the ratio is approximately 2:1 in children. Although ADHD is traditionally thought of as a childhood disorder, challenges continue into adulthood for most people with the disorder.

Individuals with ADHD may be extremely bright or gifted (IQ scores that fall in the top 5% of individuals). Some people with ADHD may have exceptional fluid reasoning (solving new problems), visual spatial skills (seeing how objects fit together) or verbal knowledge.

At least one of the two areas of symptoms (inattention and/or hyperactivity/impulsivity) must be present and causing challenges in multiple environments (home, school, extracurriculars, etc.). If symptoms are present for inattention only, the individual is diagnosed with the Inattentive presentation. If symptoms are present for hyperactivity/impulsivity only, the individual is diagnosed with the Hyperactive/impulsive presentation. If both sets of symptoms are present, the individual is diagnosed with the Combined presentation.

Symptoms of Inattention: makes careless mistakes, difficulty sustaining attention, does not seem to listen to directions or follow instructions fully, loses focus easily/ distracted, disorganized, forgetful, loses important items, poor time management, avoids tasks that require a lot of focus and attention

Symptoms of Hyperactivity/impulsivity: fidgets, squirms, is often out of his seat, moves while in line, speaks out of turn, interrupts, running and climbing when not appropriate, appears to be sensory seeking

Although many interventions are available, only a few have been validated with enough research to be named as Tier 1 “Best Support” by the American Academy of Pediatrics. Those interventions include the following options: Medication, Behavior Therapy, Parent Management Training, Biofeedback, and Self-verbalization. A combination of these therapies has been known to help many children and adults with ADHD. For many children, intervention becomes the difference between success and failure in school.  Further, the ability or inability to stay on task and to hold back impulses is not unique to school; in fact, it often carries over to social settings. For many children, interventions help their self-esteem and socialization.

Research has shown the challenges inherent in significant attention problems. The largest scale study ever to be conducted (to date) by the National Institute of Mental Health (NIMH) investigated the impact of ADHD on children and families. The study involved over 600 students with attention problems in six sites across the country [10]. Findings were as follows:

• “Two-thirds of these children had at least one other disorder such as depression, anxiety, or learning disabilities.
• Medication alone was more effective than behavioral interventions alone.
• Medication alone was almost as effective as the combined treatment of medication plus behavioral interventions.
• Many students may be receiving medication doses that are too low for maximum improvement in school work and behavior.” [10]

The authors of this article have been involved in a meta-analysis of ADHD interventions.  This meta-analysis, a report on a group of studies, found that although many behavioral interventions for ADHD are effective, the individual studies themselves were typically not as systematically conducted (that is, involving pre and post testing, ‘dosage levels,’ and effect size) as were the medication studies. This difference may be the reason that it sometimes appears medication alone can be more effective than combined treatment. Most psychologists generally agree that combined behavioral and pharmaceutical intervention is best. However, the science has yet to yield these results due to the lack of availability of well-designed research studies. Taken together, it is important for parents to be aware that attention problems can have a significant impact on a child’s functioning and that the provision of accurate diagnosis, psychological and medical intervention with a psychiatrist and/or pediatrician can bring lasting positive change.

The Test of Variables of Attention (TOVA) is an individually administered computerized test of attention and impulse control that is used to diagnosis and monitor interventions for ADHD. The TOVA is appropriate for individuals from age 4 to 80+ years. TOVA can be administered in two formats, visual and auditory. Both formats measure the person’s ability to sustain their attention and to inhibit their impulses in the absence of immediate reinforcement. The TOVA is an objective, neurophysiological measure of attention. Another similar measure of sustained attention in the absence of immediate reinforcement is the Conners’ Continuous Performance Test (CPT). This measure is shorter in length and may be more practical for a young child who is unable to complete the TOVA.

Performance on cognitive measures of processing speed and working memory are also utilized to assess attention. The NEPSY-II is a measure that contains subtests to measure Attention and Executive Function; it is individually administered with both oral and visual subtests. The NEPSY looks at motor persistence, the ability to hold back impulsive responding, cognitive flexibility, and the ability to start tasks and to self-monitor behavior. Measures of Executive Function, such as the Comprehensive Trail-Making Test, Wisconsin Card Sorting Test, Tower of London – Second Edition, Stroop Color & Word Test, and others, are also useful in the assessment of ADHD.

A number of rating scales can screen for symptoms of ADHD, including BASC-3, BRIEF, as well as the Conners’ 3 rating scales. Looking across measures at various symptoms, the clinician is going to determine whether or not your child’s symptoms are significant and what the explanation may be for those symptoms.

A referral for a comprehensive neuropsychological evaluation is most appropriate when concerns are suspected about ADHD. This type of assessment includes evaluation of attention, cognitive ability, adaptive skills, executive functioning skills, academic profile, social skills and sensory processing. Other areas may be evaluated as concerns arise. Taking a comprehensive neuropsychological report to the following professionals will help them to get an understanding of your child and his/her specific needs. Next, it’s important to think about how these therapies fit together and how different skills are being built and addressed to best support your child.

Psychiatrist. It is estimated that at least 85% of children diagnosed with ADHD are treated with stimulant medication. For most children and adults with ADHD, stimulant medication reduces some of the core behavioral characteristics associated with disorder, including hyperactivity, impulsivity, and distractibility.

Behavior Therapy/ Parent Training. Behavioral therapy develops a set of skills in children and parents to increase attentive, desired behaviors and/or to decrease impulsive problem behaviors.

Parent Consult. Parent consultation can follow behavioral therapy or the Family Systems model and can provide guidance to families on strategies to use, systems to set up and principles of reinforcement. Consultation can also focus on the parent’s experience and emotional well-being.

School Services. School-based supports like an IEP or a Section 504 plan can help your child receive accommodations and modifications that they may require to access learning in the classroom setting.

Occupational Therapy. Occupational therapy addresses sensory issues and challenges that may be associated with ADHD. Occupational therapy can be very helpful for some children with ADHD. A referral may be appropriate if your child has significant sensory differences, such as sensory seeking behavior. Many kiddos with ADHD benefit from developing proactive movement activities and using exercise as a precursor to schoolwork.

Although ADHD presents a myriad of challenges to children and families, interventions tend to be successful at treating many of the challenged associated with the disorder. Indeed, for many children, medication and organizational support allow them to be successful in school and beyond. That said, most people continue to have some impairments in adulthood. Early intervention can help individuals develop strategies and systems to manage their inattentive symptoms and to curb their impulsivity. Such supports allow for gainful employment and interpersonal success as an adult.

• Non-Compliance
• Impulsivity
• Initiate
• Inhibition
• Planning
• Flexibility
• Metacognition
• Organizing Materials
• General Memory
• Memory for Faces
• Memory for Names
• Procedural Memory
• Working Memory
• Joint Attention
• Focused Attention
• Selective Attention
• Visual Tracking
• Sensory Sensitivity
• Sensory Seeking
• Handwriting
• Body Space Awareness
• Domestic
• Interacting
• Following Directions
• Processing Speed
• Sequencing
• Auditory Processing

For Parents:

[1] Evidence-Based Child and Adolescent Psychosocial Intervention: https://www.aap.org/en-us/documents/resilience_anxiety_interventions.pdf

[2] How does Behavior Therapy Work? http://www.additudemag.com/adhd/article/3577.html

[3] Dawson and Guare (2009). Smart but scattered: The revolutionary “executive skills” approach to helping kids reach their potential. The Guilford Press, NY.

http://www.amazon.com/Smart-but-Scattered-Revolutionary-Executive/dp/1593854455

[4] Dawson and Guare (2010). Executive skills in children and adolescents: A practical guide to assessment and intervention, second edition. The Guilford Press, NY. https://www.amazon.com/Executive-Skills-Children-Adolescents-Second/dp/1606235710

[5] Barkley, Russell A. (2013) Taking Charge of ADHD, Third Edition: The Complete, Authoritative Guide for Parents. https://www.amazon.com/Taking-Charge-ADHD-Third-Authoritative/dp/1462507891/

[6] Zeigler Dendy, Chris A (2003). Teaching teens with ADD and ADHD. Woodbine house. https://www.amazon.com/Teaching-Teens-ADD-ADHD-Reference/dp/1890627208/

[7] Zeigler Dendy, Chris A. (2011). Teaching Teens With ADD, ADHD & Executive Function Deficits: A Quick Reference Guide for Teachers and Parents.

https://www.amazon.com/Teaching-Teens-Executive-Function-Deficits/dp/1606130161/

[8] Giler, Ph.D., Janet Z. Socially ADDept: A manual for parents of children with ADHD and / or Learning Disabilities (2000). https://www.amazon.com/Socially-ADDept-Children-Learning-Disabilities/dp/0966696921/

[9] Giler, Ph.D., Janet Z. Socially ADDept: Teaching social skills to children with ADHD, LD, and Asperger’s. https://www.amazon.com/Socially-ADDept-Teaching-Children-Aspergers/dp/047059683X/

[10] Barkley, Russell A. (2013) Taking Charge of ADHD, Third Edition: The Complete, Authoritative Guide for Parents. https://www.amazon.com/Taking-Charge-ADHD-Third-Authoritative/dp/1462507891/

[11] ADDItude Editors (n.d.) Focus the Attention of Distracted Children http://www.additudemag.com/adhd/article/1032.html

[12] Zeigler Dendy, Chris A (2003). Teaching teens with ADD and ADHD. Woodbine house. https://www.amazon.com/Teaching-Teens-ADD-ADHD-Reference/dp/1890627208/

[13] Zeigler Dendy, Chris A. (2011). Teaching Teens With ADD, ADHD & Executive Function Deficits: A Quick Reference Guide for Teachers and Parents. https://www.amazon.com/Teaching-Teens-Executive-Function-Deficits/dp/1606130161/

For Kids:

[14] Cook, Julia (2012). Personal Space Camp. National Center for Youth Issues. https://www.amazon.com/Personal-Space-Camp-Julia-Cook/dp/1931636877/

[15] Esham, Barbara (2015). Mrs. Gorski, I think I have the Wiggle Fidgets. (New edition) Adventures of Everyday Geniuses. Mainstream Connections. https://www.amazon.com/Gorski-Fidgets-Adventures-Everyday-Geniuses/dp/1603368175/

[16] Smith, Bryan & and Griffen, Lisa M. (2016). What were you thinking? A story about controlling your impulses. National Center for Youth Issues. https://www.amazon.com/What-Were-You-Thinking-Learning/dp/1934490962/

[17] Cook, Julia & Hartman, Carrie (2006). My mouth is a volcano. https://www.amazon.com/My-Mouth-Volcano-Julia-Cook/dp/1931636850/

[18] Stein, David Ezra (2011). Interrupting Chicken. https://www.amazon.com/Interrupting-Chicken-David-Ezra-Stein/dp/0763689033/

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