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Overview of ADHD, its symptoms, and impact on
children's behaviour and learning. Exploring
effective counselling techniques
ATTENTION-DEFICIT/HYPERACTIVITY
DISORDER
Children with Attention-Deficit/Hyperactivity Disorder (ADHD)
display difficulties in maintaining sustained attention, excessive and
exaggerated motor activity, and impulsivity relative to their
developmental level leading to social, occupational/academic activities.
The classification criteria for ADHD remains largely unchanged in
DSM-5. An exception being that ADHD is no longer considered as a
Disruptive Behavior Disorder and instead lists it as a
neurodevelopment disorder.
Cont..
Other change specified in DSM-5 (DSM IV specified presence of some of the
symptoms before 7 years of age), is several inattentive or hyperactive-impulsive
symptoms to be present prior to 12 years of age. Additionally, similar to other
disorders in DSM-5, it has added specification for current severity: mild,
moderate and severe. Consistent with DSM IV criteria, DSM-5 codes Attention
Deficit/Hyperactivity Disorder under three sub-types: combined presentation,
predominately inattentive presentation (Attention Deficit Disorder; ADD) and
predominately Hyperactive/Impulsive presentation. ADHD combined type is the
most common presentation, whereas ADHD predominantly inattentive type may
be cases of pure ADD or may include children who display attention difficulties
along with sub-threshold hyperactivity.
Clinical Picture:
Attention deficit is a multi-dimensional construct that includes problems with
arousal, alertness, selective focus, sustained attention/vigilance, and distractibility.
These difficulties can manifest in many situations making it difficult to function
adequately in school, workplace or with friends and family. Issues with arousal and
alertness can lead to children failing to give attention to details, losing track of time
or things, making careless mistakes or day dreaming. A child with deficit selective
attention is likely to fail to understand instructions and follow through instructions.
She/he could appear to others as if she/he is "not listening” or that their “mind is
elsewhere”. Problems with sustained attention can most often be seen in boring and
repetitive activities but can also be apparent in free play. The child has a tendency to
“tune out” of these tasks, and would perceive tasks requiring sustained attention
(e.g. reading, mathematics, board games, etc.) are seen as aversive and are generally
avoided.
Cont..
Sustained attention deficits may lead the child to shift from one task to another
without completing any one of them. Finally, distractibility is the ability to be easily
attend to irrelevant stimuli in the environment (e.g. noise, background
conversations, object in a room, etc.). Attentional difficulties affect daily lives of
people with ADHD. Their work is often messy, disorganized and appears to have
been done without any considered thought. School material like pen, Tiffin boxes,
books and notepads are often scattered, lost or damaged. Attentional problems also
make children and adolescents forgetful, for instance they would forget to bring
lunch, books, homework etc. Socially, ADHD individuals find it difficult to keep
track of conversations. Such children often find it challenging to follow rules in
games or different activities.
Cont..
Hyperactivity refers to excessive activity manifested in two forms: motor hyperactivity
(restlessness, squirminess, and unnecessary body movements) and vocal hyperactivity
(excessive talking). Manifestation of hyperactivity may vary with developmental level. In
pre-school children hyperactivity can be seen in children to engage in excessive jumping
and climbing on furniture, running around the house, and in difficulty in engaging the
children in sedentary activity like listening to story. In school aged children similar
behaviour may be seen in hyperactive children although the behavior maybe lesser in
intensity and frequency. Hyperactivity in children can be seen in the child’s difficulty to
remain seated, they get up frequently, squirm, and hang onto the edge of their seat. Not
only do they fidget during academic activities, they also find it challenging to sit through
meals, TV, or play that requires them to sit in one place. One is likely to find them
fidgeting with objects, pen, or shaking legs.
Cont..
Girls with ADHD are more likely to display hyperactivity through excessive
talking and interruptions when others are talking. It is a common misbelief
that adolescents/adults “out grow” their hyperactivity. However, in older
children hyperactivity manifests more as restlessness, excessive speech,
difficulty in engaging in solitary activities and increased aggression and
conflicts. Professionals stress on pervasiveness of hyperactivity, ADHD
children display hyperactivity throughout the day and even during night.
ADHD children find it difficult to fall asleep and may wake up early.
Hyperactivity is pervasive and displayed in all domains including home,
school, and playground. Impulsivity refers to the tendency to act on urges,
apparently without thinking. Impulsivity is one of the most common
complaints parents and teacher’s make about people with ADHD.
Cont..
Most common complaint made about children with ADHD by parents
and teachers is about this symptom. Impulsivity can be seen in
impatience, difficulty in waiting for their turn, inability to blurt out
answers, interrupting and intruding others to the point of causing
difficulties in school, social or occupational setting. Impulsivity is often
responsible for the many accidents that hyperactive children get into.
More often than not children with ADHD may knock over objects, bang
into people, grab to hold a hot pan, or even engage in potentially
harmful activity like repeatedly climbing trees and riding bicycle in
traffic.
Cont..
Children with ADHD also display some secondary problems. ADHD is related to
cognitive and academic difficulties as children with ADHD are found to have delay
in intelligence of about 7-10 IQ points, may be at high risk for learning disability,
and have lower academic intelligence than their peers. Many children with ADHD
suffer from socio-emotional difficulties also. There is high rate of rejection by
peers amongst ADHD children, which is not because they are unfriendly but
because ADHD may make them inattentive to social cues and peers may get tired
of their hyperactivity and excessive talking. Unpopularity amongst peers may also
be a result of aggression and depression. Peer rejection and negative criticism from
parents and teachers negatively effects the self-esteem of these children.
Prevalence :
The prevalence rate of ADHD has been increasing over the years. The average
prevalence of ADHD worldwide is found to be 5.9 - 7.1 percent and 2.6 - 4.5
percent (Willicut 2012, Polanczyk et al. 2015). Some researchers believe that the
increase in the number of children diagnosed with ADHD may be a result of an
increase in awareness about ADHD or society’s intolerance to childhood
activities because of urban life pressures and loss of support, or extended family.
Also, boys are three times more likely to be diagnosed with ADHD. This may be
because adults may be more tolerant of hyperactivity in girls who engage in less
direct aggressive. Secondly, research on ADHD has focused on boys, thereby
ignoring the experience and manifestation of ADHD symptoms in girls. There is
high co-morbidity of aggression and depression in ADHD.
DSM-5 Criteria for ADHD (APA, 2013)
A. A persistent pattern of inattention and/or hyperactivity- impulsivity that
interferes with functioning or development, as characterized by (1) and/ or (2):
1) Inattention: Six (or more) of the following symptoms have persisted for at
least 6 months (for children up to age 16) to a degree that is inconsistent with
developmental level and that negatively impacts directly on social and
academic/occupational activities:
Note: The symptoms are not solely a manifestation of oppositional behaviour,
defiance, hostility, or failure to understand tasks or instructions. For older
adolescents and adults (age 17 and older), at least five symptoms are required.
Cont..
a) Often fails to give close attention to details or makes careless mistakes in school
work, at work, or during other activities (e.g., overlooks or misses details, work is
inaccurate).
b) Often has difficulty sustaining attention in tasks or play activities (e.g., has
difficulty remaining focused during lectures, conversations, or lengthy reading).
c) Often does not seem to listen when spoken to directly (e.g., mind seems
elsewhere, even in the absence of any obvious distraction).
d) Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily
side-tracked).
Cont..
e) Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks;
difficulty keeping materials and belongings in order; messy, disorganized work; has poor time
management; fails to meet deadlines).
f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
(e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing
forms, reviewing lengthy papers).
g) Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools,
wallets, keys, paperwork, eyeglasses, mobile telephones).
h) Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include
unrelated thoughts).
i) Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents
and adults, returning calls, paying bills, keeping appointments).
Cont..
2) Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted
for at least 6 months (children up to the age of 16 years) to a degree that is inconsistent with
developmental level that negative impacts directly on social and academic/occupational
activities:
Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance,
hostility, or a failure to understand tasks or instructions. For older adolescents and adults
(age 17 and older), at least five symptoms are required.
✓ Often fidgets with or taps hands or feet or squirms in seat.
✓ Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her
place in the classroom, in the office or other workplace, or in other situations that require
remaining in place).
Cont..
✓ Often runs about or climbs in situations where it is inappropriate.
(Note: In adolescents or adults, may be limited to feeling restless.)
✓ Often unable to play or engage in leisure activities quietly.
✓ Is often "on the go, "acting as if "driven by amotor”(e.g., is unable to be or
uncomfortable being still for extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep up with).
✓ Often talks excessively.
✓ Often blurts out an answer before a question has been completed (e.g.,
completes people’s sentences; cannot wait for turn in conversation).
Cont..
✓ Often has difficulty waiting his or her turn (e.g., while waiting in line).
✓ Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may
start using other people’s things without asking or receiving permission; for adolescents and
adults, may intrude into or take over what others are doing).
✓ Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.
✓ Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g.,
at home, school, or work; with friends or relatives; in other activities).
✓ There is clear evidence that the symptoms interfere with, or reduce the quality of, social,
academic, or occupational functioning.
✓ The symptoms do not occur exclusively during the course of schizophrenia or another psychotic
disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety
disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).
Causal Factors:
Researchers understand that the causes of attention deficit hyperactivity disorder are not
social in origins. Genetic factor's plays a role in ADHD as twin and family studies report
high degree of heritability of ADHD. Adoption researches have also reported higher rates of
hyperactivity in biological parents of hyperactive children than adoptive parents of such
children. Molecular genetic studies have found that multiple genes contribute to the risk for
ADHD. In particular, DAT-1 or dopamine transporter gene has been implicated.
Neuropsychological studies have found structural and functional difference in brains of
people with ADHD and typical control. In particular, difference have been seen in frontal
lobe, basal ganglia, and cerebellum. Executive functions (high order cognitive processes),
such as working memory, attention, and inhibition of responses has been found to be poorer
for ADHD individuals relative to typical control. ADHD is related to dysfunction in two
neurotransmitters, dopamine and nor-epinephrine.
Cont..
Scientists have found that inattention and distractibility appear to be related to low levels
of nor epinephrine whereas impulsivity and hyperactivity problems appear to be related to
low levels of dopamine in the brain. Thus, because child feels lack of stimulation in the
brain, hyperactivity is a way to compensate for that. That is why, stimulants are prescribed
as medicines for children with ADHD. Pregnancy and birth factors like mother’s age at
delivery (younger), mother’s educational level (lower), time between labour (longer), and
premature delivery related to higher probability of the child developing ADHD. Prenatal
exposure to environmental toxins like lead, alcohol and tobacco have been implicated.
Certain medicines, such as medicines for seizures are likely to result in problems with in
attention and hyperactivity. Some researchers also report that the behaviour of some
ADHD children is worsened after eating foods with artificial colours, certain preservatives,
and/or allergens.
Cont..
While social factors like parenting style, schooling, and peer relations
may moderate the types and degrees of impairment but they do not cause
ADHD. Overall critical, harsh and negative behavior of parents of
hyperactive children is related to difficult, disruptive and non-compliant
behavior of ADHD children. Early TV viewing has also been found to
shorten attention span of children. Aggressive and hyperactive portrayal
of characters in TV shows has also been found to exaggerate difficult
behavior.
Treatment:
Psychological interventions along with medications are important in providing
holistic treatment. Behavioral strategies include selective reinforcements in
classroom and structuring of material in a way that enhances the experiences of
success. For instance, a girl with ADHD should be praised for increasing the
amount of time she sits in classroom even if she sits for 15 minutes in a half an
hour class, if she was unable to previously sit for anything more than say five
minutes. Family therapy helps in making parents and sibling understand
behavioral strategies to maximize productive behavior and extinction of aggressive
and destructive behavior.
School based intervention programs aim to teach teachers to deal with
hyperactivity and inattention difficulties in classroom.
Home work :
Case Study: Attention Deficit Hyperactivity Disorder
Rubin is a 9-year-boy who has been referred to a child psychologist at the request of his school
counsellor. The counsellor had been receiving multiple complaints about Rubin from his class teacher.
The teacher complained that Rubin is extremely restless, he is hardly ever on his seat and roams around
in the class in spite of the many instructions given against getting up in class. He finds it difficult to pay
attention to lessons in class and his work is messy and incomplete. His restlessness disturbs other
children. Sometimes, he talks to other students making it difficult for them to concentrate on their
individual class work. The teacher reports that Rubin does not seem to have any control over his
unpredictable behavior and is quite polite and good natured. Clinical interview with parents revealed that
Rubin has had behavioral difficulties ever since he was a toddler. Even when he was three years old, he
was and extremely restless who required little sleep and woke before anyone else. When he was four, he
had managed to unlock the door of the house and wandered off by himself on a busy road. He was
brought back by a neighbor who found him wondering on the streets. Teachers in play school complained
that Rubin would find it difficult to follow any instructions given to him and his restlessness made it
difficult for the teacher to look after his well-being.
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