Attention Deficit Hyperactivity Disorder

Definition of Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder is one of the most common neurodevelopmental disorders of childhood. It is usually first diagnosed in childhood and often prevails into adulthood.

The Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-V) (American Psychiatric Association, 2013), is a handbook that is used by professionals around the world to diagnose mental disorders.

The DSM–V describes ADHD as a type of neurodevelopmental disorder, which means there is atypical growth and development of the brain or central nervous system resulting in their abnormal functioning. 

ADHD is defined by a pattern of behaviour involving inattention, disorganisation and/or hyperactivity-impulsivity. An individual can have symptoms in one or both categories of inattention and/or hyperactivity/impulsivity to receive the diagnosis of ADHD.

The diagnosis is generally made by the age of 12 and ADHD can continue into adulthood. From time to time, most of children will have trouble sitting still, paying attention, or controlling their impulses – as part of normal development. Whilst most children gradually grow out of such behaviours, individuals with attention deficit hyperactivity disorder (ADHD) do not and may need help to treat ADHD through behavior therapy.

Diagnose ADHD

To diagnose ADHD Attention-Deficit/Hyperactivity Disorder we use a multi-step process that involves gathering comprehensive information from multiple sources to assess the presence and impact of ADHD symptoms. The following steps outline the typical process for diagnosing and eventually treating ADHD:

Steps in ADHD Diagnosis of Children

Initial Screening and Referral

• Often begins with concerns raised by parents, teachers, or healthcare providers about a child’s behaviour or academic performance.

• Referral to a specialist, such as a pediatrician, psychiatrist, psychologist, or neurologist, who is experienced in diagnosing ADHD.

Comprehensive Clinical Interview

• Parent interview: Collect detailed information about the child's developmental history, behaviour patterns, medical history, family history of mental health disorders, and the presence of symptoms across different settings.

• Child interview: Directly interview older children to understand their perspective on their behaviour, difficulties, and feelings.

Behavioural observations

• Observe the child in different settings (home, school) to note behaviours that are characteristic of ADHD, such as inattention, hyperactivity, and impulsivity.

Rating scales and questionnaires

• Utilise standardised rating scales and questionnaires completed by parents, teachers, and sometimes the child, to assess the frequency and severity of ADHD symptoms.

• Common tools include the Conners’ Rating Scales, the Vanderbilt ADHD Diagnostic Rating Scale, and the ADHD Rating Scale-IV.

Assessment of symptoms against DSM-5 criteria

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the diagnosis of ADHD requires:

• Inattention: At least six symptoms (for children) or five symptoms (for adolescents and adults) of inattention that have persisted for at least six months to a degree that is inconsistent with developmental level.

• Hyperactivity-Impulsivity: At least six symptoms (for children) or five symptoms (for adolescents and adults) of hyperactivity-impulsivity that have persisted for at least six months to a degree that is inconsistent with developmental level.

• Age of Onset: Several symptoms must be present before age 12.

• Settings: Symptoms must be present in two or more settings (e.g., home, school, work).

• Impact: Clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.

• Exclusion: Symptoms are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder).

Medical and psychological evaluation

• Physical exam: Rule out other medical conditions that might cause ADHD-like symptoms, such as thyroid problems or vision/hearing impairments.

• Psychological testing: Assess cognitive functioning, learning disabilities, and other mental health conditions that might coexist with or mimic ADHD.

Gathering information from multiple sources

• Collect information from parents, teachers, and other caregivers to get a complete picture of the child's behaviour across different settings and over time.

Steps in ADHD Diagnosis in adults

Diagnosing ADHD in adults follows a similar process but focuses on how symptoms have persisted from childhood into adulthood.

Adults often provide self-reports and may need retrospective assessment of childhood behaviour. The criteria for adults also include considerations for how symptoms manifest differently with age.

Importance of Accurate ADHD Diagnosis

Accurate diagnosis of ADHD is crucial because it guides the development of an effective treatment plan. Misdiagnosis can lead to inappropriate treatment and unmet needs.

An accurate diagnosis helps ensure that individuals receive the support and interventions necessary to manage their symptoms and improve their quality of life.

Types of ADHD

In the DSM-V (American Psychiatric Association, 2013), three presentation types of ADHD are identified:

• Predominantly inattentive type: the individual has trouble paying attention, poor concentration, ignoring distractions and getting organised. The individual can sit still and appear to be working as their symptoms are less obvious.

• Predominantly hyperactive/impulsive type: the individual has difficulty staying on task, constantly talking and fidgeting and never seems to slow down. The individual does not think through consequences before acting so may constantly be interrupting others and taking risks.

• Combined type: the individual exhibits both inattentive and hyperactive/ impulsive symptoms.

The associated symptoms of the child's behavior interfere with or reduce the quality of social, academic or occupational functioning. A range of classroom behaviour management strategies are required to address ADHD symptoms. 

Causes and Risk Factors of ADHD

Attention-Deficit/Hyperactivity Disorder (ADHD) does not have a single known cause. Instead, it arises from a complex interplay of various genetic, biological, environmental factors, and temperamental factors. Understanding these risk factors helps in comprehending the multifaceted nature of ADHD.

1. Genetic factors

Hereditary influence: ADHD often runs in families, indicating a strong genetic component. Research shows that individuals with a family history of ADHD are at a higher risk of developing the disorder. Studies have identified specific genes that may contribute to the development of ADHD, particularly those involved in the dopamine neurotransmitter system.

2. Parental Health Factors

Infections and diseases during pregnancy: Maternal health conditions during pregnancy, such as infections, can impact the developing fetus and increase the risk of ADHD.

Parental behaviours

Smoking: Maternal smoking during pregnancy has been linked to an increased risk of ADHD in children. Nicotine exposure can affect fetal brain development.

Alcohol consumption: Drinking alcohol during pregnancy can lead to fetal alcohol spectrum disorders, which include symptoms similar to those of ADHD.

Drug use: Illicit drug use during pregnancy can negatively affect fetal brain development and increase the risk of ADHD.

3. Environmental toxins

Exposure to environmental toxins: High levels of exposure to environmental toxins, such as lead, particularly in utero, have been associated with an increased risk of developing ADHD. Lead exposure can interfere with brain development and function.

4. Perinatal factors

Low birth weight and prematurity: Babies born with low birth weight or those born prematurely are at higher risk for ADHD. These conditions can affect brain development and increase vulnerability to neurodevelopmental disorders.

Obstetric complications: Complications during birth, such as oxygen deprivation or other birth traumas, can contribute to the risk of developing ADHD.

5. Postnatal factors

Exposure to infections and Diseases: Postnatal exposure to certain infections and diseases can impact brain development and increase the likelihood of ADHD.

Malnutrition: Poor nutrition in early childhood can affect brain development and contribute to ADHD symptoms.

Brain injury: Traumatic brain injuries, particularly those affecting the frontal lobes, can lead to symptoms consistent with ADHD.

History of abuse and neglect: Children who experience abuse or neglect may develop behavioural and emotional issues, including symptoms of ADHD.

6. Temperamental traits

Behavioural inhibition: Individuals with reduced behavioural inhibition may struggle with impulse control, a core characteristic of ADHD.

Negative emotionality: High levels of negative emotionality, such as frequent irritability and mood swings, can predispose an individual to ADHD.

Elevated novelty seeking: A strong preference for novelty and high levels of activity and impulsivity can be temperamental traits associated with ADHD.

Symptoms of ADHD

Individuals with ADHD may exhibit some, or all of following:

Inattention Symptoms:

• Fails to pay attention to details or makes careless mistakes in schoolwork.

• Exhibits impulsive behaviors

• Difficulties with sustaining attention during tasks or play.

• Appears not to listen when spoken to directly.

• Does not follow through on instructions and moves from task to task without finishing anything.

• Difficulties with organising tasks and activities.

• Avoids, or dislikes doing tasks that require sustained mental effort or concentration.

• Often loses things needed for tasks or activities.

• Easily distracted.

For more help with attention span and ADHD see:

• Strategies for Improving Attention Span and Avoiding Distraction

Hyperactivity/impulsivity symptoms:

• Constantly restless, fidgets with hands or feet or squirms in seat.

• Leaves seat in classroom or in other situations in which remaining seated is expected.

• Runs about or climbs excessively in situations where it’s inappropriate.

• Has difficulty playing quietly.

• Is often ‘on the go’, acts as if ‘driven by a motor’.

• Talks excessively.

• Blurts out answers before questions have been completed (or before raising hand).

• Has difficulty waiting turn.

• Interrupts or intrudes on others.

For more help with Hyperactivity/impulsivity and ADHD see:

• Strategies to Manage Hyperactivity

Without adequate support, children with ADHD experience academic, social, self-esteem, personal organisation and emotional difficulties.

Attention-Deficit/Hyperactivity Disorder (ADHD) often coexists with other mental health conditions and learning disorders, a phenomenon known as comorbidity.

These comorbid conditions can complicate the diagnosis and treatment of ADHD, as they may present overlapping symptoms and exacerbate the challenges faced by individuals with ADHD.

Common Comorbid Conditions with ADHD

Learning disabilities

• Dyslexia: Difficulty in reading and interpreting words, letters, and other symbols.
• Dyscalculia: Difficulty in understanding numbers and learning math concepts.
• Dysgraphia: Difficulty with writing, including problems with spelling, handwriting, and putting thoughts on paper.

Anxiety Disorders

• Generalised Anxiety Disorder (GAD)
• Social Anxiety Disorder
• Panic Disorder
• Specific Phobias

Mood Disorders

• Depression: Persistent feelings of sadness, hopelessness, and lack of interest or pleasure in activities.
• Bipolar Disorder: Alternating periods of depression and mania/hypomania, characterised by elevated mood, increased activity, and impulsive behaviour.

Oppositional Defiant Disorder (ODD)

• A pattern of angry/irritable mood, argumentative/defiant behaviour, and vindictiveness toward authority figures.

Conduct Disorder

• More severe than ODD, characterised by aggressive behaviour, deceitfulness, theft, and serious violations of rules.

Substance use Disorders

• Increased risk of developing problems with alcohol, nicotine, and other drugs.

Autism Spectrum Disorder (ASD)

• Difficulties with social communication and interaction, along with restricted, repetitive patterns of behaviour, interests, or activities.

Sleep Disorders

• Insomnia
• Restless Legs Syndrome
• Sleep Apnea

Tic Disorders

• Tourette Syndrome: Repetitive, involuntary movements and vocalisations called tics.

Impact of Comorbidity

1. Diagnosis challenges

   • Overlapping symptoms can make it difficult to distinguish between ADHD and comorbid conditions.

   • Comorbid conditions might be overlooked, leading to incomplete treatment.

2. Increased symptom severity

   • Comorbid conditions can exacerbate the core symptoms of ADHD, making them more severe and harder to manage.

3. Complex treatment needs

   • Treatment plans must address multiple conditions, requiring a comprehensive and integrated approach.

   • Medication management becomes more complicated due to potential interactions and side effects.

4. Functional impairment

   • Greater difficulties in academic performance, social interactions, and daily functioning.

   • Higher risk of poor outcomes, such as school failure, job difficulties, and relationship problems.

      

     Note: This is not an exhaustive list of all the possible causes, symptoms and interventions but some general information that can be further explored. Based on what you have read if you have any concerns about an individual, please raise them with the individual/s. The caregiver can then raise these concerns with their local doctor who can provide a referral to the relevant professional (e.g. paediatrician, psychologist, psychiatrist, allied health professional and learning specialists) for diagnosis and interventions accordingly.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).Arlington, VA: American Psychiatric Association.

Positive Behaviour Support Resource for ADHD

Attention deficit hyperactivity disorder (ADHD) is defined by a pattern of behaviour involving inattention, disorganisation, and/or hyperactivity-impulsivity.

Without adequate support from a mental health professional, educators can spend a considerable amount of time and energy on the instructional and behavioural management of children with ADHD with little success.

This takes valuable teaching time away from not only children with ADHD, but also the rest of their class as well. In addition, it can become a principal source of frustration and stress. Does this sound familiar?

Positive Behaviour Support Strategies for Students with ADHD: A Step by Step Guide to Assessing, Managing, and Preventing Emotional and Behavioural Difficulties is a highly practical book that can be used by educators in childcare, preschool, schools, and community services to learn the evidence-based approach of Positive Behaviour Support (PBS) to assess, manage, and prevent challenging behaviours in children of all ages with ADHD.

Learn how to complete a functional behaviour analysis to document behaviour incidents, identify triggers, and determine the reasons for specific challenging behaviours.

Consult the bank of proactive strategies that can be tailored to an individual child’s environment to prevent triggers and promote positive ways of communicating, behaving, and managing emotions.

Develop an escalation profile to describe the different verbal and non-verbal signals the child exhibits as their levels of stress, anger, and/or frustration increase, and determine strategies for responding to each escalation stage.

This book provides templates, banks of practical strategies, and a framework for developing a behaviour management plan so that all staff supporting a child can respond to challenging behaviours effectively and efficiently in a planned, safe, and least disruptive manner.

This book will educate, empower, and enable you to help your child learn positive ways of behaving and managing their emotions, so they can spend more time learning and developing, and you can spend more time doing what you do best: teaching.

This invaluable resource is useful for parents, caregivers, childcare educators, primary and secondary educators, supervisory, allied health professionals and mental health professionals.