ADHD in Children

It is characterised by difficulties in the areas of attention, level of activity and impulse control. These difficulties are present before the age of 7 years and can affect many areas of the child’s and family’s life.

It is sometimes called “hyperkinetic disorder”. It is also, at times, referred to as “attention deficit disorder” (ADD) if problems are mainly due to difficulties with attention rather than overactivity.

What are the key symptoms of ADHD in young children?

The difficulties with attention, overactivity and impulsivity can show themselves in the following ways:

• Inattentiveness:
  • Listening difficulties
  • Not following instructions
  • Making careless mistakes
  • Highly distractible
  • Day dreaming
  • Forgetting/Losing things
  • Not finishing tasks
  • Easily bored
• Overactivity:
  • Squirming/fidgety
  • Restless, leaving seat without permission
  • Talking too much
  • Moving quickly and forcefully
• Impulsivity:
  • Find waiting for things difficult
  • Control/interrupt conversation
  • Have trouble with taking turns
  • Difficulty resisting temptation
  • Blurting out answers before the question is complete
  • Risk taking/little or no sense of danger

What are the key symptoms in older children?

Older children will show the same symptoms as younger children with risk-taking and impulsive behaviours becoming increasingly more problematic.

The impact of the symptoms on their social interactions, relationships with peers, family members and teachers as well as on their vulnerability will become more apparent and worrisome. The young person will also show more planning and organisational difficulties and probably more significant behavioural difficulties including conduct problems.

How common is ADHD in children?

ADHD is one of the most common neuropsychiatric and behavioural disorders in children and young people.

About 1.5% of 5-15-year-old children in the UK have ADHD at any given point. The rates vary significantly depending on how the study is done. The prevalence can go up to 4-8% in the general population and up to 20% in children and young people with intellectual disability. It is more common in boys.

Are there additional symptoms of ADHD?

More than half of children with ADHD have associated behavioural problems (tantrums) or more serious behavioural disorders such as oppositional defiant disorder (ODD) or conduct disorder.

Often, these children have associated learning problems such as dyslexia or other developmental problems with their language or motor coordination.

Some children who have ADHD also have social communication difficulties, repetitive behaviours, tics, anxiety-related problems or even depression. The latter are often missed as it is the disruptive behaviour that is more evident and challenging to others and therefore becomes the focus of concerns.

Does the behaviour need to occur both at home and at school?

Largely yes. Some children can show ADHD symptoms and behavioural difficulties in all settings, but some may present with more difficulties in one setting than in other settings.

For example, the child may struggle more at school as he is not completing tasks, is highly distractible and therefore becomes easily disruptive by talking and not following instructions during lessons, leaving the seat, avoiding tasks or even getting into arguments with others.

Some other children may have more behavioural difficulties at home as the structured school environment, especially if they receive the appropriate support, helps them with managing their ADHD symptoms at school.

When problems are more evident at home, it can be very difficult for parents to feel understood and especially not blamed.

Also, the child may not present with the same degree of difficulties every day. They will have bad and good days. This presentation may make it difficult for the school to recognise the presence of ADHD as it may seem as though the child can control their behaviour.

What are the risk factors for developing ADHD?

ADHD is not caused by “bad parenting”. The true cause for all cases of ADHD is still unknown, however, things that may contribute include:

• Genetic vulnerability – ADHD tends to run in families however inheritance is complex and is unlikely to be related to a single genetic fault.
• Brain function and structure – small possible differences in the brains of people with ADHD e.g. size differences of particular areas of the brain, length in maturity or a chemical imbalance.
• Other potential contributors include: being born prematurely, having a low birth weight, brain damage (for example, physiological, or due to alcohol/smoking/drug intake while pregnant).

What are the long-term consequences of ADHD?

ADHD symptoms can result in poor educational attainment and disruptive behaviours that can lead to school exclusions and several disruptions to school placements with implications for long-term educational outcomes. The poor impulse control can seriously affect peer and family relationships which lead to poor self-esteem, peers and siblings being less likely to want to play with them, social isolation in school and increased family stress in the home environment.

Young people with ADHD, especially the ones who also have conduct problems and are socially isolated, are vulnerable to being easily led by others, to misusing substances and engaging in more and more risk-taking behaviours.

Young people with ADHD, particularly when associated with conduct disorder, have increased contact with the criminal justice system. ADHD continues to be an impairing condition in adulthood for about half of the young people.

What parents and caregivers can do to help

Children can benefit from work that is done with their parents and caregivers to address the ADHD symptoms such as:

• Give simple instructions
• Create a low stimuli environment to complete homework
• Set realistic goals for homework, for example, ten minutes at a time
• Reinforce achievement
• Manage disruptive behaviours

Parenting programmes that focus on reinforcing desirable behaviour can be helpful such as working with the child on self-esteem issues, on impulse and emotional control and on ensuring that parenting is consistent across caregivers, for example, within the home and in school.

What teachers can do to help

Teachers can help the child with understanding that it is not their fault, but that ADHD is a neuro-divergence to be managed even though there might be a lot that they can do to help themselves.

They should pitch teaching/learning appropriately, allowing for individual pacing of work, proximity to teacher, movement breaks, classroom aide, structuring the play and lunch breaks.

They can help with managing classroom behaviours by using token economy, clear goals and timely feedback, support children with peer relationships and wise counselling and psychoeducation.

Teachers are important in supporting treatment with medication and systematic monitoring of any interventions. They are key to facilitating an appropriate educational health care plan and help with transition.

Teachers should also look for signs of emotional distress, anxiety or depression as these can make the ADHD symptoms and disruptive behaviours worse.

When to refer

Many children will show some level of inattentiveness, overactivity or poor impulse control especially when they are very young, anxious or when they have special learning needs.

However, when these symptoms are more than one would expect for the child’s age and level of development and they are interfering with learning and other aspects of functioning at school, a referral to a specialist should be considered for further assessment. Even when tantrums and other disruptive behaviours are more evident than anything else and it is difficult to identify ADHD symptoms per se, it is always wise to refer to a specialist so that ADHD can be considered and appropriately assessed.

Whom to refer to

The GP or school SENCO (Special Educational Needs Coordinator) or teacher can help by making a referral to the local mental health service such as CAMHS (Child and Adolescent Mental Health Service), community paediatrician or another appropriate local support service.

After a child is accepted to an appropriate mental health service, they will undergo an assessment to better understand their difficulties and recommend treatment.

What treatments are available

Group Parent/Carer Training Programmes – These programmes provide psychoeducation about ADHD and associated problems and support caregivers to respond to the child’s behaviour in a way that helps to minimise misbehaviour and increase prosocial behaviours, using social learning theory principles.

Individualised Parent/Carer Training – This training is recommended when a child’s behavior is particularly extreme or complex. This also uses social learning theory principles to assist caregivers to manage misbehaviour, but can be better tailored to fit the family’s unique circumstances and can involve the use of live-coaching of parenting skills.

Group Child-Focussed Programmes – These programmes assist older children with social skills and problem-solving skills, stress management and emotional control. They also provide psychoeducation so that they better understand the condition and how to manage its symptoms. Cognitive- behavioural strategies are used in doing this work.

Often, children approaching secondary school age need professional help with managing their organizational difficulties, preparing for and taking exams, planning for further education and managing peer relationships.

Treating other mental health difficulties and addressing special learning needs often makes a difference in how ADHD is managed.

Medication – Some children whose ADHD is severe will require medication. There is a range of medication used. When this is prescribed, it requires close monitoring of whether it is working and of any side effects. A specialist professional (a child psychiatrist or paediatrician) should do the prescribing and monitoring but it will need the support of the parents and for older children the compliance and cooperation of the young person. Often GPs also help with continued prescriptions and some of the monitoring.

Dr Iris Rathwell
South London and Maudsley NHS Foundation Trust