Characteristics of Attention Deficit Hyperactivity Disorder (AD/HD)

1. Characteristics of Attention Deficit Hyperactivity Disorder (AD/HD) Presented by Connie McDonald BrookinsDeveloped by Renee B. Leach, Consultants

2. Definition of ADHD • ADHD(attention deficit hyperactivity disorder) is “a condition characterized by severe problems of inattention, hyperactivity, and/or impulsivity.” (Hallahan and Kauffman, 2003, p.513) 

3. Prevalence of ADHD • ADHD is the most common behavioral disorder in children in America. (Kollins, Barkley, and DuPaul, 2001)  • It exists in between 3 and 5 percent of school-aged children.  • Boys are more often diagnosed with ADHD than are girls, ranging somewhere between a 2.5 : 1 and 5 : 1 ratio. • This may be because the behaviors associated with ADHD are more characteristic and natural in boys than they are in girls. 

4. Girls that do have ADHD most likely have the inattentive type.  (Boschett, 2002).  • Less than half of the children who have ADHD use special education programs in school.

5. Three Types of ADHD as defined under Diagnostic and Statistical Manual of Mental Disorders (DSM). • -ADHD Predominately Inattentive Type • -ADHD Predominately Hyperactive Impulsive Type • -ADHD Combined Type (Inattentive and Hyperactive Impulsive)

6. Signs of Hyperactivity -Impulsivity • Feeling restless, often fidgeting with hands or feet, or squirming while seated • Running, climbing, or leaving  a seat in situations where sitting or quiet behavior is expected • Blurting out answers before hearing the whole question • Having difficulty waiting in lines or taking tours

7. Signs of Inattention • Often becomes easily distracted by irrelevant sights and sounds • Often failing to pay attention to details and making careless mistakes • Rarely following instructions carefully and completely losing or forgetting things  like toys, or pencils, books, and tools needed for a task • Often skipping from one uncompleted activity to another

8. The Symptoms • Typically, AD/HD symptoms arise in early childhood, unless associated with some type of brain injury later in life. • Some symptoms persist into adulthood and may pose life-long challenges. • Although the official diagnostic criteria state that the onset of symptoms must occur before age seven, leading researchers in the field of AD/HD argue that criterion should be broadened to include onset anytime during childhood.

9. Criteria for the three primary subtypes are summarized as follows:

10. AD/HD predominately inattentive type: • Fails to give close attention to details or makes careless mistakes. • Has difficulty sustaining attention. • Does not appear to listen. • Struggles to follow through on instructions. • Has difficulty with organization. • Avoids or dislikes tasks requiring sustained mental effort. • Loses things. • Is easily distracted. • Is forgetful in daily activities.

11. AD/HD predominately hyperactive-impulsive type: • Fidgets with hands or feet or squirms in chair. • Has difficulty remaining seated. • Runs about or climbs excessively. • Difficulty engaging in activities quietly. • Acts as if driven by a motor. • Talks excessively. • Blurts out answers before questions have been completed. • Difficulty waiting or taking turns. • Interrupts or intrudes upon others.

12. AD/HD combined type: • Individual meets both sets of inattention and hyperactive/impulsive criteria.

13. Because everyone shows signs of these behaviors at one time or another, the guidelines for determining whether a person has AD/HD are very specific. • To be diagnosed with AD/HD, individuals must exhibit six of the nine characteristics in either or both DSM-IV categories listed above.

14. In children and teenagers, the symptoms must be more frequent or severe than in other children the same age. • In adults, the symptoms must affect the ability to function in daily life and persist from childhood. In addition, the behaviors must create significant difficulty in at least two areas of life, such as home, school, social settings and work. • Symptoms must be present for at least six months.

15. The Evaluation • Determining if a child has AD/HD is a multifaceted process. • Many biological and psychological problems can contribute to symptoms similar to those exhibited by children with AD/HD. • For example, anxiety, depression and certain types of learning disabilities may cause similar symptoms.

16. There is no single test to diagnose AD/HD. • Consequently, a comprehensive evaluation is necessary to establish a diagnosis, rule out other causes and determine the presence or absence of co-existing conditions. • Such an evaluation should include a clinical assessment of the individual’s academic, social and emotional functioning and developmental level.

17. A careful history should be taken from the parents, teachers and when appropriate, the child. • Checklists for rating AD/HD symptoms and ruling out other disabilities are often used by clinicians.

18. There are several types of professionals who can diagnose AD/HD, including school psychologists, private psychologists, social workers, nurse practitioners, neurologists, psychiatrists and other medical doctors. • Regardless of who does the evaluation, the use of the Diagnostic and Statistical Manual IV(DSM-IV)criteria is necessary.

19. A medical exam by a physician is important and should include a thorough physical examination, including hearing and vision tests, to rule out other medical problems that may be causing symptoms similar to AD/HD. • Only medical doctors can prescribe medication if it is needed.

20. According to a June 1997 AMA study, “AD/HD is one of the best researched disorders in medicine, and the overall data on its validity are far more compelling than that for most mental disorders and even for many medical conditions.” • Goldman, L.S., Genel, M., Bezman, R, et.al. (1998) Diagnosis and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Journal of the American Medical Association.

21. The exact causes of AD/HD remain illusive. • Currently, most research suggests a neurobiological basis. • Since AD/HD runs in families, inheritance appears to be an important factor. • U. S. Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General (Children and Mental Health).

22. Even though a diagnostic test for AD/HD does not exist, the 1998 National Institute of Health Consensus Statement concludes, “there is evidence supporting the validity of the disorder.” • National Institute of Health. (1998). Diagnosis and treatment of attention deficit hyperactivity disorder. Washington, D.C.: NIH Consensus Statement.

23. Multimodal Treatment • There may be serious consequences for persons with AD/HD who do not receive treatment or receive inadequate treatment. • These consequences may include low self-esteem, social and academic failure, career underachievement and a possible increase in the risk of later antisocial and criminal behavior.

24. Treatment plans should be tailored to meet the specific needs of each individual and family. • So treating AD/HD in children often requires medical, educational, behavioral, and psychological intervention.

25. This comprehensive approach to treatment is called “multimodal” and often includes: • Parent training • Behavioral intervention strategies • An appropriate educational program • Education regarding AD/HD • Individual and family counseling • Medication, when required

26. Research from the landmark NIMH Multimodal Treatment Study of AD/HD is very encouraging. • Children who received medication, alone or in combination with behavioral treatment showed significant improvement in their behavior and academic work plus better relationships with their classmates and family.

27. Psychostimulants are the most widely used class of medication for the management of AD/HD related symptoms. • Approximately 70 to 80 percent of children with AD/HD respond positively to psychostimulant medications.

28. Significant academic improvement is shown by students who take these medications: increased attention and concentration, compliance and effort on tasks, amount and accuracy of schoolwork produced and decreasedactivity levels, impulsivity, negative behaviors in social interactions and physical and verbal hostility

29. Other medications that may decrease impulsivity, hyperactivity and aggression include some antidepressants and antihypertensives. • However, each family must weigh the pros and cons of taking medication.

30. Behavioral interventions are also a major component of treatment for children who have AD/HD. • Important strategies include being consistent and using positive reinforcement, and teaching problem-solving, communication, and self-advocacy skills. • Children, especially teenagers, should be actively involved as respected members of the school planning and treatment teams.

31. School success may require a variety of classroom accommodations and behavioral interventions. • Most children with AD/HD can be taught in the regular classroom with minor adjustments to the environment. • Some children may require special education services if an educational need is indicated. • These services may be provided within the regular education classroom or may require a special placement outside of the regular classroom that meets the child’s unique learning needs.

32. Behavioral treatments for AD/HD should be started as soon as the child receives a diagnosis. • There are behavioral interventions that work well for preschoolers, elementary-age students, and teenagers with AD/HD, and there is consensus that starting early is better than starting later. • Parents, schools, and practitioners should not put off beginning effective behavioral treatments for children with AD/HD

33. What is behavior modification? • With behavior modification, parents, teachers and children learn specific techniques and skills from a therapist, or an educator experienced in the approach, that will help improve children’s behavior. • Parents and teachers then use the skills in their daily interactions with their children with AD/HD, resulting in improvement in the children’s functioning in the key areas noted above. • In addition, the children with AD/HD use the skills they learn in their interactions with other children.

34. Behavior modification is often put in terms of ABCs: Antecedents (things that set off or happen before behaviors), Behaviors (things the child does that parents and teachers want to change), and Consequences (things that happen after behaviors).

35. In behavioral programs, adults learn to change antecedents (for example, how they give commands to children) and consequences (for example, how they react when a child obeys or disobeys a command) in order to change the child’s behavior (that is, the child’s response to the command). • By consistently changing the ways that they respond to children’s behaviors, adults teach the children new ways of behaving.

36. Parent, teacher and child interventions should be carried out at the same time to get the best results. • The following four points should be incorporated into all three components of behavior modification:   • Start with goals that the child can achieve in small steps. • Be consistent — across different times of the day, different settings, and different people. • Implement behavioral interventions over the long haul — not just for a few months. • Teaching and learning new skills take time, and children’s improvement will be gradual.

37. Parents who want to try a behavioral approach with their children should learn what distinguishes behavior modification from other approaches so they can recognize effective behavioral treatment and be confident that what the therapist is offering will improve their child’s functioning.

38. How does a behavior modification program begin? • The first step is identifying a mental health professional who can provide behavioral therapy. • Finding the right professional may be difficult for some families, especially for those that are economically disadvantaged or socially or geographically isolated.

39. The mental health professional begins with a complete evaluation of the child's problems in daily life, including home, school (both behavioral and academic), and social settings. • Most of this information comes from parents and teachers. The therapist also meets with the child to get a sense of what the child is like.

40. The evaluation should result in a list of target areas for treatment. Target areas — often called target behaviors — are behaviors in which change is desired, and if changed, will help improve the child’s functioning/impairment and long-term outcome.

41. Target behaviors can be either negative behaviors that need to stop or new skills that need to be developed. • That means that the areas targeted for treatment will typically not be the symptoms of AD/HD — overactivity, inattention and impulsivity — but rather the specific problems that those symptoms may cause in daily life.

42. Common classroom target behaviors include “completes assigned work with 80 percent accuracy” and “follows classroom rules.” • At home, “plays well with siblings (that is, no fights)” and “obeys parent requests or commands” are common target behaviors.

43. After target behaviors are identified, similar behavioral interventions are implemented at home and at school. • Parents and teachers learn and establish programs in which the environmental antecedents (the A’s) and consequences (the C’s) are modified to change the child’s target behaviors (the B’s). • Treatment response is constantly monitored, through observation and measurement, and the interventions are modified when they fail to be helpful or are no longer needed.

44. Parent Training • Behavioral parent training programs have been used for many years and have been found to be very effective. • Although many of the ideas and techniques taught in behavioral parent training are common sense parenting techniques, most parents need careful teaching and support to learn parenting skills and use them consistently.

45. It is very difficult for parents to buy a book, learn behavior modification, and implement an effective program on their own. • Help from a professional is often necessary.

46. However, with early identification and treatment, children and adults can be successful. • Studies show that children who receive adequate treatment for AD/HD have fewer problems with school, peers and substance abuse, and show improved overall functioning, compared to those who do not receive treatment.

47. The topics covered in a typical series of parent training sessions include the following: • Establishing house rules and structure • Learning to praise appropriate behaviors (praising good behavior at least five times as often as bad behavior is criticized) and ignoring mild inappropriate behaviors (choosing your battles) • Using appropriate commands • Using “when…then” contingencies (withdrawing rewards or privileges in response to inappropriate behavior) • Planning ahead and working with children in public places • Time out from positive reinforcement (using time outs as a consequence for inappropriate behavior) • Daily charts and point/token systems with rewards and consequences • School-home note system for rewarding behavior at school and tracking homework

48. The Prognosis • Children with AD/HD are “at-risk” for potentially serious problems: academic underachievement, school failure, difficulty getting along with peers, and problems dealing with authority. • Furthermore, up to 67 percent of children will continue to experience symptoms of AD/HD in adulthood.

49. Additional resources: • www.chadd.org • http://www.help4adhd.org/index.cfm • http://www.chadd.org/fs/fs2.htm • http://www.familyeducation.com/article/1,1120,23-16631,00.html • www.add.org

50. For your attention!!!!