Understanding ADHD

A Guide to Symptoms, Management and Treatment

Anna Maria Re, Agnese Capodieci

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429513831
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This essential guide provides accessible, concise, evidence-based guidelines on Atttention Deficit Hyperactivity Disorder (ADHD), offering a deeper scientific understanding of the condition and its consequences. It offers ideas and insights for managing the condition in daily family life and promoting the most effective self-regulation strategies for children and adolescents, allowing parents to better understand the origins of their child's behaviour and avoid potential negative consequences.

In this straightforward text, Capodieci and Re set out the basic theories on ADHD and cover key topics including parent-child relationships, helping children understand their condition, friendships with peers, comorbidities, classroom strategies, and how families and professionals can best work together. Taking into account the most recent updates to the DSM-5 definition of ADHD, the authors emphasise the importance of a multifocal approach to the treatment of ADHD, involving the child's teachers, parents and peers, to better develop family and peer relationships. They offer strategies for the classroom, for good sleep and for healthy eating and physical activity, and support for any other learning, language, movement and emotional problems an ADHD child might have.

Understanding ADHD will be essential reading for parents of children with ADHD, as well as health, education and social care professionals involved in the field.

Chapter 1

Signs and symptoms

Francis is an only child. He is ten years old and attending the last year of primary school. For some time now, his teachers have been insisting that his parents have him seen by a specialist because of his behaviour. From an early age, Francis was a difficult child to manage. He was always restless, and found it hard to adapt to regular sleeping and eating routines. At school he was very lively, but even when playing he would briefly pay attention to one game and then quickly move on to another. Even at home with his parents, his behaviour was no better. He would badger them incessantly for something, but often lose interest as soon as he had been granted what he wanted. His grandparents often accused his parents of being too indulgent with him and spoiling him. When he started primary school, the situation became worse. He had trouble staying seated at his desk, and was unable to concentrate during the lessons. He soon fell behind the rest of the class and his academic performance was generally poor. Getting his homework done was by no means easy. Francis would constantly postpone getting started, then do his homework all in a rush, making numerous mistakes. Sometimes he did not finish his homework because he had not written in his diary everything he was supposed to do, and sometimes he did none because he had not written anything at all. He often received notes from his school teachers or was punished at home for not doing his homework or for not trying hard enough. For Francis, life with his classmates was not easy either. He was often excluded from their games because he would keep wanting to dictate the rules, or he would want to play another game because he quickly became bored with one activity and wanted to move on to another. In an effort to make himself popular with his companions, he would often be the “class jester”, telling jokes even when the teacher was explaining something, or poking fun at a classmate who was struggling. The teachers complained not only about Francis’s behaviour, but also about his erratic academic performance. Sometimes he succeeded in completing a task with excellent results, and other times he refused even to try. This attitude gave his teachers the impression that Francis was “lazy”, “poorly motivated” and “spoilt by his parents”.

Introduction

The above description is typical of the picture of children with Attention Deficit Hyperactivity Disorder (ADHD) painted by their parents during their first meeting with a psychologist. “Charles can’t sit still, not even for a minute”, “Miki never succeeds in finishing anything he starts. He has hundreds of ideas but never follows any of them through”, “Claude is always running around and climbing all over the place”, “Francis never thinks about the consequences. He speaks and acts without thinking twice”. These are the sort of comments that parents of children with ADHD often hear.

The reason why this disorder has such a long name (and one that is also rather daunting for a parent) is because it is characterized by its symptoms: inattention, hyperactivity and impulsivity.

Let us take a closer look at what is meant by each of these aspects.

The term attention deficit is used mainly to describe a difficulty in keeping focused on something for a prolonged period of time, especially when this demands a degree of intellectual effort. This difficulty is often revealed by a tendency to change the subject, a lack of perseverance and disorganization. It is not caused by an oppositional attitude or inability to understand what is required. Being easily distracted is another very common sign of attention deficit. In describing how difficult he found it to stay concentrated on listening to the teacher’s explanation, a child once told me: “I really want to pay attention, but then if a pencil drops, or a fly goes by, I just can’t keep my eyes on the teacher”. His words give us a clue to how difficult it can be for a child with ADHD to stay focused, however hard they try. To better explain how our attention functions, we can imagine a net with holes in it that may be large or small, depending on what material we want to allow through. When the net has large holes, lots of material can pass through, but if we only want to let a little material through – in other words, when we want to select what we allow through the net – then we narrow the holes so that all the larger material remains outside. Our attention works in much the same way. When we are relaxing and going for a stroll, for instance, we are not paying attention to anything in particular. We allow our attention to wander from one thing (such as a shop window) to another (such as a passer-by). In other words, we allow the stimuli around us to briefly capture our attention. But when we are concentrating on something (when we are reading a book, for instance), then our attention focuses only on what we are reading and we are barely aware of all the stimuli around us (such as background noise). Children with ADHD struggle to narrow the holes in their “attention net”, and are consequently easily distracted by the many stimuli in their surrounding environment (see Box 1.1). Many parents might be thinking that their children succeed in remaining concentrated for quite a while, oblivious to anything around them, when they are amusing themselves playing video games, for instance. This stems from the fact that motivation is a very important factor that can strongly influence anyone’s behaviour – and children with ADHD are no exception. Another very important factor that contributes to making video games particularly appealing to children generally lies in the immediate gratification they receive. Like some other games (such as certain puzzles), video games are characterized by various levels of difficulty. They are designed in such a way that every player, even a beginner, can find a level of difficulty on which they are successful. With success comes some form of gratification (such as a cumulative score), and this motivates players to continue the game, to keep practising in order to improve their performance and move on to the next level of difficulty. Simply put, players are always dealing with a level of difficulty that coincides with the “optimal challenge”: not so easy that it becomes boring and success can be taken for granted (in which case players would lose interest), and not so difficult that it discourages them from going ahead. This makes players think “I can do it if I try” and gives them great satisfaction when they succeed. These are the ideal conditions for learning (Vygotsky, 1931), and if school work and homework could be presented in the same way, there would be no more demotivated students – but sadly this is virtually impossible!

Now let us look at the other symptoms that are usually seen in ADHD: hyperactivity and impulsivity. Symptoms of hyperactivity mainly affect physical movements, appearing as excessive and unfocused motor activity, especially at inappropriate times. Examples are fidgeting, drumming fingers on the table and chattering excessively (Marzocchi, Re, & Cornoldi, 2019). Hyperactive children are usually extremely lively, constantly running and climbing, and show little interest in calmer pastimes. Impulsivity, on the other hand, is defined as the inability to control one’s behaviour (Barkley, 1998). It becomes manifest in extremely hurried actions that have to be taken instantly, often at high risk to the individual concerned. Impulsivity can express a desire for immediate compensation. It can take the form of invasive behaviour (e.g. constantly interrupting other people) or making important decisions without reflecting on the possible longer-term consequences. Impulsive children may answer impetuously before someone has finished asking them a question. They cannot wait for their turn in a game. They switch from one activity to another without completing what they had previously started. It is usually a child’s difficulty with keeping still and controlling their behaviour when the circumstances require them to do so that is the most obvious sign of ADHD. It is therefore hardly surprising that, for a long time, specialists would speak not of ADHD, but of hyperkinetic disorder, because hyperactivity seemed to be the main feature of the condition.

So, if we imagine a six-year-old child with ADHD entering a primary school classroom for the first time and being asked, right from the start, to remain seated in their place and listen to the teacher or perform tasks that demand concentration and cognitive effort, how are they likely to react? Predictably enough, many children with ADHD try to run out of the classroom in their early days at school, and one of their teachers’ primary goals is to keep these children in class for a whole school day. Hyperactivity and impulsivity are the aspects of ADHD most difficult for teachers to manage. Children with ADHD behave in certain ways – such as acting without thinking and failing to wait their turn in conversations and games – that also pose problems when they play with their peers. They often want to change the rules of a game, refuse to play by the rules or want to play a different game. These are all types of behaviour that, with time, can damage their relations with their classmates. Sometimes, caught up in the excitement of a game, children with ADHD may be unable to control their actions or predict the consequences of an action, so they may be too abrupt, cause an accident and even do serious harm to someone they were playing with. It is easy to imagine the negative fallout on their social life. It is important not to confuse the impulsive and sometimes clumsy behaviour of children with ADHD with a form of aggressiveness, however. They have no intention of hurting their playmates or seeking revenge for some action taken by other children. Nonetheless, despite their good intentions, the “accident-prone”, troublesome behaviour of children with ADHD can make their social life complicated.

Another characteristic of children with ADHD is a tendency to prefer tasks or games that offer instant compensation (however modest), rather than those that might be more rewarding but involve a greater commitment in terms of time and effort. This would explain why these children struggle to find their own inner motivation to engage in activities that are more demanding and take longer to complete (Sonuga-Barke, Taylor, & Heptinstall, 1992; Sonuga-Barke, Williams, & Hall, 1996). All these features become apparent in the spontaneous, sometimes violent, unfiltered way in which they express their emotions too. That is why children with ADHD are often considered rude and insensitive, and this adds to their problems when it comes to establishing mature and durable relationships.

Box 1.1 How to prepare the study environment

To avoid children with ADHD being easily distracted, parents and teachers are advised to create an environment that is not too stimulating when the children have to cope with a demanding task, such as studying. Suggestion: Before getting down to work, make sure that only the materials indispensable for the task are on the desk, e.g. a book, a pencil and a rubber. All the other items that children usually have in their school bags can be distracting. There is no need for them to have a whole pencil case to hand; if they do, the temptation to play with the various colours and the other pens will be too strong and they will become inattentive.

Characteristics of ADHD

It is easy to imagine that many people can see the features we have just described in themselves, or are thinking of various other people, adults or children, who have trouble keeping focused on a job or act impulsively. In fact, many of us have these traits, though in most cases we do not have them all the time, but maybe only when we are more tired or stressed, and such behaviour is usually not obvious enough to have a negative effect on our daily lives. It is no accident that the main diagnostic manuals (Diagnostic and Statistical Manual of Mental Disorders, DSM, and International Classification of Diseases, ICD) always add the consideration: “There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning” (Symptoms and diagnostic criteria according to the DSM-5, APA, 2013), which represents one of the crucial criteria enabling a diagnosis to be established. Inattention, hyperactivity and impulsivity can all be seen as traits distributed along a continuum with an absence of the trait (e.g. no attention deficit) at one end and its constant presence (a continuous attention deficit) at the other. We all occupy a space somewhere along this continuum and it is only when we exceed a threshold such that our attention difficulties interfere with our daily lives that we can speak of symptoms and not just personality traits.

Although we might be inclined to think that ADHD is a very common disorder, major epidemiological studies and the main diagnostic manuals indicate that it affects from 3% to 5% of the school-age population. This percentage may not seem much to worry about, but it means that nearly one child in every 20 has the disorder. ADHD is more likely to affect boys than girls (the ratio is three to one). The reasons for this gender disparity are still not known, but any hyperactive behaviour is probably more obvious in boys, making those with ADHD easier to identify. Inattention may be the prevailing feature in girls, whose hyperactivity could be less evident. In fact, some authors believe that the disorder is likely to be underestimated in girls, and this would partly explain why the condition appears to have a male predominance.

In fact, ADHD can develop differently in different children. In the majority of cases children have symptoms of both attention deficit and hyperactivity to much the same degree, but in some cases they may only show signs of inattention (in which case we speak of children with the predominantly inattentive subtype of ADHD), or only appear predominantly to be hyperactive and impulsive (in which case we speak of the hyperactive-impulsive subtype of ADHD).

Children with the predominantly inattentive subtype of ADHD have severe difficulties in focusing their attention on anything. They are often described as having their “head in the clouds”. They are not disruptive in class – and that is why their behaviour often goes unreported – but they fail to keep up with the lessons and they fall behind in their school work, in class and at home. Their parents need to constantly remind them to do their homework and keep them focused on the task. These children are always the last to finish getting ready to go somewhere, or at mealtimes. They are usually assessed by a specialist because of their learning difficulties in all school subjects, which are due to the fact that they find it so hard to pay attention to the lessons. They are very easily distracted when they are studying, and often fail to complete their homework, either because they forget to write down what they were meant to do or because they run out of time. Their parents often describe them spending whole afternoons over their books and still not finishing the tasks they were set because they are continuously becoming distracted or stopping for some reason.

Children with the hyperactive-impulsive subtype of ADHD are extremely lively. They make a nuisance of themselves in the classroom but succeed nonetheless in following the lessons and completing their assigned tasks or activities. Teachers and parents very often complain that these children could do so much better but it is as if they were constantly “in a hurry”. For them, doing well means getting the job done as soon as possible and finishing before anyone else. Such children are often reprimanded or punished (with a low mark, for instance) because if they had worked more calmly and paid more attention they would have been able to do so much better. In this subtype of ADHD, there may also be more evident signs of aggressive or oppositional behaviour and this makes the picture rather more complex.

Secondary aspects of ADHD

As already mentioned in the previous section, the core symptoms of ADHD can have repercussions on a child’s daily life. The problems that children with this disorder are likely to experience mainly concern their relationships with family, peers and teachers. Because of their particular behavioural traits, these children are often in trouble, both at home and at school. It may be because they are slow to get ready to go out or the last to finish their lunch. They often behave in a manner that makes them seem immature. For instance, they may interrupt when a parent is speaking on the telephone or make a fuss about not wanting to go to bed. The same sort of thing happens at school as well, where they butt in when the teacher is explaining something, only to report an episode that has nothing to do with the lesson underway. With their head in the clouds, they are often unable to keep up with their classmates when it comes to following an explanation or completing a task. Teachers often describe situations where they and the rest of the class have moved on from a history lesson to a dictation but then they no...