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Condition
 

Children with Attention Deficit Hyperactivity Disorder (ADHD) have problems with attention, controlling their impulses, trouble completing tasks and may be hyperactive. They often have other problems, such as learning difficulties, making friends, oppositional behaviour, anxiety and ill-health that may need to be looked into. It is hard for these children to control their behavior and/or pay attention. ADHD symptoms can be caused by a number of other problems, including learning difficulties, social issues, ill-health and other mental health issues.

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Symptoms of Inattention

  • Fails to give close attention to details
  • Makes careless mistakes in schoolwork, work, or other activities
  • Has difficulty sustaining attention in tasks or play activities
  • Does not seem to listen when spoken to directly
  • Does not follow through on instructions
  • Fails to finish schoolwork, chores, or duties at home.
  • Has difficulty organizing tasks and activities
  • Avoids engaging in tasks that require sustained mental effort (such as homework)
  • Loses things necessary for tasks or activities (toys, school assignments, pencils or books)
  • Is easily distracted by outside stimuli
  • Is forgetful in daily activities

Symptoms of Hyperactivity

  • Fidgets with hands or feet or squirms in seat
  • Leaves seat in classroom or in other situations in which remaining seated is expected (e.g. to watch a drama performance)
  • Runs about or climbs too much which is often inappropriate to the situation
  • Has difficulty playing quietly
  • Is 'on the go' or acts as if 'driven by a motor'
  • Talks too much, will ask many questions that are often silly and repetitive.

Symptoms of Impulsivity

  • Will shout out answers before questions have been completed
  • Has difficulty waiting his or her turn
  • Interrupts or intrudes on others (such as butting into conversations or games)

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Types

According to the DSM-IV (Diagnostic Statistical Manual - IV), there are three sub-types of ADHD.

1. ADHD, Predominantly Inattentive Subtype.

This subtype is diagnosed if symptoms of inattention have persisted for at least 6 months and are age inappropriate. The inattentive ADHD child may fail to give close attention to details or may make careless mistakes. The child may have difficulty sustaining attention in tasks or play activities, and may not seem to listen when spoken to directly. Often the child may not follow through on instructions and may fail to finish schoolwork and chores, and may have difficulties organizing tasks and activities. The child may be forgetful and often lose things necessary for school assignments, pencils, books and school jumpers. There may be a reluctance to engage in tasks that require sustained mental effort. Hence there may be considerable arguments and excuses to avoid schoolwork or homework.

2. ADHD, Predominantly Hyperactive-Impulsive Subtype.

This subtype is diagnosed if there are some symptoms of hyperactivity-impulsivity along with fewer symptoms of inattention.

Hyperactivity symptoms: These include frequent fidgetiness with hands or feet or squirming particularly when required to sit still. There is likely to be difficulties playing or engaging in leisure activities quietly, and the child may seem to be constantly on the go, or may talk excessively. Often the child will leave his/her seat in the classroom or in other situations in which remaining seated is expected. There may be excessive inappropriate running and climbing. As the child grows into adolescence or adulthood, this may subside and feelings of restlessness may remain.

Impulsivity symptoms: The impulsive child often blurts out answers before questions have been completed, and has difficulties awaiting his/her turn. Consequently there may be frequent inappropriate interruptions, intrusions into games or butting into conversations.

3. ADHD Combined Subtype.

When both symptom of inattention and hyperactivity-impulsivity are present, the child may be diagnosed as having the Combined Type of ADHD

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Conditions co-existing with ADHD

Learning disabilities

Many children with ADHD, approximately 20 to 30 percent, also have a specific learning disability (LD). In preschool years, these disabilities include difficulty in understanding certain sounds or words and/or difficulty in expressing oneself in words. In school age children, reading or spelling disabilities (Dyslexia), writing disorders (Dysgraphia) and arithmetic disorders (Dyscalculia) may appear.

Tourette syndrome

A very small proportion of people with ADHD have a neurological disorder called Tourette syndrome. People with Tourette syndrome have various kinds of nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others may clear their throats frequently, snort, sniff, or bark out words. These behaviors can be controlled with medication. While very few children have this syndrome, many of the cases of Tourette syndrome have associated ADHD. In such cases, both disorders often require treatment that may include medications.

Oppositional defiant disorder

As many as one-third to one-half of all children with ADHD (mostly boys), have another condition, known as oppositional defiant disorder (ODD). These children are often defiant, stubborn, non-compliant, have outbursts of temper, or become belligerent. They argue with adults and refuse to obey.

Conduct disorder

About 20 to 40 percent of ADHD children may eventually develop conduct disorder (CD), a more serious pattern of antisocial behavior. These children frequently lie or steal, fight with or bully others, and are at a real risk of getting into trouble at school. They need immediate help.

Anxiety and depression

Some children with ADHD often have co-occurring anxiety or depression. If the anxiety or depression is recognized and treated, the child will be better able to handle the problems that accompany ADHD. Conversely, effective treatment of ADHD can have a positive impact on anxiety as the child is better able to master academic tasks.

Bipolar disorder

There are no accurate statistics on how many children with ADHD also have bipolar disorder. Differentiating between ADHD and bipolar disorder in childhood can be difficult. In its classic form, bipolar disorder is characterized by mood cycling between periods of intense highs and lows. But in children, bipolar disorder often seems to be a rather chronic mood dysregulation with a mixture of elation, depression, and irritability. Furthermore, there are some symptoms that can be present both in ADHD and bipolar disorder, such as a high level of energy and a reduced need for sleep. To differentiate children with ADHD from those with bipolar disorder, symptoms like elated mood and larger than life feeling of superiority of the bipolar child are distinguishing characteristics.

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Diagnosing ADHD is difficult, since most children, are impulsive or inattentive some of the time. Because ADHD is a lifelong condition and may require medication, careful and thorough assessment is essential. Ruling out other disorders and assessing for possible co-existing disorders enhances proper diagnosis and most effective intervention program for e.g. Learning disabilities experienced by many children with ADHD may further complicate the task of identifying the scope of the difficulty and in providing the most effective treatment.

A thorough assessment should include gathering information from individuals familiar with the child (parents/care-giver, teacher) and should include consideration of other diagnostic possibilities. Often included in the assessment procedure is an intelligence test (IQ), test of achievement, along with evaluating their emotional functioning.

Conditions for a diagnosis of ADHD:

•  A child must display behaviors from one of the three subtypes (refer types) before age 7.
•  These behaviours must be more severe than in other kids the same age.
•  The behaviours must last for at least 6 months.
•  The behaviours must occur in and negatively affect at least two areas of a child's life.
    (such as school, home, day-care settings, or friendships).

To avoid misdiagnosis it is very important to consider factors that may affect a child's behaviour such as home environment, general health, emotional stability, school experiences etc. Children who have experienced an illness, a divorce, stress at home, change in living conditions, a change in school, or other significant event may also suddenly begin to exhibit unacceptable behaviour or show signs similar to children with ADHD such as being disorganized, forgetful etc.


A correct diagnosis often resolves confusion about the reasons for the child's problems and helps the parents and the child move forward in their lives with more accurate information on what is wrong and what can be done to help. Once the disorder is diagnosed, the child and family can begin to receive whatever combination of educational, medical, therapeutic and emotional help they need.

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•  Psychiatrists - Child psychiatrists are doctors who specialize in diagnosing and treating childhood mental and behavioral disorders. A psychiatrist can provide therapy and prescribe any needed medications.

•  Psychologists - Child psychologists are also qualified to diagnose and treat ADHD. They can provide therapy for the child and help the family develop ways to deal with the disorder. But psychologists are not medical doctors and must rely on the child's physician to do medical exams and prescribe medication.

•  Paediatricians - Paediatricians are doctors who work with children and their health in general. It is recommended that every child should have one fixed paediatrician so that it becomes easy to follow up on any treatment program.

•  Neurologists - Neurologists are doctors who work with disorders of the brain and nervous system. They can also diagnose ADHD and prescribe medicines. But unlike psychiatrists and psychologists, neurologists usually do not provide therapy for the emotional aspects of the disorder.

In selecting a specialist, it's important to find someone with specific training and experience in diagnosing and treating the disorder. Whatever the specialist's expertise, his or her first task is to gather information that will rule out other possible reasons for the child's behavior. Ideally, in ruling out other causes, the specialist checks the child's school and medical records. The child's teachers, past and present, are asked to rate their observations of the child's behavior on standardized evaluation forms, known as behavior rating scales, to compare the child's behavior to that of other children the same age. In looking at the results of these various sources of information, the specialist pays special attention to the child's behaviour during situations that demand a lot of self-control, as well as noisy or unstructured situations such as parties, or during tasks that require sustained attention, like reading, working math problems, or playing a board game. Behaviour during free play or when the child is getting individual attention is given less importance in the evaluation. In such situations, most children with ADHD are able to control their behavior and perform better than in more restrictive situations. The specialist then pieces together a profile of the child's behaviour.

Not everyone who is overly hyperactive, inattentive, or impulsive has ADHD. Since everyone shows some of these behaviours at times, for a proper diagnosis, such behavior should be demonstrated to a degree that is inappropriate for the person's age and effects his/her normal functional skills.

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ADHD is a condition that becomes apparent in some children in the preschool and early school years.

If parents, teachers, and other professionals discover a child's disability early and provide the right kind of help, it can give the child a chance to develop skills needed to lead a successful and productive life. It begins from birth or first diagnosis. It involves specialized therapy services for the child, as well as support for the whole family through information, assisstance, and emotional support. Early Childhood Intervention has several goals. Firstly, it is provided to support families to support their children's development. Secondly, it is to promote children's development in key areas such as learning, communication or mobility. Thirdly, it is to promote children's confidence to cope with the condition, and finally it is to prevent the development of greater future problems.

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An all-inclusive or a comprehensive intervention plan includes psychological, educational and social measures. It involves advice and support to parents and teachers, and could also possibly include specific psychological treatment (such as behavioural therapy). Doctors often recommend that children with ADHD or ADD be treated asymptomatically with stimulant medication, special education and counseling. Although these approaches often yield positive benefits, they do not target the underlying causes of the condition.

The child should be provided services in an interdisciplinary setting. Look for a centre which has a team comprising people with varied expertise. A key feature of "interdisciplinary model" is where members discuss together and work on goals as a team. This approach would be more beneficial to the child as well as the family. A good intervention plan must be feasible and manageable over a long period of time as it is likely that treatments for the child with ADHD will continue throughout the childhood.

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A good program should involve the following consultants (along with medical practitioners) who will work as a team to enhance overall development and facilitate independence in the mainstream society. Parents play an integral role and hence should be actively involved in the whole process.

  • Psychologists
  • Occupational Therapists
  • Speech-Language Therapists
  • Special Educators

Psychologists: Psychologists: Psychologists work with the child and the family to cope with the emotional demands the disorder may have on both. They often plan a Behaviour Therapy program, which helps parents/teachers to reorganize the child's home and school environment to sort out issues that could possibly be affecting the child's behaviour. This is done by setting up a system of consistent rewards for appropriate behaviours and negative consequences for inappropriate ones, giving clear directions and commands, and making life simple. Some of the strategies that help modify behaviour are Positive reinforcement, Reward systems, Creating a routine, Avoiding distractions, Changing the style of interaction with the child, Limiting choices, Discovering a talent, Helping the child organize his/her life.

Occupational Therapists : Occupational therapists : Occupational therapists evaluate the motor and other functional skills of the child which can provide information on the developmental age of a child and this may or may not agree with the psychological results. Profiling the child's sensory history (for example parents or care-givers are asked about the child’s reaction to loud noises, unexpected touch, certain types of clothing etc) can also provide crucial evidence in the determination of ADHD. It is often difficult to distinguish behaviours that are often found in Sensory Integration Dysfunction (a neurological disorder causing difficulties with processing information from the five senses, the sense of movement and/or the positional sense) and ADHD. However there are some broad patterns that could be helpful. It is important to remember that not all children with ADHD have sensory processing issues but most children with sensory integrative problems may present with symptoms of ADHD.

Occupational therapy for children with ADHD enhances their ability to process lower level senses related to alertness, body movement and position, and touch. This allows them to pay more attention to the higher level senses of hearing and vision. For example, skills related to vision include tracking the object, fixing on the object, changing focus, merging what both eyes are seeing and finally forming a mental image. When all of these are well developed, children can sustain attention, make less errors while reading/writing, give meaning to what they hear and see, and rely less on movement to stay alert. The therapy focuses mainly on reducing hyperactivity, impulsivity, wrong adaptive behaviours and enhances attention and concentration to improve social skills like, co-operative play, sharing skills, develop self-concept / self-esteem, attention, listening skills, taking turns, following directions, cognitive perceptual skills, and produce expected adaptive behaviour. The other main areas that are targeted include self-care and school performance. In self care the occupational therapist provide orientation to the child about the dress materials, eating, bathing and grooming equipments and provide simulation activities that improves the independent performance of the child in various contexts. Therapists also focus on developing pre-handwriting skills, writing, colouring, alphabet and numeral learning and recognition, which helps improve the school performance of the child.

Speech-Language Therapist: Children with ADHD need to learn how to use language socially to communicate. That includes knowing how to hold a conversation, thinking about what the other person in a conversation understands and believes, and tuning in to the meta-linguistic signals of the other person, such as facial expression, tone of voice and body language. It is important to remember that communication is as much nonverbal as it is verbal, and people with autism have great difficulty understanding nonverbal language.

Special Education: They might need special inputs to perceive and comprehend the vast information presented to them using special instructional methodology and instructional material, learning aids and equipment specific to each individual's learning needs.

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Children with ADHD require a stable, consistent environment. It is important that the child is exposed to a positive family environment and that any family issues and problems be attended to as priority. It has been repeatedly demonstrated that even the best of ADHD treatments fail when placed within chaotic or unsupportive homes and educational settings. Parents have to be encouraged to use positive reinforcements and reward systems to enhance good behaviour. Parents need to understand what drives their child's behaviour and how to adjust the way they interact accordingly.

It is important not only to work towards shaping your child's behaviour, but also to help them feel good about themselves in the process. Parent training does not mean that there is something wrong in your current style of parenting, it is just a guidance to help parents gain better understanding into the problems you face with your child and the most suited way to handle it. It is essential to address any behaviour that might hinder the child's development into a physically and mentally healthy individual.

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Parents and professional support groups can increase awareness of the issue, dispel misconceptions, help establish educational systems that provide for the needs of children with learning disabilities, and get support for each other considering that the condition itself is very mentally demanding.

The other areas that require very careful planning, keeping in mind the individual needs of the child are:

•  Choosing the right school.
•  Choosing an appropriate educational plan.
•  A good behaviour management program.
•  Individual cognitive approach.
•  Parental Counselling.
•  Comfortable and stimulating home environment.

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  • Be very clear, about what behaviour is expected of your child and stay consistent with your response.
  • Rules must be laid down at the beginning and adhered by everyone, adults, and children alike. It is important to play good role models.
  • Make sure your expectations are reasonable. Accept your child's weaknesses and help him/her cope with it.
  • Keep a simple schedule as multi-tasking or remembering too many instructions may be hard on your child
  • Design the program so that your child get positive experiences right at the start, then gradually increase the complexity.
  • Provide more feedbacks, visual and verbal.
  • Set short term rather than long term goals

 
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