Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by symptoms of inattention, impulsivity and hyperactivity that are inconsistent with a childâs developmental level and cause impairment to their functioning.
The prevalence of ADHD is around 5 % in children and 2.5 % in adults (American Psychiatric Association, 2013). In childhood, boys are diagnosed with ADHD up to four times more than girls, whereas in adulthood, females are just as likely to be diagnosed as males (Ford, Goodman & Meltzer, 2003; Kessler et al., 2006). This may be because young boys present with greater hyperactivity than girls, with girls presenting as more inattentive, and thus boys may be more likely to be noticed and referred for assessment.
ADHD is highly heritable and it is believed to be caused by a complex mixture of genetic and environmental factors including: genes associated with the dopamine and serotonin systems in the brain (Stergiakouli & Thapar, 2010); a variety of prenatal and perinatal factors such as smoking, substance use, preâterm birth, low birth weight, birth trauma and maternal depression (Thapar, Cooper, Jefferies & Stergiakouli, 2012); and the degree of nurture and stimulation that a child receives in early life (Rutter, 2005).
Due to the cognitive and behavioural impact of ADHD, there is an association between ADHD and a variety of problems, including academic underachievement, conduct problems and interpersonal relationship difficulties (Shaw et al., 2012). Boys are at greater risk of developing behavioural and conduct difficulties than girls, and such problems may increase the rate of referral and assessment for boys. The behaviour of young people presenting with comorbid disruptive behavioural problems is especially challenging for both parents/carers and teachers, and the demands of managing these problems can often lead to stress.
ADHD Across the Lifespan
As children grow and develop, their brains and behaviour are constantly adjusting and evolving; they will refine their cognitive abilities, learn to cope with challenges and learn to overcome obstacles. However, there are key transitions in an individualâs life when ADHD may become more prominent. Children with ADHD are often first recognized when demands at primary school begin to move away from play and academic expectations increase. The child may present as being unable to stay seated on the carpet, listen to a story and/or complete a short task on their own without getting up and/or becoming distracted. Their behaviour is noticeably different to that of their peers.
The transition to secondary school may also be a trigger for referral due to changes in the curriculum, with a greater need to plan and organize, longer days, fewer breaks and higher expectations for sustained periods of concentration. At this time, children are expected to navigate new peer groups, manage their own time and belongings, and organize themselves at home and school whilst receiving reduced adult support and direction. In parallel, they are also coping with the changes that puberty brings and managing new feelings and body changes.
For some individuals, symptoms and impairments will persist into adulthood. Most typically this includes inattention and restlessness, whilst overt hyperactive and impulsive symptoms may reduce.
ADHD and Comorbidity
It is widely observed that coexisting conditions are the rule rather than the exception, with up to twoâthirds of children with ADHD having one or more coexisting conditions. Common comorbidities include oppositional defiance and conduct disorder, anxiety and mood disorders, as well as emotional regulation difficulties (Biederman, Newcorn & Sprich, 1991; Goldman, Genel, Bezman & Slanetz, 1998; Pliszka, 1998; Elia, Ambrosini & Berrettini, 2008). Other comorbid conditions include autism spectrum disorders, tic disorders, social problems, sleep difficulties, generalized intellectual impairment and/or specific learning difficulties such as dyslexia.
Gifted children may also develop ADHD. In these cases, impairment is relative to intellectual ability, as the child doesnât reach its potential. Gifted children often develop compensatory strategies that mask their problems; however, this may become challenging with increasing academic demands and feelings of stress.
ADHD and the Family
Greater parenting stress has been associated with the families of children with ADHD, especially in the presence of oppositional behaviour and/or maternal depression (Theule, Weiner, Tannock & Jenkins, 2013). Whilst there may be many positive and fun times, it is not always easy bringing up a child with ADHD, and parents/carers need support too, especially at times when they feel weary, fatigued and emotionally drained. This highlights the need to stand back from the condition and the child, and take into account what is going on within the family. Hence, the therapist must not only focus on the needs of the child, but also on the needs of other family members and consider whether these are being met. It is important to note family dynamics and gain an understanding of how reciprocal relationships operate within the family, as the behaviour of one will influence the behaviour of another. Whilst negative cycles within the family have been reported, there is a potential positive here: change in the behaviour of one may influence change in the behaviour of another.
When taking a family perspective, it is important that siblings are not forgotten. This may reinforce what is happening in everyday life, with the needs of the child with ADHD demanding so much attention that the relatively fewer needs of the nonâADHD sibling are often deferred. Whilst siblings may be caring and supportive (Kendall, 1999), they may feel minimized or overlooked and resent or envy the attention received by their brother or sister (Mikami & Pfiffner, 2008). It is important that parents/carers maintain positive family relationships by ensuring that the needs of all siblings are met, and that rewards and sanctions are fair.
ADHD and School
Classrooms are rich and stimulating environments. For a child with ADHD they are also places with a mass of distractions; for example, teachers speaking, children chatting, outside noise from sport or lawnmowers, other classes/people coming and going, the scribble of pencils, rustling papers, bells ringing and chairs scraping. For a child with ADHD it can be an overwhelming sensation, leading them to lose focus, go offâtask and miss important information. In addition, teachers have many competing demands in the classroom, hence it is important that they have a good understanding about the difficulties experienced by children with ADHD and the potential methods that can be applied to minimize problems and maximize effort. Additional demand is put on teachers when ADHD is combined with oppositional behaviours, conduct problems and/or social communication impairments (Greene et al., 2002). This emphasizes the need for early and targeted interventions to help promote skills for children with ADHD and the people around them.
Some children will access additional support in schools to enhance learning, selfâmonitoring and staying on task. For children with high levels of selfâdoubt or low selfâefficacy, such learning support can make a wealth of difference by encouraging them to take achievable steps, and by receiving recognition and reward for effort.
Promoting Resilience
All children have their own unique skills, talents, qualities and priorities. The difference between a child with ADHD and a child without ADHD is that the former needs more guidance and nurture during their journey to learn how to overcome lifeâs hurdles and reach their potential. It is important that they focus on the positive and learn to embrace what makes them unique. Children with ADHD often have fast and creative minds, which helps them to be innovative and to develop new and exciting ideas. They may be sociable, funny, extroverted and intuitive. They may channel their energy into sports and seek out novel and interesting ways of doing things. However, they also need to learn how to cope with challenges and difficult times. They must develop skills to cope with setbacks, promote interpersonal skills, set goals and work toward their aspirations.
Resilience is a quality that draws upon a personâs inner strength as well as their skill set. It is a lifelong characteristic that requires a person to have developed confidence, skills and competencies across life domains. Early intervention is important for promoting strength and resilience and reducing risk factors, such as low selfâesteem, which may impact on the childâs future development and wellbeing. With resilience, a person can adapt and bounce back from stressful or adverse incidents. As research adds to our knowledge about ADHD as a lifespan condition, the contribution of early interventions in building psychological resilience will become better understood. The aim is not to solely promote skill development, but to also strengthen coping and support mechanisms, which may protect children from emotional distress, behavioural problems and academic underachievement. Early intervention may prevent the development of maladaptive patterns that lead a child to become entrenched or stuck.
We are strongly influenced by those who are around us. Children are like sponges; they soak up what they see and hear. As a child grows up it will receive various (and sometimes conflicting) âmessagesâ from parents/carers, teachers, peers, the media and others in society. These messages may shift between generations and cultural norms, but the messages that are communicated need to be hopeful and positive if a child is to internalize a view of himâ/herself that is functional and adaptive. A child who perceives themselves as a problem or burden is more likely to develop low selfâesteem and lack the resilience to cope with the challenges and difficulties in life that they will inevitably face as they mature and become a young adult.
As described by SonugaâBarke and Halperin (2010), ADHD does not have to be understood as a fixed pattern of core deficits, but rather a fluctuating interplay between individual child factors, developmental neurobiology, phenotypes and interpersonal dynamics. This means ADHD has to be seen as a condition that changes as the child develops. Hence, ADHD has a dynamic presentation across the chi...
