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When they say ADHD…

By Loi Eberle, M.A.
Educational Consultant &
Editor of Woodbury Reports, Inc.
loi@woodbury.com
208-267-5550

Most people have heard the terms ADD or ADHD. Either a family member or a friend’s child has received the diagnosis, or they have heard it frequently mentioned in the media, due to the increasing number of people who are affected in one way or another by this behavior. In fact, when they hear the definition, many people feel they probably would have received that diagnosis themselves, if the questionnaires and rating scales had existed when they were in school. Yet, although the term is familiar, there seems to be less clarity about what exactly it is, and even more confusion about what to do about it.

Definition & Diagnosis: ADHD is not so much a single condition, but one that can “include a loosely defined set of common childhood problem behaviors…noncompliance, academic difficulties, social skills deficits, aggression, overactivity and attentional defects.”¹

These behaviors can be caused by a variety of factors, so there has been a great deal of effort placed on developing a better understanding of this behavior when it occurs. Other causes of ADD/HD types of behavior, such as structural and/or physiological deficits of the central nervous system due to prenatal, natal and postnatal trauma, or metabolic and seizure disorders, need to be ruled out, for example. Efforts are made to isolate a “pure ADD/HD group” by evaluating each child according to psychiatric, neurological, cognitive, educational, and social parameters.

There are actually three ways it is categorized: ADD refers primarily to inattention (attention deficit disorder); ADD/HD refers to predominately hyperactivity; and ADHD refers to a combination of inattentive and hyperactive behaviors (attention deficit hyperactivity disorder). The symptoms of inattention and impulsivity are difficult to define; it is not easy to measure them. ADHD symptoms which usually are present in a child might not be observed in a highly structured or novel setting with interesting tasks or one-to-one attention; it may require observations in a variety of settings.² Merely describing hyperactivity is “not meaningful without referring to the situation in which these behaviors occur.”³

ADHD symptoms are assessed through questionnaires completed by parents, teachers, peers, and even the children themselves. It is a diagnosis that is determined with a checklist of symptoms, with 6 out of 9 symptoms on one rating scale needing to be present to receive a diagnosis of inattention, and 6 of nine symptoms on another rating scale being necessary to be diagnosed with hyperactivity. The symptoms not only need to be present, they also must have occurred for at least 6 months, at a level that has caused adjustment problems beyond what would be considered normal for their age and are clearly having an adverse affect on their social, academic, or occupational functioning.

More recently, other diagnostic tools are being explored. For example, neuroimaging and functional imaging studies have found differences in metabolism and in the shape of the brain⁴ among those with ADHD. There is also some indication of a genetic predisposition for ADHD. Studies done on twins show that hyperactivity and inattention can be inherited separately. Some research also indicates that possibly a deficit in a combination of neurotransmitters might be involved with ADD/HD behaviors.⁵

Because behaviors that are broadly defined as ADHD may be the result of a variety of causes, understanding why they are occurring will give insight about the best way to help. If the child’s behavior is determined to be the result of pervasive developmental disorders, autism, anxiety, or personality disorders, then these children should work with mental health professionals who have experience in these areas. On the other hand, “if clinical findings indicate that the symptoms of inattention and/or impulsiveness are due to developmental disorders, structural defects of the central nervous system, or inappropriate or inadequate stimulation at critical ages, then…a diagnosis of ADHD can be considered.”⁶

Even if the child’s behavior truly fits within the set of behaviors given the ADD or ADHD diagnosis, the issue remains, what to do about it?

Parenting Skills The literature certainly indicates that most children with ADHD also develop other dysfunctional patterns such as depression, anxiety, oppositional defiant disorder, and even conduct disorders, that co-exist with their ADHD. In some cases parents contribute to conduct problems by their inconsistent and impotent responses to their child’s rages. Behavioral management skills can help families work with their child in more helpful ways, so that the child can become more self-reliant and less anxious. Since rage reactions can be triggered by anxiety, if the anxiety is reduced, it can result in less raging behavior. Although sometimes medications can help a child gain some control over moods and behaviors, even in those cases, it is still important for parents to develop good parenting skills.⁷

Family Therapy It also is helpful for parents to fortify their relationship with each other, when they are dealing with their ADHD child. The parent’s marital boundaries, which are sorely needed to protect their own relationship, are often weak and diffuse in ADHD families. These boundaries need to be strengthened and the parents need to be supported to help them let go of their excessive focus on parenting their ADHD child. These families can greatly benefit from family systems therapy, where the family itself is the focus of treatment, helping them to create a safer, more relaxed environment for their ADHD child. Extended, long-term therapy with ADHD children is usually unnecessary if the families are in therapy to work on their entire family system. The ADHD child will be benefit far more by the parents working to solidify their own relationship through enhanced intimacy and communication. Long-term therapy with the ADHD child only serves to reinforce the child’s self-perception of being “damaged”. Short-term therapy for the ADHD child should consist of family sessions designed to educate parents with knowledge and skills that will enable them to become advocates for their ADHD child and help them to create a healthier family environment for all of their children.⁸

Medication & Diet Research has shown that stimulant medication will relieve inattention and restless behavior in approximately 75% of hyperkinetic children, however, “most studies do not find clear evidence of improvement in academic learning.”⁹ Particularly when central nervous system dysfunction is involved, stimulants have no clear role to play in relation to learning disabilities. While most side effects of stimulant medication are more annoying than dangerous, the emergence of Tourette’s syndrome has been reported and there is evidence of growth suppression with prolonged use of stimulants. Response to stimulant drugs cannot be used as a confirmation of the diagnosis of ADHD, since children who did not demonstrate symptoms of ADD or ADHD responded in the same way to stimulants.

Dr. Feingold, Emeritus chief of the Department of Allergy at the Kaiser-Permanente Medical Care Program in San Francisco, specifically indicated that salicylates, food colorings, preservatives, and additives trigger allergies that are a precipitating factor in what he called the Hyperkinetic Learning Disability syndrome. The use of the Feingold or the Kaiser- Permanente diet has not received scientific confirmation, and “no objective challenge study of the effect of sugar on hyperactivity has been done to date,” although there are many anecdotal reports of the diet’s success.¹⁰

How Should They Be Taught? It is important to provide these children and adolescents with “persistent, patient instruction in systematic ways.” They need help in “organizing assignments and learning materials…Teachers need to give clear directions in classes and to provide organized media for communicating assignments and require organized notebooks and assignments books, with time provided for their consistent use. Teachers should also stockpile a few extra copies of assignment schedules, textbooks, and other materials to avoid the inevitable confrontations that occur when the student forgets them elsewhere. Teachers should understand that at home, parents of children with ADHD have organizational problems of their own to deal with. Expecting them to manage their children’s work at school by remote control is unrealistic.”¹¹

Teachers who are successful teaching students with ADD or ADHD, consider these students as a challenge, not a burden. They recognize that their role not only includes imparting knowledge, they need to teach skills in socialization as well. These teachers are not annoyed by these student’s behaviors, and respect them as human beings. It is important to convey acceptance and support for the students with ADD/ADHD who may be less popular with their classmates because they are impatient and talkative. “Students with ADHD are easy targets for scapegoating or being made the object of mirth in the classroom…In the final analysis, no specific kind of class placement, no single set of curriculum objectives, no special list of teaching techniques exist for teaching students with ADHD.”¹²

Prognosis Studies have “estimated that more than 70% of hyperactive children continue to meet criteria of ADHD in adolescence and up to 65% as adults.”¹³ “At the 5-year followup with children 11 to 16 years old, the initial symptoms of hyperactivity, distractibility, impulsive behavior, and aggression were generally decreased but still were greater than in the normal controls. Further, the hyperactive children, now young adolescents, were considered immature, had difficulty maintaining goals, failed more grades in school, and had lower academic achievement than their matched controls. Twenty-five percent of them were considered antisocial. “While few hyperactive children become grossly disturbed or chronic breakers of the law and none were diagnosed as being psychotic or schizophrenic, the majority continue as young adults to have…continued symptoms of the hyperactive child syndrome…lower educational achievement, poorer social skills, lower self- esteem…continued impulsivity and restlessness.”¹⁴

Later studies indicated “core symptoms of inappropriate restlessness, attention difficulties, and impulsivity were still present in adolescence, though somewhat muted. Poor school performance, social deviance, and difficulties in relationships with peers and with adults were prominent, with 10% to 50% of the ADHD group having a history of anti-social behavior, although approximately 50% were indistinguishable from normal peers. However, the remaining 50% had a history of antisocial behavior, used alcohol and marijuana, and 20% had a DSM-III diagnosis of Antisocial Personality Disorder. Drugs that were so effective in the short term to reverse the core symptoms of ADHD were not effective in the long term with adolescents, who were still failing in school, having behavior problems and poor self-esteem, still at high risk for academic and social difficulty.”¹⁵

Can Emotional Growth Programs Benefit ADHD? To date, all the followup studies have focused on traditional approaches to education and medication. The data from these studies has shown the long- term outcome for children with ADHD has generally been disappointing, with half of the children studied showing continued symptoms of decreased impulse control, lower educational achievement, poorer social skills, and low self-esteem16 These studies did not include data on students who are being educated in emotional growth settings that focus on developing skills in the areas self-esteem, impulse control, and social skills. Anecdotal evidence indicates that students who improve in these areas also improve their ability to achieve academically, and they are able to develop the skills that will enable them to find successful employment and develop healthy relationships. Given that the problems associated with ADD/HD are becoming more familiar to a greater number of people, hopefully more research will be directed towards alternative forms of educational programs. This would serve to validate anecdotal evidence which shows greater success with ADHD students when the education includes: a strong emotional growth component, a structured environment that enhances self-esteem based on true achievement, offers needs-based instruction in academics, and helps students to develop skills in self-monitoring and self-regulation.

1. Ostrom, N.N. & Jensen, W.R. (1988). Assessment of attention deficits in children. Professional School Psychology, 3, 254-269.
2. Practice Parameters, attention deficit/hyperactivity disorders. (1997). Journal of the Academy of Child and Adolesccent Psychiatry, 36 (Suppl.), 85S-121S.
3. Porges, S.W., & Smith, K.M. (1980). Defining hyperactivity: Physiological and behavioral strategies. In C.K. Whalen & B. Henker (Eds.), Hyperactive children: The social ecology of identification and treatment (pp.75-104.) New York: Academy Press.
4. (reduced glucose utilization bilaterally with significant reduction in superior frontal and premotor cortices and reduced anterior frontal width and smaller volume of left caudate, frontal interior bilateral retrocallosal.).
5. (dopamine, norephinephrine, or serotonin systems may be involved)
6. Disorders of Learning in Childhood, A. Silver & R. Hagin, (2002 Wiley & Sons, Inc.)
7. Ibid.
8. C.A. Everett & S. Volgy Everett, Family Therapy for ADHD, (1999 Guildford Press).
9. A. Silver & R. Hagin, op cit.
10. Ibid.
11. Ibid.
12. Ibid.
13. Barkley, R.A. (1996). Critical issues in research on attention. In G.R. Lyon & N.A. Krasnegor (Eds.), Attention, memory and executive functions ) pp.45-56. Baltimore: Brookes; and Goldman, L.S., Genel, M., Bezman, R.J./, & Slanetz, P.J. (1998). Diagnosis and treatment of attention- deficit/hyperactivity disorder in children and adolescents. Journal of the American Medical Association, 279, 1100-1107.
14. Weiss, G. (1983). Long-term outcomes: Findings, concepts and practical implications. In M. Rutter (Ed.), Developmental neuropsychiatry (pp.422-436). New York: Guilford Press.
15. A. Silver & R. Hagin, op cit. 16 A. Silver & R. Hagin, op cit.