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... see also Conduct Disorders in children

ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

Written and Developed by the Centre for Community Child Health and Ambulatory Paediatrics Royal Children's Hospital, Melbourne for the Victorian Government Department of Human Services. April 1997

Fact Sheets for Health Professionals

Hyperactive and inattentive children have always been with us - they are not a product of the 1990s - but over recent years in Australia there has been increasing professional and public awareness of Attention Deficit Hyperactivity Disorder or ADHD.

In the past there has been an under-recognition of what is undoubtedly a behavioural syndrome with a significant biological basis.  The terminology has undergone considerable evolution, from post-encephalitic behaviour disorder through minimal brain dysfunction, hyperkinetic reaction, attention deficit disorder, with and without hyperactivity, through to Attention Deficit Hyperactivity Disorder, the term in use today.

At present ADHD is by far the most commonly diagnosed behavioural condition of childhood.  However, there is no evidence that the numbers of children with these problems are increasing.  ADHD is the latest in a series of labels used to describe a pattern of behaviour of inattentiveness, impulsivity, and sometimes overactivity that is extreme for age.  Over the past 30 years many thousands of research articles have been published on children with these problems, and there has been a progressive increase in our understanding of this.

There is a wide range of opinion and debate out ADHD, ranging from those who stridently believe that professionals are seriously under-diagnosing and undertreating it, through to those who seriously question whether it even exists as a discrete condition, and those who are concerned that medication is used to control behaviour in children.

Definition and Incidence

ADHD affects up to five per cent of children.

It is three times more common in boys than girls.

ADHD is a developmental disorder characterised by developmentally inappropriate degrees of:

• Inattentiveness
• Overactivity
• Impulsivity

Symptoms usually arise in early childhood, are relatively chronic, and are not readily accounted for by gross neurologic, sensory, language or motor impairment, intellectual disability, or severe emotional disturbance. These difficulties are typically associated with deficits in rule-governed behaviour and in maintaining a consistent pattern of schoolwork performance over time.

ADHD was once called hyperactivity, but now it is recognised that inattention and acting impulsively are the major behavioural problems exhibited by these children and not all are overactive.

These behaviours themselves are not abnormal, but are more pronounced in children with ADHD. All young children are inattentive and impulsive to some degree; but only a small proportion of these children will truly have ADHD. Concerns are only raised when the behaviours are causing significant ongoing difficulties in the life of the child or the family

In general, these behaviours contribute to:

• Difficulty in academic performance despite normal intelligence.
• Difficult peer relations, social isolation and low self-esteem.
• Temper outbursts and mood liability.

The Basis of ADHD

Current research indicates true ADHD may have multiple biological determinants, with symptoms being modified by family and social factors. Differences have been found between children with ADHD and other children in brain neurochemistry, autonomic nervous system function, cerebral blood flow, electroencephalographic patterns and glucose metabolism. A strong genetic component to hyperactive-inattentive behaviour has also been established. Despite the lack of a unifying biological theory to draw together the research findings described above, it is possible that the diagnoses of ADHD can be approached in a consistent way.

How is ADHD Diagnosed?

Referral to a paediatrician, child psychologist or child psychiatrist is needed for diagnostic assessment and treatment. Behavioural checklists completed by both parents and teachers are used as part of the assessment and diagnosis. A diagnosis of ADHD should only be considered when these prerequisites are present:

• The current DSM criteria are fulfilled (see Table 1).
• A history of hyperactive-inattentive-impulsive behaviour has been displayed in most areas of the child's life since early childhood.
• Physical health problems, particularly gross neurologic and hearing/vision problems, have been ruled out by examination.
• The child's general development is assessed as normal.

The diagnosis of ADHD has little validity in two to three year-olds, so as much of the normal behaviour of children this age is hyperactive, inattentive and impulsive and resolves with maturity.

Observations of the child's behaviour in the consulting room are not a reliable guide to the child's behaviour in other settings. Motoric overactivity is not a prerequisite for the diagnosis of ADHD.

Reports from parents and teachers are the best source of information to guide the diagnosis. These observations can be quantified if standardised rating scales such as the Conners' Hyperactivity Scales or the Achenbach Child Behaviour Check Lists are used. Scores above the 95th (or 98th) per centiles for age on parent and teacher checklists enable the identification of a group of children who fall statistically outside the normal range and this improves the validity of clinical diagnosis.

If the child is having difficulty in schoolwork then further developmental testing (preferably cognitive testing by a psychologist) is indicated. The results will be valuable for assisting the child at school, irrespective of whether or not a final diagnosis of ADHD is given.

Results from additional laboratory investigations such as neurometric studies and computerised tests of attention are not diagnostic of ADHD and are rarely if ever clinically indicated.

The diagnostic criteria for ADHD by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV), are listed in table 1.

Table 1:  Diagnostic Criteria for ADHD

A. Either 1 or 2

1. Inattention

At least six of the following symptoms have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

• Often fails to give close attention to details or makes careless mistakes in schoolwork or other activities.
• Often has difficulty sustaining attention in tasks or play activities.
• Often does not seem to listen to what is being said to him or her.
• Often does not follow through on instructions and fails to finish schoolwork chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions).
• Often has difficulty organising tasks or activities.
• Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort.
• Often loses things necessary for tasks or activities (for example, school assignments, pencils,books, tools or toys).
• Often easily distracted by extraneous stimuli.
• Often forgetful in daily activities.

2. Hyperactivity/Impulsivity

At least six of the following symptoms of hyperactivity-impulsivity for at least six months to a degree that is maladaptive and inconsistent with developmental level:

• Hyperactivity
  • Often fidgets with hands or feet and squirms in seat.
  • Leaves seat in classroom or in other situations in which children are expected to remain seated.
  • Often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults this may be limited to feelings of restlessness).
  • Often has difficulty playing or engaging in leisure activities quietly.
  • Is often on the go or often acts as if driven by a motor.
  • Often talks excessively.
• Impulsivity
  • Often blurts out answers to questions before the questions have been completed.
  • Often has difficulty waiting in line or awaiting turn in games or group situations.
  • Often interrupts or intrudes on others.
• Onset no later than seven years of age.
• Symptoms must be present in two or more situations (for example, at school, at home and/or at work).
• The disturbance causes clinically significant distress or impairment in social, academic and/or occupational functioning.
• Does not occur exclusively during the course of a Pervasive Developmental Disorder,
• Schizophrenia, or other Psychotic Disorder, and is not better accounted for by a Mood Disorder, Anxiety Disorder, Dissociative Disorder or Personality Disorder.

Differential Diagnoses

Differential diagnoses for ADHD include normal behaviour, mental retardation, visual or hearing problems, and psychiatric diagnoses, such as adjustment reaction, anxiety disorder, depression, conduct disorder, oppositional defiant disorder, psychosis, personality disorders, and autistic spectrum disorders. Specific learning disabilities, which co-occur with ADHD in twenty-five per cent of cases, may further complicate diagnosis.

Correlates of ADHD

Children with ADHD are generally of normal intelligence, yet they often score lower on standard aptitude and achievement tests because of their inattentive-impulsive responding style and higher incidence of specific learning disabilities. Children with ADHD also typically have problems with organisation, motor planning and motor coordination. They have a higher incidence of minor physical problems for example, enuresis, injuries, sleep problems, other emotional problems such as depression, social isolation, peer rejection and family conflict. These secondary problems frequently become the major negative influences in the child's life.

Long-Term Outcomes

About eighty per cent of ADHD children will continue to have symptoms through adolescence/adulthood, and thirty to forty per cent will have major ongoing problems with academic under-achievement, early school leaving, anti-social behaviour and delinquency. Multi-disciplinary interventions of the type described below offer the best prospects for improving the prognosis.

Role of Primary Health Care Professionals

The decision to intervene and the direction taken is influenced by the extent of difficulty the behaviours are causing in the child's life, the age of the child, the extent of any secondary problems that have developed and the parent's preferences and commitments.

Primary care professionals have a role to:

• Explain the basis of the child's behaviour to the child, parents, siblings and school.
• Be supportive and non-judgmental.
• Encourage adults to have reasonable expectations of the child and reduce blame for
• Foster and promote the child's strengths.
• Support the child in home, preschool and school environment.
• Help parents to be aware of their own needs.
• Put families in contact with local ADHD support groups.

Home Management

Despite commonalities across symptoms, it is important to recognise the individual differences between children with ADHD. Parents, however, share common experiences in relation to the impact of ADHD on the family such as greater stress in parenting, a possible loss of pleasure in their relationship with their child and social isolation from other families. The impact on siblings in also affected by parents' reduced confidence in their parenting and level of attention required by the child with ADHD. Consequently, parents need to look after themselves and their relationship in light of these family stresses.

Management needs to be individualised and includes a combination of one or more of the following interventions:

• Develop consistent routines at home, and school.
• Keep rules clear and simple and give reminders calmly;(remember the child does not intend to be difficult); try and redirect behaviour.
• Talk to the child with their full attention and keep reinforcing this.
• Check the child is making eye contact before giving instructions and give instructions one or two at a time.
• Supervise closely; the child's impulsivity may place them in dangerous situations.
• Be positive about the child and continually look out for them 'being good' and praise them.
• Try to ignore minor irritating behaviour.
• Provide clear disciplinary consequences such as time-out (ages 18 months to six years) or withdrawal of privileges (over six years) for major negative behaviours.

Educational Management

Cooperation between parents and teachers is essential for the management of any child with additional needs. >Blaming staff or parents is counter-productive to addressing the child's needs within the existing resources that schools and home can provide. A diagnosis of ADHD does not necessarily mean the child will be eligible for greater assistance in an educational setting and parents may need to find other services to support particular needs of their child. Although few in number, children with ADHD in preschool need management along similar lines to those suggested for home management. Concerns about the child's safety and adequate supervision are particularly important to address in this setting.

Children with ADHD at school need to be supported with an educational program designed for their specific needs. School is often where the child faces their greatest difficulties, and the benefits of stimulant medication are most dramatic in this setting. A management plan needs to be developed in collaboration with teachers.

Department of Education, school support staff, parents and health professionals.

Children with ADHD respond best to a highly organised and routine classroom structure, with a minimum of visual distraction and noise. They perform best if seated at the front of the room, as close to the classroom teacher as possible, preferably at a single table separated from nearby students, or next to a child who can function as positive role model. Frequent adult input through the day is necessary, as are frequent breaks to move around and burn off excess motor energy.

The child should be praised and rewarded for on-task behaviour, perhaps utilising score cards leading to special privileges within the classroom or at home. Daily report cards and a home communication book assist self-monitoring. Clear graded consequences for unacceptable behaviour need to be specified.

Underlying learning difficulties will require additional individual or small group remedial instruction. Other allied health professionals may be involved for example, occupational therapists can offer specific programs for handwriting difficulties, as can a speech pathologist for language difficulties.

Specific Therapies

Parent Education

Parents may be referred by paediatricians and mental health professionals to specialised parenting programs conducted by professionals skilled in supporting parents with children with special needs. The parents' own emotional state often determines the success of parenting techniques. Working with parents on fine-tuning the way they handle their child's behaviour can help reduce some of the more difficult aspects of ADHD.

Cognitive Behaviour Therapy

Older ADHD children (over ten years) can improve their self-control, self-monitoring and self-reinforcement and learn to modify their impulsive responding style. Anger management programs targeted at adolescents are one form of cognitive behaviour therapy. These programs aim to develop skills in recognising risk situations and using alternative strategies to prevent outbursts of temper.

Family Therapy

Parents of children with ADHD frequently report problems in areas of individual, marital or family functioning.  These problems include a lack of confidence in parenting skills, social isolation, marital conflict and depression - all factors likely to decrease the effectiveness of parenting programs. Successful family therapy establishes lines of communication between family members, elecits affective responses, allows insight into the mechanisms and causes of family conflict and facilitates the establishment of assertive interactional patterns. Referral for family therapy should be considered if significant family tension is present or poor interactional patterns are preventing the application of effective parenting techniques.

Individual Counselling

Children with ADHD may benefit from an opportunity to express their feelings of distress, connect with a supportive adult who will help them gain insight to their problems and place appropriate external expectations about their behaviour.

Other Therapies

Dietary Therapies

Research indicates only about five per cent of ADHD children are genuinely sensitive to dietary triggers such as artificial colourings, preservatives and salicylates. There is no objective research evidence to support dietary sugar being a trigger of hyperactive/inattentive behaviour despite this being an anecdotal impression reported by many parents. If parents are concerned about the likely affects of food on their child's behaviour, a referral to a dietitian may be suggested.

Medication

Medication is often prescribed with children with ADHD and is very effective in most cases. Extensive research studies have shown these medications to be safe as well as effective. The most commonly used medications for ADHD are stimulants (methylphenidate and dexamphetamine). There is no evidence that simulant medication used in correct dosage and under medical supervision is associated with addiction or physical, or psychological dependence over time. Currently, in Victoria these medications can only be prescribed by a paediatrician, neurologist or psychiatrist. The medications can enhance an inattentive child's abilities and help focus attention and improve concentration. They do not cure ADHD, but rather help the child function better at school and home.

Medications should not be used in isolation from behavioural treatments, as previously described in home and educational management. Various techniques for handling the child's behaviours and remedial education can be implemented by parents and teachers to supplement the effects of medication.

Whilst medications are clearly a treatment option, there is surprisingly little data available about long-term benefits. Some parents and professionals are reluctant to use medications for philosophical reasons. When compared for short and medium-term effects, stimulant medications are far more effective than any other treatment strategy. However, it is important to remember a response to psychostimulant drugs does not confirm the diagnosis, as children without ADHD may also exhibit a positive response.

Types of Medication

Stimulants

Two related but pharmacologically distinct stimulant drugs are available for restricted prescription in Australia, methylphenidate (Ritalin) and dexamphetamine.

About seventy-five per cent of ADHD children treated with stimulants display dramatic improvements in behaviour, school performance, cognitive processing and socialisation. Response is usually immediate, and tolerance to drug effects does not appear to develop over time. Changes in behaviour are observed within 20 to 60 minutes or oral ingestion, with a peak action at 90 to 180 minutes. Therapeutic effects usually subside within four to eight hours; side-effects may persist longer but are usually over within 24 hours and lessen dramatically over the first week of treatment. These include decreased appetite, insomnia, tearfulness, abdominal cramps and headaches. Weight loss and growth suppression are reversible with dose reduction or drug withdrawal. In rare instances facial tics or Tourette's syndrome may develop while children are being treated with stimulants and require cessation of medication.

Stimulants are usually taken at breakfast and lunchtime; occasionally a late afternoon dose is provided to assist with late afternoon behaviour problems and to facilitate completion of homework. Weekend and school holiday breaks from the drug are sometimes recommended but are not essential. Most children have their medication ceased for a trial period each six to twelve months to determine whether it is still producing significant therapeutic benefits.

Tricyclic Antidepressants

Desipramine and imipramine are the two most commonly used tricyclics in ADHD. Tricyclics may be particularly valuable for children with symptoms of anxiety or depression, which in general predict a poor response to stimulants.

Clonidine

Used for many years as a centrally anti-hypertensive, clonidine has recently been shown to be effective in ADHD, particularly in children with tic disorders, where stimulants and tricyclics may be contraindicated.

Conclusion

There is certainly a group of children whose problems with attention and or impulsivity/hyperactivity have a significant negative impact on their learning, social interaction and general functioning.

In establishing a diagnosis of ADHD there is agreement that multiple sources of information should be obtained (observations of parents, teachers and assessment by professionals). There are a number of reliable and validated parent and teacher questionnaires which provide quantitative measures of behaviour.

At least a proportion of these children appear to have a biological basis for their problem behaviours. However. this does not mean that it is the cause of the condition.

A good management plant incorporates home management, classroom adaption, remedial teaching and behavioural therapy. There is recent evidence to suggest stimulant medication should be instituted early in multi-disciplinary treatment as it enhances the effectiveness of psychological therapies, rather than being left as a last resort after all other treatment options have failed.

References

DSM-1V, American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.

Barkley RA.  Attention Deficit Hyperactivity Disorder.  A Handbook for diagnosis and treatment.  Guilford Press, New York 1993.

Green C, & Chee K.  Understanding ADHD.  Doubleday, Sydney 1994.

NHMRC, Working Party on ADHD (to be published 1997)

For Further Information

General practitioners and paediatricians specialising in developmental delay.

Department of Human Services, Specialist Children's Services in your region (for children under 6 years).

Regional Child Mental Health Services

Royal Children's Hospital/Travancore

Tel: (03) 9345 6011

Alfred Child and Adolescent Mental Health Service

Tel: (03) 9526 4400.

Austin Hospital Child and Family Psychiatry

Tel: (03) 9496 5108

Monash Medical Centre Child and Adolescent Psychiatry

Tel: (03) 9550 1300

Maroondah Hospital Child Mental Health Service

Tel: (03) 9870 9788

Western Hospital, Sunshine Child and Adolescent Psychiatry

Tel: (03) 9365 1217.

Department of Education, Independent Schools and Catholic Education: educational psychologists.

Department of Human Services, School Nursing Program in your region.

Department of Human Services, Positive Parenting Program in your region.

Private psychologists or child psychiatrists.

Local government Home & Community Care services.

Parent Support Groups

ACTIVE Victoria Tel: (03) 96520 2570

Association for Children with a Disability

Tel: (03) 9427 0827, Freecall 1800 654 013.

Child Health Information Centre, Royal Children's Hospital, Melbourne

Tel: (03) 9345 6429.

Written and Developed by the Centre for Community Child Health and Ambulatory Paediatrics Royal Children's Hospital, Melbourne for the Victorian Government Department of Human Services.

Produced by the Office of the Family, Youth and Family Services Division, Victorian Government Department of Human Services.

April 1997