Attending to deficits … recognising the symptoms of ADHD

Most kids could be described at some point as ‘not paying attention’, ‘impulsive’ or ‘hyperactive’. Explanations for this behaviour vary widely, ranging from the child being ‘overtired’ to ‘overexcited’. However when such behaviour lasts over significant periods of time and interferes with functioning at school and at home, the explanation may be due to a condition such as Attention Deficit Hyperactivity Disorder (ADHD).

ADHD is common, affecting 3-10% of school aged children in Australia. Parents therefore need to be aware of some of the signs of ADHD, and know how and where to seek help if they feel their child may have this condition. Parents may not be aware that their child has ADHD, though they usually know that something is ‘not right’.

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 said, "Usually the school recognises it or in some cases another parent says ‘I’ve noticed your child doing the same sort of things as mine and mine has been diagnosed with ADHD.’

"It is particularly common for ADHD, Predominantly Inattentive type to be overlooked in girls, whose main symptom is commonly inattention, rather than hyperactivity."

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.

Attention Deficit Hyperactivity Disorder is a syndrome composed of three core symptom categories: hyperactivity, inattention, and impulsivity. Symptoms of ADHD are usually present before a child is seven years of age. Symptoms of ADHD must occur in two or more settings, for example at school and at home. In order for ADHD to be diagnosed, symptoms must clearly interfere with functioning socially, at home, or in the classroom.

Symptoms that may indicate hyperactive behaviour include difficulty remaining seated when asked to do so, excessive fidgeting or talking, seeming to be "on the go" a lot of the time, restlessness or difficulty playing quietly. These ‘hyperactive symptoms’ tend to be present by the age of four, with an increase over the next three or four years. These symptoms are typically worst at age 7 to 8, then gradually get better. Hyperactive symptoms tend to settle down by adolescence.

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. 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. Peak severity is at age 7 or 8. Impulsive symptoms are more likely to continue throughout adulthood.

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.

If your child displays some of the symptoms discussed above, how do you know whether their behaviour is part of normal development, or due a condition that may lead to negative outcomes if it is left untreated? According to Professor Houghton, "Parents tend to know innately if something is not right. If the child is very hyperactive in comparison to their peers over a period of 6-12 months, and they are behaving this way not just at home but also at school or in places like shopping centres, it may indicate that they have ADHD."

Professor Houghton recommends that all children suspected of having ADHD should have "a formal psychological and educational assessment." "This 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. Ideally the child should attend a specialist centre that offers a comprehensive assessment of children and adolescents suspected to have ADHD. These centers may also coordinate appropriate referrals to other specialists such as occupational therapists, and liaise with the child’s school, teachers and carers.

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 WA (LADS). This resource was also cited as the most helpful to parents. Professor Houghton said that "LADS have a Comprehensive library covering a wide range of topics. Parents go to LADS and devour the information there."

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’s need is, 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.