| Leading Article
ADHD _ an Overview
Monidipa Banerjee
Consultant Pediatrician
Peerless Hospital and Manovikas Kendra, Kolkata
Attention Deficit Hyperactivity Disorder (ADHD) is the commonest neurobehavioral disorder of childhood that usually appears before the age of 7 years. It is characterized by inattention, hyperactivity and impulsivity to a degree that is maladaptive or inconsistent with the developmental level of the child.
ADHD (DSM IV) or hyperkinetic disorder (ICD 10) has increasingly been recognized to be hampering educational and social achievements. It also severely affects family life. Effective behavioral modification strategies, educational strategies and medication have been developed to treat the condition. The consequences of untreated hyperactivity are detrimental to these children and their families and the children are unable to achieve their educational potential. Current estimates indicate about 10%
of school going children may be affected. Girls as yet have probably been under
recognized as they more often present with
attention deficit rather than hyperactivity. ADHD
is, in most cases, of familial origin. Twin studies have demonstrated
genetic influences: Concordance rates higher for monozygotic
twins2. Brain injury, brain infections have been implicated but direct casuality can not be inferred from this association. Social adversity like marital discord could well be a consequence of the disorder rather than a cause of the hyperactivity.
Many ADHD children followed up into adolescence show lower educational achievement than controls3. As adults, half continue to have disabling symptoms of ADHD. About 23% of adults with ADHD were
found to have an antisocial
personality disorder4. A major challenge therefore is to try to prevent the child developing a conduct disorder. Current known predictors of poorer outcome are family history of ADHD, psychosocial adversity and comorbidity with conduct mood and anxiety disorders.
Medical treatment should only be one element of a management program. Stimulants, antidepressants and anti-psychotics have been used with success. It is still to be decided whether children should remain on the medication long term. There are some children who seem to benefit in the long term. Thus it may be advisable to stop medication after one or two years of successful treatment to reassess if further medical treatment is warranted.
The goal of behavior modification is the promotion of attentive and controlled behavior rather than reduction of hyperactivity. Behavior modification in ADHD.uses reward orientated token system,
time out, positive reinforcement and compliance. Parents are trained to be the
main therapists.
Educational strategies include recognizing the syndrome and differentiating it from mere bad behavior or lack of academic interest. Awareness needs to be fostered amongst teachers. To optimize learning the child's individual problems will need to be assessed and resources and provisions organized.
Teaching the child about the disorder and its consequences are the first steps in helping them to understand and how to cope with it. Parents and siblings of ADHD children need education about the condition and support. Parents should also be involved in the behavior modification programs and receive necessary training. Respite care may need to be organized as well as counseling at the time of severe distress.
References:
1. Vanstraelen M, Thompson M, Titcomb J, Cronk E. Attention deficit hyperactivity disorder: hyperkinetic disorder. Southampton Health J 1998; 53.
2. Goodman R Stevenson. A twin study of hyperactivity; J Child Psychol Psychiatry 1989; 30 : 691- 709
3. Wilson JM, Marcotte AC. Psychological adjustment and educational outcome in adolescents with a childhood diagnosis of ADD. J AACAP 1996; 35 : 579-87.
4. Weiss CB, et al. Psychiatric status of hyperactive adults; J AACP 1985; 24 : 211-20.
Information on ADHD
· ADHD Handbook for Treatment and Diagnosis _ By Russell Barkley 1990, The Guildford Press
· Understanding ADHD. By Dr Christopher Green 1997, Vermilion Press
· Teenagers with ADHD _ A parent guide by Chris A. Siegler Dandy
· Attention Deficit Disorder. By Edward Hallowell & John Ratey
· Positive Parenting- Raising Children with Selfesteem _ By Elizabeth Hartley-Brewer 1994
· Is My Child Hyperactive? Jo Douglas, Penguin Publications
· ADDNET UK : The UK Website www.tv.co.uk/addnet.html
· www.sdqinfo.com
· http://add.about.com/mbiopage.htm
Special Article
Evaluating a Child with ADD / ADHD
J R Ram
Consultant Psychiatrist
Institute of Child Health and Apollo Gleneagles Hospitals,Kolkata
Introduction
The syndrome of restless, inattentive and impulsive child behaviour is known as Attention Deficit Hyperactivity Disorder (ADHD) in North America and Hyperkinetic Disorder (HD) in Europe1. It is one of the most common childhood psychiatric disorders. Hyperactivity, a term commonly used to describe this behaviour is an ambiguous term and ideally should not be used by professionals. There is ambiguity in the nomenclature and this ambiguity is reflected in diagnostic variations between both sides of the Atlantic. There is a 5 fold variation in the proportion of children diagnosed to have the disorder between North America (more are diagnosed) and Europe2. The purpose of this review is to outline the key issues in conceptual background, diagnosis and management of the disorder for a busy clinician and it is not intended to be a major scientific review of the subject.
History and Nomenclature
Discovery of ADHD is not recent although the frequency of the diagnosis has increased rapidly in the 2nd half of 20th century. G.Still, a British Pediatrician, clearly described the condition in 1902 and since then various labels have been applied to the syndrome. Differences in diagnostic criterion between Europe and North America were markedly obvious in 1940's. In recent years there has been a greater rapprochement across North American classificatory system (DSM IV)
and European system (ICD 10)
although important differences still
remain3,4.
Diagnostically, there are 3 main groups of symptomatology _ overactivity, impulsivity and inattentiveness. For a diagnosis of Hyperkinetic Disorder under European classificatory system, presence of all 3 are required. Hyperkinetic Disorder (HD) is viewed as a unitary condition. In North American classificatory system, there are three possible subtypes of the ADHD and presence of one or two symptom cluster is enough to make a diagnosis. The three subtypes are hyperactive-impulsive, inattentive and combined. It is the combined type which is commonest and closest to HD.
Epidemiology
These differences in diagnostic practice have had a profound impact on estimates of prevalence of the disorder and its treatment. There has been concerns expressed in many quarters in North America and Europe regarding the over inclusiveness of the diagnosis and appropriateness of treating children with stimulant medication without exercising sufficient diagnostic rigour. Prevalence of ADHD is around 3-5% whereas for HD it is around 0.5-1.0%. It is more common in males and the ratio of male to female is 3:1 in community sample5.
Clinical Features
The cardinal features of ADHD are
excessive and impairing levels of
activity, inattention and impulsiveness which are persistent pattern of behaviour for the
child. It is particularly evident in situations
that require the child to be thoughtful and restrained. The difference from normal
for each component is one of degree. The disorder is recognised purely by
behavioral signs. Laboratory findings like
Continuous Performance Test etc, although
illuminating, does not help the clinician.
Children with ADHD have great difficulty remaining seated when required to. They are more active than their peers in unstructured situations such as in the play ground. They fail to pay attention to instructions, have difficulty in withholding a response until appropriate moment, have difficulty in waiting for their turn and are easily distracted.
Criteria for Hyperkinetic Disorder (ICD-10 Research)6
Onset before 7 years of age.
Pervasive across situations. Evidence will require information from more than one source; parental reports about classroom behaviour are unlikely to be sufficient.
Clinically significant impairment in social, academic or occupational functioning items
Have persisted for at least 6 months, to a degree that is maladaptive and inconsistent with developmental level.
Inattention (6 of the following) :
1. Often fails to give close attention to details or makes careless errors in schoolwork, work or other activities.
2. Often fails to sustain attention in tasks or play activities.
3. Often appears not to listen to what is being said to him.
4. Often fails to follow through on instructions or to finish
schoolwork, chores or duties in the workplace (
not because of oppositional behavior or failure to understand instruction).
5. Is often impaired in organising tasks or activities.
6. Often avoids or strongly dislikes tasks such as homework, that require sustained mental effort.
7. Often loses things necessary for certain tasks or activities.
8. Is often easily distracted by external stimuli.
9. Is often forgetful in the course of daily activities.
Overactivity (3 of the following) :
1. Often fidgets with hands or feet or squirms on seat.
2. Leaves seat in classroom or in other situations in which remaining seated is expected.
3. Often runs about or climbs excessively in situations in which it is inappropriate ( in adolescents or adults, only feelings of restlessness may remain).
4. Is often unduly noisy in playing or has difficulty in engaging quietly in leisure activities.
5. Exhibits a persistent pattern of motor activity that is not substantially modified by social context or demands.
Impulsivity (1 of the following) :
1. Often blurts out answers before questions have been completed.
2. Often fails to wait in lines or await turns in games or group situations.
3. Often interrupts or intrudes on others
4. Often talks excessively without appropriate response to social constraints.
Assessment of Children
Diagnosis is based primarily on a clinical evaluation which includes interview with parents about child's development and behavior. Information from school is essential and a direct examination of the child is important. There are a number of semistructured interviews which can be used and are better than questionnaires or diagnostic checklists as they elicit information from a range of situations.
A recent review on scales used for assessment of ADHD listed 11 scales which are commonly used in North America and UK7.
The scale which is used in some clinics in India is Conner's Rating Scales _ Revised version (CRS-R). The CRS-R includes items specific to DSM-IV defined ADHD and its associated features, updates age and gender normative values. Parent and teacher forms are available in full (80-item, 59-item) and abbreviated (27-item, 28-item) versions. The Conner's Abbreviated Teacher Rating Scale was developed to measure drug response. It is not ideal as a diagnostic screen, because it misses children with attention deficits without hyperactivity and is over-inclusive of aggressive children.
Another commercially available scale which is occasionally used in India is thee ACTeRS.
It was originally developed as a teacher rating scale derived in part from a scale used to study behavioral difficulties in children with lead exposure. Its 11 items assessing inattention and hyperactivity are comparable to DSM-IV descriptions, although there are a few differences in wording and content. The parent form includes an additional scale with descriptors of early childhood behavior thought to be associated with the development of ADHD, such as difficult
temperament.
There appear to be halo and confounding effects between ADHD and aggression. For example, a child who is defiant toward the teacher is more likely to be rated as hyperactive or inattentive, regardless of the level of inattention or activity as measured by trained observers. Regular class teachers rate the same behavior as more hyperactive than do special education teachers. Therefore, assessment needs to take into account information from multiple sources and a description of child's behavior in atleast two settings needs to be enquired for.
However, both these and most other scales developed for use in assessment of ADHD can only be bought and are not available for free use. This problem is circumvented by a scale developed by Dr R.Goodman and is known as SDQ or Strengths and Difficulties Questionnaires. It is a 25 item scale with satisfactory psychometric properties and normative data. It covers 5 domains.
Emotional symptoms (5 items), conduct problems (5 items), hyperactivity/inattention (5 items) peer relationship problems (5 items) and prosocial behavior (5 items). It is available over the internet at www.sdqinfo.com and recently has been used widely in research studies especially in U.K.
It is essential to assess the presence of learning disability, exclude hearing problems and test for motor coordination. Stimulant medication can slow growth and therefore it is important to take a baseline height and weight measurement8.
Differential Diagnosis
ADHD can be conceptualised as manifestation of one or more underlying pathological processes rather than simply
a collection of symptoms irrespective
of etiology. ADHD should not be diagnosed if the symptoms are better accounted for
by any other mental disorder. There are a number of other
conditions/circumstances that can produce a reaction in a child
that superficially mimics ADHD. Many of these conditions can also coexist with
ADHD. These two separate issues, differential diagnosis and comorbidity can
cause difficulty in a professional who merely
relies on the presence of behavioral items on a checklist to make a diagnosis of
ADHD
3.
1. Normal Variation :
There are as yet no unequivocal dividing line between normal and abnormal levels of activity, impulsivity and inattention. Pervasiveness across situations and impairment are therefore important threshold criterion. Teachers have experience of the normal range of behavior at a particular age and therefore their view is important.
2. General Mental Handicap :
Children with moderate and severe mental handicap may have attention and activity levels that are appropriate for their developmental but not their chronological age. The fact that ADHD is commoner among children with mildly low levels of intelligence only complicates this.
3. The Consequences of Neglect,Indulgence or Chaotic Parenting :
Poor parenting can result in a child who has not learned self restraint and they usually pester adults for the sake of social involvement.
4. Restlessness, Demanding Behaviour in the Presence of Maternal Depression :
Children of mothers who are clinically depressed may be restless and demanding as a reaction to her unresponsiveness.
5. Sense Organ Deficits :
Fluctuating hearing loss in glue ear or fixed unilateral hearing losses can elude identification and present in children as apparently inattentive behaviour.
6. Conduct Disorder :
This may be a differential diagnosis as well as comorbid condition. Restlessness and inattention are common amongst conduct disordered children. A good developmental history will clarify which came first and a full assessment will sort out whether the inattentive restlessness is sufficiently severe to merit separate diagnosis1.
Medications
Anticonvulsants including phenobarbitone, lamotrigine, clonazepam and vigabatrin can cause excited irritability that mimics ADHD. On an anecdotal level, benzodiazepines and sedative antihistamines can have paradoxical exciting effect and it is held by some pediatricians that bronchodilators can cause hyperactivity although one might expect them to have a stimulant like effect.
Comorbid Problems
Comorbid problems are common in ADHD and children with comorbidity are more likely to be brought for treatment in a clinical setting1.
Conduct disorders are strikingly associated with ADHD, so that their differentiation is often an arduous process.
The comorbid rate of emotional disorder is also raised. The clinical anxiety may represent a subgroup ADHD. Longer term follow up of ADHD patients suggests an increased risk of depression and substance abuse in late adolescence and adult life.
Children with ADHD show an increased rate of specific learning problems. Data from American and European studies show approximately one third have specific problems in reading, spelling and mathematics unaccounted for by
low intelligence8.
Apart from the above specific conditions that are raised in frequency among children with ADHD, there are other important issues which are not clinical conditions but coexisting difficulties, which is important to detect. These include:
(a) Relationship difficulties with peers and family members.
Sleep wake problems.
(b) Poor self esteem.
(c) General academic shortcomings.
The implication of high rates of comorbidity is that simply recognising ADHD is not enough and a full appraisal of the child is necessary.
Treatment
Treatment of ADHD is multimodal and it is
covered in other sections in this issue.
The key domains under which treatment is offered are as
follows9,10:
(a) Education and information for parents and children.
(b) Family intervention.
(c) Behavioural management.
(d) School interventions.
(e) Individual cognitive approaches.
(f) Medication.
Conclusion
ADHD is a common and disabling condition. Children presenting with key symptoms of ADHD warrant a comprehensive assessment as there is a high prevalence of comorbidity. Assessments should focus on gathering information from multiple sources. It has to be borne in mind that ADHD is a clinical diagnosis and merely relying on a checklist to diagnose ADHD is inadequate and poor practice.
1. American Psychiatric Association Diagnostic and Statistic Manual of Mental Disorders 4th ed. 1994.
2. Prendergast M et al The diagnosis of childhood hyperactivity. A U.S-U.K cross national study J Child Psychol Psychiatry 1988; 29 : 289-300.
3. Hill P, Cameron M. Recognising hyperactivity: A guide for the cautious clinician. Child Psychol Psychiatry Rev 1999; 4 : 50-60.
4. Sandberg S, Barton J. Historical Development. In Sandberg S, ed. Hyperactivity Disorders of Childhood London : Cambridge Univercity Press, 1996 : 1-25.
5. Taylor E, Schachar R, Thorley G, et al. The epidemiology of childhood hyperactivity. London : Institute of Psychiatry, 1989.
6. World Health Organisation. International Classification of Diseases, 10th ed. Geneva:
WHO Division of Mental Health.
7. Collett BR Ohan JL, Jenval L, et al. Ten-Year Review of rating scales, V: scales assessing attention-deficit hyperactivity disorder. J Am Acad Child Adolescent Psychiatry 2003; 42: 1015-37.
8. Barkley RA. McMurray MB,. Edelbrock CS. Side effects of methylphenidate in children with attention deficit disorder. Pediatrics 1990; 86 : 184-92.
9. Overmayer S, Taylor E. Principles of treatment for hyperkinetic disorder. J Child Psychol Psychiatry 1999; 40 : 1147-57.
10. Barkley RA. Attention deficit hyperactivity disorder: A Handbook for Diagnosis and Treatment. New York: Guildford Press, 1990.
Review Article
Integrating Children with ADHD _ The Indian Scenario
Smitha Awasthi
Special Educator & Behavior Analyst
Mainstreaming and Inclusion of children with a diagnoses of ADHD / ADD, is a product of a carefully planned strategy. Research weighs heavily in favour of behavior intervention procedures like Applied Behavior Analysis (ABA), and Early Intervention.
Most children with a diagnoses of ADHD / ADD are controlled by their internal environments and do not respond to instructions. Although medication to some extent might slow them down, it is the goal directed behavior intervention strategy which changes behavior enough to exhibit results. To enumerate this further, a child's on-seat behavior when targeted will show specific changes in terms of how long a child can be seated as compared to how long he sat earlier along with a reduction in running during instruction time.
Motivation is the key to teaching ADHD / ADD children to respond to external stimulation.
Reinforcement is an important procedure because of its role in producing new operant units, and also in increasing the frequency of instances of a previously acquired operant. (Sigrid Glenn 2002) Reinforcement is powerful enough to bring about desired behaviour change as well as "shape" new behaviours. When a person implements a response-consequence
contingency, the change in the learner's behavior occurs over time. Expecting behavior change to occur immediately, and failing to continue the reinforcement procedure long enough might not get the desired result because lasting behaviour change almost always takes time. Use of Differential Reinforcement and fading it over time being highly specialized skills.
Increasing compliance, generalization of learned skills and teaching the child to work in a loose setting as opposed to a structured setting while mainstreaming a child, should include task analysis of each skill while establishing a collaborative relationship with school(Sonya De Boer Ott) including recurrent evaluation.
In India mainstreaming these children is a big problem faced by the family. These children do get into normal schools but once their disruptive behavior appears the schools are unwilling to accommodate them. The "integrated" schools with special educators are comfortable with mentally retarded children but are unable to cope with hyperactive behavior. Awareness is definitely increasing but staff need more structured training and smaller class sizes. The parents may be taught to simulate classroom scenarios at home before formal placements in school.
Special Article
Behavior Modification
Anindita Chatterjee
Consultant Psychologist, Manovikas Kendra & Apollo Gleneagles Hospital,Kolkata
Behavior modification is a key part in the management of ADD/ADHD. There is nothing really new, magical or not commonly known in this technology. It is the systematic rigorousness of its approach to ADD/ADHD that makes the difference. This treatment only works if it is consistently and methodically applied. Getting it right sometimes or not always getting it wrong, will not work.
The typical problem is that applying its methods often tap into personal emotions related to situations in the parent's own life. For example, if one is feeling stressed at work, it is very difficult for this not to be carried home and have those feelings interfered with parenting, no matter how hard you try. Occasionally, parents lose the consistency in relationship, reward or consequences; which are the pillar of success of this programe.
Most experts agree that combining medication treatments with extended behavior modification is the most effective way to manage ADD/ADHD in children and adolescents.
There are three basic categories or levels of ADD/ADHD behavioral training for children:
1. Parent training in effective child behavior management methods.
2. Classroom behavior modification techniques and academic interventions.
3. Special educational placement.
Behavior Modification is most often used with younger children, but it can be used in adolescents up to 18 years old and even adults. In children and adolescents, the two basic principles are:
1. Modeling behavior by encouraging good behavior with healthy praise or rewards. This works best if the reward or praise immediately follows the positive behavior.
2. Negatively reinforcing bad behavior by allowing appropriate consequences to occur naturally.
The 7 steps of Behavior modification program
1. Evaluate and repair your relationship _ Take some time to evaluate your relationship. If you have developed patterns of becoming exasperated and angry each time your child misbehaves, or if you find yourself yelling and punishing with much frequency, but without results, try to first take some time to repair the relationship with your child.
2. Choose a behavior _ In order to help children with ADD/ADHD develop better habits and behaviors, you will need to choose one specific behavior to work on at a time. Later, as you develop your program, you can add one or two more behaviors, but in the beginning, work only with one. You may want to choose not talking back, not running in the house, not being aggressive toward siblings, completing homework etc. Start
with the behavior that has the largest negative effect on your child's life
and self-esteem.
3. Choose a reward _ Rewards will not be monetary but must be a tangible reward for an extended period of time of compliance. Smaller goals may have rewards such as stickers, stars, or just a "You have been doing a wonderful job."
4. Choose a consequence _ Conse-quences should be delivered calmly each time. Using a time out works, if the same is delivered calmly, without ceremony and is a "real" time out. During time out, there should be no conversation of any kind; the child should not be able to participate in any `goings on' in their surroundings or in any discussion. They should be gently removed from the environment and be left alone for a few minutes.
5. Be consistent _ This can't be said often enough or strongly enough. Consistency is the key. If you are not consistent with your rewards, your child will not have the same motivation to act correctly. If you are inconsistent with your consequences, your child will still act out; taking the chance that this time you will not deliver a consequence.
6. Add Variety _ You can add variety to your behavior program without changing the rules. By adding variety, your child will not become as bored with the new way. Rules should remain the same, but changing the delivery can help to keep it fresh.
7. Continue to another behavior _ Once you feel your child has mastered the initial behavior and is doing well, move
on to something else. Use the same steps to set up specific
goals, rewards and consequences.
The behavior management strategies for preschoolers (Age 5 and Younger)
1· Provide a consistent routine to the days and structure to the environment. Let them know when the routine is changing or something unusual is going to happen, such as a visit from a relative, a trip to the store or a vacation.
2· Give your child clear boundaries and expectations. These instructions and guidelines are best given right before the activity or situation.
3· Devise an appropriate reward system for good behavior or for completing a certain number of positive behaviors, such as a merit point or gold star program with a specific reward, such as a favorite activity. Avoid using food and especially candy for rewards.
4· Engage your child in constructive and mind-building activities, such as reading, games and puzzles by participating in the activities yourself.
5· Some parents find that using a timer for activities is a good way to build and reinforce structure. For example, setting a reasonable time limit for a bath or playtime helps train the child to expect limitations, even on pleasurable activities. Giving a child a time limit for chore completion is also useful, especially if a reward is given for finishing on time.
Behavior management strategies for children ages 6-12
1· As much as possible, give clear instructions and explanations for tasks throughout the day. If a task is
complex or lengthy, break it down
into steps that are more manageable, keeping in mind that as the
child learns to manage their behavior, the steps and tasks can become
more complex.
2· Reward the child appropriately for good behavior and tasks completed. Set up a clear system of rewards (point system, gold stars) so that the child knows what to expect when they complete a task or refine their behavior.
3· Bear in mind that as your child gets older they will be more sensitive to how they appear to others and may overreact or be unduly ashamed when they are disciplined in front of others. It is important to have a plan for appropriate discipline for misbehaving that does not require carrying out in front of others. Setting up a specific consequence for a certain behavior is probably the best method of providing consistency and fairness for your child.
4· Communicate regularly with your child's teachers so that behavior patterns can be dealt with before they become a major problem and before the teachers get overly frustrated with the situation.
5· Always set a good example for your child. Children with ADHD need role models for behavior more than other children, and the adults in their lives are very important.
Behavior management strategies for teenagers
1· As your child matures, it is important to involve them in setting expectations, rewards and consequences. Empowering them
in this manner will improve their self-esteem and reinforce the concept
that they are ultimately the masters of their own behavior and can create
positive results with good behavior.
2· Teenagers are often very sensitive of how they appear to others and may overreact or be unduly ashamed when they are disciplined in front of others. As adolescents they are experiencing hormonal changes and sexual development, and this brings up a whole host of new issues. Teenage years can be tough enough without ADHD, so be gentle and understanding. Communicate openly with them about the issues surrounding physical and sexual maturation.
3· Continue to communicate regularly with your child's teachers so that behavior patterns can be dealt with before they become a major problem and before the teachers get overly frustrated with the situation.
4· Continue to be consistent and fair in your own behavior. Having a predictable, reasonable parent is always an asset for children with ADHD.
5· Continue to set a good example for your child. Children with ADHD need role models for behavior more than other children, and the adults in their lives are very important.
6· If you find yourself becoming overwhelmed by the situation, speak to a professional. It is only natural that you have needs and questions in this process, so seek help when needed.
Special requirement for children with ADD/ADHD
Organizing :
Children with ADHD may need help in organizing. Therefore, parents should encourage the child with ADHD to:
1· Schedule _ The child should have the same routine every day, from wake-up time to bedtime. The schedule should include homework time and playtime.
2· Organize needed everyday items _ The child should have a place for everything and keep everything in its place. This includes clothing, backpacks and school supplies.
3· Use homework and notebook organizers _ Stress the importance of having the child write down assignments and bring home needed books.
Doing homework :
Parents can help a child with ADHD achieve academic success by taking steps to improve the quality of the child's homework. They should make sure their child is:
1· Seated in a quiet area without clutter or distractions.
2· Given clear, concise instructions.
3· Encouraged to write each assignment in a notebook as it is given by the teacher.
4· Responsible for his/her own assignments. Parents should not do for the child what he/she can do for himself/herself.
Relationships :
Some ADHD children have trouble getting along with others. For those who do, steps can be taken to improve a childs relationships. The earlier a
child's difficulties with peers are noticed, the more successful such steps may be.
It is helpful for parents to :
1· Recognize the importance of healthy peer relationships for children.
2· Involve a child in activities with his or her peers.
3· Set up social behavior goals with the child and implement a reward program.
4· Encourage social interactions if the child is withdrawn or excessively shy.
5· Encourage a child to play with only one other child at a time.
General guidelines
Provide clear, consistent expectations, directions and limits. Such children need to know exactly what others expect from them.
Set up an effective discipline system. Parents should learn discipline methods that reward appropriate behavior and respond to misbehavior with alternatives such as time out or loss of privileges.
Create a behavior modification plan to change the most problematic behaviors. Behavior charts that track a childs chores or responsibilities and that offer potential rewards for positive behaviors can be helpful tools.
Children with ADD/ADHD tend to have difficulty relating a consequence to an action if they do not occur simultaneously or shortly after. Provide immediate feedback and rewards /consequences that helps to keep a child focused and on track.
Finally, using short-term goals helps. It is much easier for a child to behave for 15 minutes than it is for them to behave for an entire day. Breaking the day down.
Table 1. Technique, behavior, consequence and effect in various cases
Classification Exhibited behavior Consequences Effect on behavior
Positive Sonali cleans her room. Sonali's parents praise her. Sonali will continue to
reinforcement clean her room.
Positive Shubho brushes his teeth Shubho receives a token Shubho will continue to
reinforcement after meals. each time. brush his teeth after meals.
Negative Deb complains that older Deb's parents allow him to Deb will continue to miss
reinforcement boys consistently beat remain at home because school.
him up, he refuses to of his complaints.
attend school.
Negative Raja complains of Raja is allowed to go to bed Raja will have headaches
reinforcement headaches when it is without doing his homework. whenever homework to
time for homework. do.
Extinction Jim washes his father's Jim's car washing behavior Jim will stop washing his
car. is ignored. father's car.
Extinction Carmen puts glue on Carmen is ignored. Carmen will stop putting
Joe's seat. glue on Joe's seat.
Punishment Samik puts Gwen's The teacher administers Samik will not put Gwen's
pigtails in the paint. the paddle to Samik's pigtail in the paint.
posterior
to short intervals can help in creating a desire to suceed.
An outtime of technique behavior, consequence and effect in various ases is given in The Table 1.
Thought on ADHD
1· Cognitive interventions are important strategies to consider for use with children with ADHD.
2· Caution should be used with interventions that have not been validated with the ADHD population.
3· Self-management includes varied
techniques such as
self-assessment, self-instruction and self-monitoring.
4· Self-monitoring is an intervention that has been used successfully with students varying disabilities and attention problems.
5· Study and organizational skills represent an important curricular area of students who are ADHD.
6· Social skill training programs provide explicit instructions for individuals who do not acquire social competence via typical human interactions and indirect instruction.
1. Mather N, Goldstein S. Learning Disabilities and Challenging Behaviors: A Guide to Intervention and Classroom Management. Baltimore: Paul H. Brookes Publishing Co. 2001 : 96-117.
2. Walker JE, Shea TM. Behavior management: A practical approach for educators 5th ed.. New York: Macmillan, 1991.
3. Goldstein S, Goldstein M. The talking out/ou of seat/ Attention problem/ Disruption (Toad) system. In : Managing Attention Disorders in Children : A Guide for Practitioners. New Yourk : John Wiley & Sons, 1990 : 93-4.
4. http://add.about.com/mbiopage.htm
Voice of a Parent
Know Your Child Better
Rajeeb K Dutta
Parent of an ADHD Child
In today's fast, competitive and demanding world, how are we as parents coping with our children? Do we know our children? What do we want from them? We expect our children to cope with everything around them. Be it at home, at school or in a social gathering.
But, what happens when we see our most lovable little one has started causing a big worry to us as he starts socializing. As the first time parent we often do not appreciate the problem. Also it is mostly ignorance on our part about any symptoms that is causing problem to our child.
It happened to us and we were really very worried since we had no idea what was wrong with our son. Since his early days he was little active but as we were away from home we never took it seriously. But we faced real problem when he started schooling at the age of 5 years. Here our schools need readymade disciplined and perfect children. Teachers did not have the time for extra care for a particular child. The school cannot take care of children who needs some special attention and care. We initially thought this kind of behavior is not abnormal for a child of 5 yrs of age but constant pressure from school compelled us to look for a solution. Not knowing anything we searched the internet and it was amazing to see that there are hundreds of internet sites where 70-80% of present day's parents are facing the same kind of problem all over the world. This is a well known condition called Attention Deficit Hyperactivity Disorder (ADHD). It was also amazing to know that this can be largely cured with the help of medication and
other forms of therapies. Our child's behavior completely matched with the symptoms
of an ADHD child.
1· Often fails to give close attention to details.
2· Often has difficulty sustaining attention in tasks or play activities.
3· Often becomes easily distracted by irrelevant sights, sounds and extraneous stimuli.
4· Often does not seem to listen when spoken to directly.
5· Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace.
6· Often has difficulty organizing tasks and activities.
7· Often avoids tasks, such as schoolwork or homework, that require sustained mental effort.
8· Often loses things necessary for tasks or activities, like school assignments, pencils, books, or tools.
9· Often is forgetful in daily activities.
10· Rarely follows instructions carefully and completely.
With our experience we can share that, if you have a child with such symptoms, you can take help of a child psychiatrist. But most importantly, you should know that, these symptoms are not very uncommon for a child during tender age and can be
handled effectively.
1· Consult child psychiatrist and take medication as advised
2· Discuss with the school authority and make them aware of the problems and seek help
3· Give enough quality time with the child while doing his work
4· Take help of yoga, concentration exercises or other mental therapies
5· Follow a perfect routine for your child's activities Most importantly.
1· Do not loose patience. Such children are usually very sharp with great grasping power. If they are helped, they can also perform excellently.
2· Normally, these symptoms go away by 11 yrs of age.
3· Behave normally with your child and never try to teach him through punishment or threatening
4· Constant counseling and mentoring is a must.
Timeline
There is considerable evidence to suggest that ADHD is not a recent phenomenon.
l 2500 years ago, the great physician-scientist Hippocrates described a condition that seems to be compatible with what we now know as ADHD. He described patients who had "quickened responses to sensory experience, but also less tenaciousness because the soul moves on quickly to the next impression". Hippocrates attributed this condition to an "overbalance of fire over water". His remedy for this "overbalance" was "barley rather than wheat bread, fish rather than meat, water drinks, and many natural and diverse physical activities."
l 1845 _ ADHD was alluded to by Dr. Heinrich Hoffmann, a physician who wrote books on medicine and psychiatry. Dr. Hoffman was also a poet who became interested in writing for children when he couldn't find suitable materials to read to his 3-year-old son. The result was a book of poems, complete with illustrations, about children and their undesirable behaviors. "Die Geschichte von Zappel-Philipp" (The Story of Fidgety Philip) was a description of a little boy who could be interpreted as having attention deficit hyperactivity disorder.
l 1902 _ The English pediatrician Dr George Still, in a series of lectures to the Royal College of Physicians in England, described a condition which some have claimed is analogous to ADHD. Still described a group of children with significant behavioral problems, caused, he believed, by an innate genetic dysfunction and not by poor child rearing or environment.
l 1937 _ Dr. Bradley in Providence RI reported that a group of children with behavioral problems improved after being treated with stimulant medication.
l 1957 _ The stimulant Methylphenidate became available. It remains one of the most widely prescribed medications for ADHD.
l 1960 _ Stella Chess described "Hyperactive Child Syndrome" introducing the concept of hyperactivity not being caused by brain damage.
l 1961 _ Ritalin first indicated for "various behavior problems in children".
l 1970s _ Canadian Virginia Douglas released various publications to promote the idea that attention deficit was of more significance than the hyperactivity, influencing the American Psychiatric Association.
l 1975 _ Pemoline is approved by the FDA for use in the treatment of ADHD. While an effective agent for managing the symptoms, the development of liver failure in at least 14 cases
over the next 27 years would result in the manufacturer withdrawing this medication from
the market.
l 1980 _ The name Attention Deficit Disorder (ADD) was first introduced in DSM-III, the 1980 edition.
l 1987 _ The DSM-IIIR was released changing the diagnosis to "Undifferentiated Attention Deficit Disorder."
l 1994 _ DSM-IV described three groupings within ADHD, which can be simplified as mainly inattentive, mainly hyperactive-impulsive, and both in combination.
l 1996 _ ADHD accounted for at least 40% of child psychiatry references.
l 1999 _ New delivery systems for medications are invented that eliminate the need for multiple doses across the day or taking medication at school. These new systems include pellets of medication coated with various time release substances to permit medications to dissolve hourly across an 8_12 hour period.
l 1999 _ The largest study of treatment for ADHD in history is published in the American Journal of Psychiatry. Known as the Multimodal Treatment Study of ADHD (MTA Study), it involved more than 570 ADHD children at 6 sites in the United States and Canada randomly assigned to 4 treatment groups. Results generally showed that medication alone was more effective than psychosocial treatments alone but that their combination was beneficial for some subsets of ADHD children beyond the improvement achieved only by medication. More than 40 studies have subsequently been published from this massive dataset.
l 2001 _ The International Consensus Statement on ADHD is published (Clinical Child and Family Psychology Review) and signed by more than 80 of the world's leading experts on ADHD to counteract periodic media misrepresentation that ADHD is a real disorder and that medications are justified as a treatment for the disorder. In 2005, another 100 European experts on ADHD added their signatures to this historic document certifying the validity of ADHD as a valid mental disorder.
l 2003 _ Atomoxetine, the first new medication for ADHD in 25 years, receives FDA approval for use in children, teens, and adults with ADHD.
Source : From Wikipedia, the free encyclopedia ( www.wikipedia.org)
Care for the Caretaker
The mental health of the carer is vital for the success of any management program towards a child with ADHD. Here are some suggestions taken from "Behavior problems in Preschool children", Ashurst Child and Family Center.
l Be gentle with yourself. Remind yourself that you are not a magician.
l We cannot change anybody else. We can only change how we relate to them.
l Find a hermit spot. Use it daily.
l Learn to accept support and encouragement.
l Change your routine often and your tasks whenever you can.
l On the way home, focus on a good thing that occurred during the day.
l Be a resource to yourself
l Caring and being there is sometimes more important than doing.
Guidelines
ADHD: Guidelines for Clinicians
Compiled by
Jaydeep Choudhury, Tapan Kr Ghosh
Institute of Child Health, Calcutta
Attention Deficit Hyperactivity Disorder (ADHD) is a common neurobehavioral disorder that usually appears in children before the age of 7. Current estimates indicate that 4-12% of all school-aged children may be affected.
Role of pediatrician (primary care clinician)
1. Synthesize and interpret information about a child's behaviour.
2. Identify other medical or psychosocial problems that might be causing and/or exacerbating the child's symptoms.
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