Attending to deficits … recognising the symptoms of ADHD

Most children may be considered at times "inattentive", "impulsive" or "hyperactive". Distinguishing whether this behaviour falls within the spectrum of that expected during normal development, or is due to a condition such as Attention Deficit Hyperactivity Disorder (ADHD) is essential, as these conditions may have adverse outcomes if left untreated.1-7

Three to 10% of school aged children in Australia are affected with ADHD.^8,9 In order to facilitate the support and treatment required by these children and their families to best manage this condition, parents must be able to recognise or acknowledge signs that their child may have ADHD, and be willing and able to appropriately seek help. 

Attention Deficit Hyperactivity Disorder is a syndrome composed of three core symptom categories: hyperactivity, inattention, and impulsivity. In order to reach an accurate diagnosis, the presence and pattern of development of symptoms in each of these categories must be considered. Such information may be recognised and provided by parents, teachers, or other caregivers.¹⁰ Parental observation has been found to have excellent validity and reliability in establishing a diagnosis of ADHD and monitoring progress with treatment.^11,12 It is worthwhile keeping in mind that symptoms of ADHD may not be evident within a structured clinical setting, such as a clinic visit.¹³

Attention-Deficit/Hyperactivity Disorder (ADHD) Evaluation Tool

Does your child have problems paying attention?
Do they fidget, talk a lot, or run around with seemingly endless energy?
Do they have trouble waiting their turn, and ‘butt into’ games or conversations?

If the answer to any of these is yes, you might want to find out whether your child is exhibiting symptoms of Attention-Deficit/Hyperactivity Disorder (ADHD). All children at some time or another will tend to be inattentive, hyperactive or impulsive. However some children will exhibit these qualities most of the time, and more than their peers.

Please complete the survey below to find out if you need to consult your GP about these symptoms. It is important to keep in mind that symptoms of ADHD are often common in many energetic children; therefore it might help to compare your child to other children in the same age group.

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Add up your answers to the following questions:

1. Does your child fail to pay attention to details during tasks? For example, a teacher may have reported careless errors in schoolwork.
   1. Yes: 1 point
   2. Not more than other children of the same age: 0 points
2. Does your child have trouble sustaining attention during tasks or games? For example they appear to easily lose interest and become distracted.
   1. Yes: 1 point
   2. Not more than other children of the same age: 0 points
3. Do they have trouble following through on instructions, and often fail to finish schoolwork, homework or chores?
   1. Yes: 1 points
   2. Not more than other children of the same age: 0 points
4. Do they have trouble listening, even when spoken to directly?
   1. Yes: 1 point
   2. Not more than other children of the same age: 0 points
5. Could your child be described using the following three words: forgetful; disorganised; or easily distracted?
   1. Yes, to all three: 3 points
   2. Yes, to two only: 2 points
   3. Yes, to one only: 1 point
   4. None of these words could describe my child: 0 points
6. Does your child avoid or dislike activities that require sustained mental attention such as schoolwork or homework?
   1. Yes: 1 point
   2. Not more than other children of the same age: 0 points
7. Does your child fidget, squirm in their seat, or get up from their seat in situations where sitting still or remaining seated are expected?
   1. Yes: 1 point
   2. Not more than any other child of the same age: 0 points
8. Does your child have difficulty ‘playing quietly’?
   1. Yes: 1 point
   2. Not more than any other child of the same age: 0 points
9. Does your child act as if driven by a motor, often running or climbing excessively, and in situations where it is inappropriate?
   1. Yes: 1 point
   2. Not more than any other child of the same age: 0 points
10.  Does your child talk excessively and/or blurt out answers before questions have been completed?
    1. Yes, to both: 2 points
    2. Yes, to one only: 1 points
    3. Not compared to children of the same age: 0 points
11.  Does your child have difficulty waiting their turn and/or interrupt or intrude on the conversations or games of others?
    1. Yes, to both: 2 points
    2. Yes, to one only: 1 point
    3. Not compared to children of the same age: 0 points
12.  On the scale below, please indicate how much you feel these symptoms impact on your child’s quality and enjoyment of their social and academic life
    (1 indicates that their life is not affected by the symptoms and 10 indicates their life is severely affected).
    
    

    1

    2

    3

    4

    5

    6

    7

    8

    9

    10

    Scoring: a rating of 1-5 is worth 0 points, 6-10 is worth 1 point.

Hyperactive behaviour may manifest as difficulty remaining seated when asked to do so, excessive fidgeting or talking, seeming to be "on the go" at all times, restlessness or difficulty playing quietly.¹⁰ These ‘hyperactive symptoms’ tend to be present by the age of four, with an increase over the next three or four years.¹⁴ Peak severity is typically at age 7 to 8, followed by a gradual decline.¹⁴ Hyperactive symptoms tend to resolve by adolescence.¹⁴

Impulsive behaviour may be identified through disruptive behaviours in the classroom, intrusive or interrupting behaviour, poor turn taking, blurting out answers before they are appropriate, peer rejection, and accidental injury.¹⁰ Impulsive behaviour almost always occurs in conjunction with hyperactivity, and develops in a similar pattern. Impulsive symptoms are usually observed by four years of age, increasing over the subsequent three or four years.¹⁵ Peak severity is at age 7 or 8.¹⁵ Impulsive symptoms are more likely to endure throughout adulthood.¹⁶

Signs that a child is inattentive include disorganisation, poor academic performance, poor concentration and attention to detail, being distracted easily, forgetfulness, losing things, and poor completion of tasks. These symptoms generally become apparent at 8 or 9 years of age, and tend to be life long.¹⁷

According to the DSM-IV, diagnosis of ADHD requires that some symptoms causing impairment be present before the age of seven. Further, the impairment from the symptoms must be present in two or more settings (eg at school and at home). Finally, there must be clear evidence of significant impairment in social or academic functioning.¹⁸

Professor Stephen Houghton, Director of the Centre for Child and Adolescent Related Disorders at the University of Western Australia, and author of over 100 published journal articles says "DSM-IV may be a good starting point for determining whether a child has ADHD, however if the child has 5 of the 9 symptoms listed, DSM-IV does not allow a diagnosis if you apply criteria strictly, so what do you do? This condition needs to be viewed as a continuum. These children require a formal psychological and educational assessment, carried out by experts in the field. ADHD is a complex condition that often occurs in combination with other disorders. Only around 3% of kids diagnosed with ADHD have it in isolation." Other disorders commonly associated with ADHD include Oppositional Defiant Disorder, Conduct Disorder and Anxiety disorders.^19-21

Professor Houghton suggests one of the best tests to evaluate children who may have ADHD is the Test of Everyday Attention for Children (TEA-Ch). This may be carried out by individuals with a professional post graduate qualification and training in Clinical or Educational psychology, Chartered Occupational Psychologists or individuals with a relevant PhD. Dr Houghton has co-authored with Dr Shane Langsford a tool known as Psychprofiler²² that can be used by GPs and other health professionals to screen for 23 of the most commonly occurring psychological conditions in children, including ADHD.

Once a diagnosis of ADHD has been established, parents and others involved in the care of the child require support and information in order to help them cope with the diagnosis, and learn how to best manage the condition. The ADHD support and information services that operate in each Australian state are a widely used resource. Recent research has indicated that the first port of call for most parents who suspect their child may have ADHD is a support organisation such as the Learning and Attentional Disorders Society of Western Australia (LADS).²³ This resource was also cited as the most helpful of the options available to parents.²³

Michele Toner, President of LADS, said, ‘The GP is a good starting point for parents to take a child who may have ADHD, as the GP is the gatekeeper to other services. The child may be referred to Child Psychological Services or Paediatricians, although there is often a long waiting list to access these, and some parents may not be able to afford them. Ideally the child should be seen by a clinical psychologist for a thorough assessment of all the difficulties they have. They should then be managed through a multimodal program suited to their needs, including therapies such as speech therapy, Occupational Therapy, education intervention, medication and counselling. Whatever that child needs is what they should be allowed to access."

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C.: American Psychiatric Association, c2000.
2. Fischer, M, Barkley, RA, Edelbrock, CS, Smallish, L. The adolescent outcome of hyperactive children diagnosed by research criteria: II. Academic, attentional, and neuropsychological status. J Consult Clin Psychol 1990; 58:580.
3. Lilienfeld, SO. Scientifically unsupported and supported interventions for childhood psychopathology: a summary. Pediatrics 2005; 115:761.
4. Mannuzza, S, Klein, RG. Long-term prognosis in attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am 2000; 9:711.
5. Mannuzza, S, Klein, RG, Bessler, A, Malloy, P. Adult outcome of hyperactive boys. Educational achievement, occupational rank, and psychiatric status. Arch Gen Psychiatry 1993; 50:565.
6. Merrell, C, Tymms, PB. Inattention, hyperactivity and impulsiveness: their impact on academic achievement and progress. Br J Educ Psychol 2001; 71:43.
7. Klassen, A, Miller, A, Raina, P, et al. Attention-deficit hyperactivity disorder in children and youth: a quantitative systematic review of the efficacy of different management strategies. Can J Psychiatry 1999; 44:1007.
8. Sawyer MG, Arney FM, Baghurst PA, Clark JJ, Graetz BW, Kosky RJ, Nurcombe B, Patton GC, Prior MR, Raphael B, Rey J, Whaites LC, Zubrick SR. Mental Health of Young People in Australia. Canberra: Commonwealth Department of Health and Aged Care, 2000.
9. Whiting, K. Fact Sheet. Attention Deficit/Hyperactivity Disorder 2003 update. [online]. Learning and Attentional Disorders Society. 2003 [cited 2009 Jan14]. Available from: http://www.ladswa.com.au/page.php?id=117
10. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. American Academy of Pediatrics. Pediatrics 2000; 105:1158.
11. Faraone, S., Biederman, J., & Milberger, S. 1995 How reliable are maternal reports of their children’s psychopathology? One year recall of psychiatric diagnoses of ADHD children. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 1001-1008.
12. Biederman, J., Faraone, S.V., Monuteaux, M.C., & Grossbard, J.R. (2004). How Informative Are Parent Reports of Attention-Deficit/Hyperactivity Disorder Symptoms for Assessing Outcome in Clinical Trials of Long-Acting Treatments? A Pooled Analysis of Parents’ and Teachers’ Reports. Pediatrics, 113, 1667-1671.
13. Sleator, EK, Ullmann, RK. Can the physician diagnose hyperactivity in the office?. Pediatrics 1981; 67:13.
14. Carlson, CL, Mann, M. Sluggish cognitive tempo predicts a different pattern of impairment in the attention deficit hyperactivity disorder, predominantly inattentive type. J Clin Child Psychol 2002; 31:123.
15. Byrne, JM, Bawden, HN, Beattie, TL, DeWolfe, NA. Preschoolers classified as having attention-deficit hyperactivity disorder (ADHD): DSM-IV symptom endorsement pattern. J Child Neurol 2000; 15:533.
16. Mannuzza, S, Klein, RG. Long-term prognosis in attention-deficit/hyperactivity disorder. Child Adolesc Psychiatr Clin N Am 2000; 9:711.
17. Applegate, B, Lahey, BB, Hart, EL, et al. Validity of the age-of-onset criterion for ADHD: a report from the DSM-IV field trials. J Am Acad Child Adolesc Psychiatry 1997; 36:1211.
18. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, D.C. : American Psychiatric Association, c2000.
19. Barkley, R.A. (1997). ADHD and the Nature of Self-Control. Guilford Press: New York.
20. Barkley, R.A. (1997). Behavioral inhibition, sustained attention, and executive functions: Constructing a unifying theory of ADHD. Psychological Bulletin, 121, 65-94.
21. Houghton, S., Douglas, G., West, J., Whiting, K., Wall, M., Langsford, S., Powell, L., & Carroll, A. (1999). Differential patterns of executive function in children with Attention-Deficit/Hyperactivity Disorder according to gender and subtype. Journal of Child Neurology, 14(2), 801-805.
22. Australian Council for Educational Research. Publications: Psychprofiler [online]. 2008 [cited 2009 Jan 15]. Available from: http://www.acer.edu.au/psychprofiler/index.html
23. West, J., Taylor, S., Houghton, S., & Hudyma, S. (2005). A comparison of teachers’ and parents’ knowledge and beliefs about Attention-Deficit/Hyperactivity Disorder (ADHD). School Psychology International, 26(2), 192-208.

Related Supportive Care

• Learning and Attentional Disorders Society of WA (LADS)
• ADDults with ADHD (NSW) Inc.