Module 1 | Parada SEN

Module 1: What is ADHD?

ADHD, or Attention Deficit Hyperactivity Disorder, to give it its proper name, is a neuropsychiatric disorder defined by patterns of being inattentive, disorganized, hyperactive or impulsive. Many children can show some or all of these behavioral traits but it doesn't mean they have ADHD.

We're going to look at how to spot the signs of ADHD; how to get a proper diagnosis and then ways of adapting your parenting approach to meet the needs of children who have ADHD and their families.

1.1 What Does ADHD Actually Mean?

1.2 Recognizing ADHD Symptoms and When to Ask for Help

1.3 Preparing for Your Child’s Visit for ADHD Evaluation

1.4 Under-diagnosis in Girls: How to Avoid the Bias

1.5 Stress-free ways to prepare your child for life with ADHD

1.6 Terms to Know

Module 1.1 What Does ADHD Actually Mean?

ADHD is one of those terms that has become part of the popular culture. It seems like anyone and everyone who is forgetful or impulsive is tagged, even jokingly, as ‘ADD’ or ‘ADHD’.

But what does that actually mean? The acronym ADHD stands for Attention Deficit Hyperactivity Disorder. ADHD is a bona fide neuropsychiatric disorder characterized by patterns of hyperactivity and inattention.

You may be more familiar with its predecessor, Attention Deficit Disorder (ADD). Contrary to popular belief, ADD and ADHD are not separate disorders. The term, ADD, was used in the early years of psychiatric diagnostic literature. As the disorder and the symptoms became better understood, the name of the disorder was refined for accuracy.

This is according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-V).

Clinicians outside the U.S. often rely on the International Classification of Mental and Behavioural Disorders - 10th revision (ICD-10) published by the World Health Organization (WHO).

In the ICD-10, ADHD is identified as Hyperkinetic Disorder (HKD): “This group of disorders is characterized by: early onset; a combination of overactive, poorly modulated behavior with marked inattention and lack of persistent task involvement; and pervasiveness over situations and persistence over time of these behavioral characteristics.”

What these definitions demonstrate is that ADHD is not indicated by a single symptom like forgetfulness or poor attention. ADHD symptoms actually fall along a continuum.

At one end is inattentiveness and poor concentration. At the other end lies the hyperactivity, restlessness and impulsivity that one most often associates with ADHD.

How they present over time and how they impact the person determine how the clinician will define the type of ADHD one has.

1.2 Recognizing ADHD Symptoms and When to Ask for Help

So, you’ve been told you have a really ‘busy’ little one. Maybe you’ve even gotten a few notes home from the teacher about problems paying attention or sitting still. Right about now, you might be thinking, “Could my child have ADHD?”

Recognizing ADHD symptoms in kids can be really tricky. Kids are, by nature, busy. They fidget. They wiggle. They are distractible. Their little brains are learning, exploring and soaking up so much information! Sitting still is hard on a good day! And yes, some kids are a little more energetic than others.

The fact is, not every instance of being distracted or not being able to sit still signals a problem with attention or activity. Maybe your child didn’t sleep well the night before. He might be distracted by a problem. Maybe she was a little too over-stimulated during play time. Or a million other things.

So where is the boundary between being a busy kid and a child with ADHD? Kids who have ADHD experience these behaviors more frequently and more intensely.

Over time, these problems begin to affect them not only at home but at school and in the larger community. In short, they start to struggle. It’s around this time that you might start to get behavior reports from school.

There are three main types of ADHD:

ADHD-Predominantly Inattentive

is characterized by a predominance of inattention, being unable to remain focused or complete a task.

ADHD-Hyperactive/Impulsive

is characterized by a predominance of hyperactivity, being ...unable to sit still or being excessively fidgety or impulsive.

ADHD-Combined Type

is the presence of both inattentiveness and hyperactivity. There is not a clear predominance of one or the other.

Before we talk about symptoms, it’s important to note that having ADHD is NOT a reflection of a child’s intellectual ability. They are certainly intellectually capable. Rest assured, they want to be good students and they want to make good choices. The inability to focus, the impulsivity and the hyperactivity gets in the way.

So, let’s talk about symptoms. How do you know when your child’s behavior has gone from normal to something to be concerned about?

There is no one simple answer or identifier but this checklist will help you look closer at your child’s behavior:

Inattention

Check each item if the child showed the symptom for at least 6 months to an extent that is inappropriate for the child’s developmental level.

Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
Often has trouble keeping attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (loses focus, gets sidetracked).
Often has trouble organizing activities.
Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
Often loses things needed for tasks and activities (eg. toys, school assignments, pencils, books, or tools).
Is often easily distracted.
Is often forgetful in daily activities.

Hyperactivity / Impulsivity

Check each item if the child showed the symptom for at least 6 months to an extent that is disruptive and inappropriate for the child’s developmental level.

Often fidgets with hands or feet or squirms in the seat when sitting still is expected.
Often gets up from the seat when remaining in the seat is expected.
Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
Often has trouble playing or doing leisure activities quietly.
Is often "on the go" or often acts as if "driven by a motor".
Often talks excessively.
Often blurts out answers before questions have been finished.
Often has trouble waiting one's turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games).

If you’ve checked off more than a few of these indicators or if you’re getting behavior reports from school, it might be time to have a conversation with your child’s healthcare provider about a referral to a behavior specialist for evaluation. Could it be something else totally unrelated? Absolutely! But when it comes to a child’s adjustment and well-being, it’s always best to err on the side of caution.

Some primary care providers and pediatricians are comfortable in diagnosing and treating ADHD but they often refer to a mental health clinician. Depending on where you are in the world that clinician might be a psychologist, a licensed counselor or social worker or a child psychiatrist.

So how do you choose a clinician? Here’s your checklist:

Ask for recommendations from friends, family or your child’s doctor
Choose a clinician that has a license or certification as required in your area
Choose a clinician experienced in working with children with behavioral issues
Choose a clinician trained in diagnosis and treatment of ADHD
Check with your insurance company regarding coverage for the evaluation
Verify that the clinician obtains pre-authorization if required

What’s next? Make the appointment.

1.3 Preparing for Your Child’s Visit for ADHD Evaluation

Before we talk about preparing your child for the evaluation, it’s important to talk about what you can expect.

Your appointment may take much longer than a simple, brief doctor visit. Making a clinical diagnosis involves a full assessment including a detailed history of behavior and functioning. Your provider may also utilize any number of additional tools to gather information depending on your child’s presentation and needs.

It is a common misperception that there is a single, definitive medical or psychological test for ADHD that all clinicians use. The fact is, there are a number of tools that may be used but most often, the diagnosis is made based on clinical presentation and history.

Some of the common tools a clinician might use include:

Checklists of symptoms for the parent, family members or teachers to complete
Behavior rating scales such as the Conners Comprehensive Behavior Rating Scales or the Vanderbilt Diagnostic Rating Scales. Scales like these often include Parent and Teacher versions to help clinicians get a better picture of where behaviors occur.
A medical exam to rule out any physical causes for the concerning behaviors
A complete clinical assessment including a detailed history of past and current behavior and level of functioning across settings

Sometimes, tests to assess cognitive ability and academic achievement are needed to rule out learning disabilities or other disorders that can either mimic or exacerbate ADHD symptoms. These tests are usually administered by a clinical psychologist.

Understanding the tools that might be used will help you understand how the clinician arrived at their diagnostic determinations and help your child to know what to expect.

When you make the appointment with the clinician, you will want to ask a few questions:

What will the evaluation consist of? Paper and pencil tests? Computer-based tests? Clinical interview?
Will I be in the room with my child? Will you interview him/her separately?
Are there any screening assessments or information I should gather ahead of time? Sometimes school behavior records or reports are helpful.
What is the office environment like? Is it child-friendly? You may need to pack colors or a book.
How long should we expect to be there? Hungry kids don’t do well with testing. You may need to pack a snack or make sure your child has eaten.

Once you’ve made the decision to seek help, you have one more important task: talk to your child about it. A scared, anxious child doesn’t test well in any setting. Preparing your child for what is to come can ease the fears and set your child up to have a good experience.

Kids are often intimidated – even scared – when it comes to new and unfamiliar things. They also often assume that they’ve done something wrong and seeing a therapist is punishment for their behavior.

Your child needs to know that this evaluation is not a punishment. It won’t hurt and it doesn’t mean they’ve done anything wrong. It doesn’t mean that they aren’t smart or can’t learn. They need to know this step is to find out how to help so that they can be successful and make decisions they can feel good about. And they need to know you’re in it together – as a family.

How you share information about the appointment is just as important as the details you provide. You want your child to hear you and to feel reassured that he or she will be ok during the evaluation.

Tips for Preparing Your Child for the Visit:

1. Well before the day of the appointment, explain the reason for the visit. Answer any questions your child may have. Be positive in your explanation. Seeing the visit as a positive step helps one feel empowered to participate in the process.

2. Reassure your child that there will be no shots or painful procedures.

3. Let your child know that he or she may meet with the clinician alone for part of the time. Reassure them that you will be close by and will not leave them.

4. Explain generally what will happen. For example, they will meet and talk with the clinician who may ask lots of questions. If testing is planned, it sometimes helps to describe the testing as like doing school-work.

5. Make sure your child gets a good night’s sleep the night before.

6. Make sure your child has eaten and is feeling well.

7. Encourage your child to ask any questions they might have for you or for the clinician.

1.4 Under-diagnosis in Girls: How to Avoid the Bias

It is important to be aware of some significant differences in how ADHD presents and is addressed in girls.

It is estimated that ADHD affects approximately 5% of school-age children. Of that 5%, the ratio between boys and girls is as much as 2:1. (APA, 2013) However, there is more to the story.

Historically, ADHD was thought to be a disorder that mostly affected boys. Boys tend to be diagnosed at a much higher rate. Checklists, rating scales and treatment protocols tend to focus on the typical male presentation of ADHD

Research suggests that ADHD may occur almost as frequently in girls as in boys but may be underdiagnosed in girls. The discrepancy in diagnosis is thought to be due in part to the way that symptoms manifest in girls and biases in perception and referral.

Boys tend to display symptoms of hyperactivity/impulsivity – the kinds of behaviors that draw attention. Girls are much more likely to present with inattentiveness/forgetfulness and be seen as more distracted or day dreamers.

Even girls with ADHD-hyperactive type tend to display less physical energy than boys. Girls are more likely to display behaviors such as chewing on their clothes or hair, being overly talkative or being more emotionally reactive

Girls also tend to try and cope with their symptoms by immersing themselves in tasks that they can do well. This outward appearance of success can be deceiving and mask problem behaviors. As a result, their struggles don’t immediately garner attention.

A national survey (Quinn & Wigal, 2004) highlighted the differences in perception regarding ADHD in boys and girls:

58% of the general public and 82% of teachers think ADHD is more prevalent in boys.

Girls with ADHD are thought to have less noticeable problems than boys, such as being inattentive (public: 19% vs 11%; teachers: 29% vs 10%, respectively)

Girls taking medication for their ADHD were nearly 3 times more likely to report antidepressant treatment prior to their ADHD diagnosis

Girls were more likely to report difficulty focusing on school work and getting along with parents

Both teachers and the general public think boys with ADHD are more likely than girls to have behavioral problems

Four out of 10 teachers report more difficulty in recognizing ADHD symptoms in girls.

So what does this mean for parents?

Being aware and proactive is the best approach for helping your child. Knowing that ADHD often presents differently in boys and girls, it is important to gather and share accurate information about your child’s behavior.

Ask her teachers about her behaviors and listen for signs of inattentiveness.
Ask your child. Are there things she’s struggling with in class? With homework?
Is she excelling at some things while other important tasks fall by the wayside?
Does she finish tasks or does she leave things undone or in disarray?
Does she fidget, twirl her hair, chew on her clothing?
Does she tend to ‘chatter’?
Is she emotionally reactive or sensitive?

Remember, these things alone do not confirm or rule out ADHD for your daughter. Only a qualified mental health professional can make that determination. These are simply some examples of behavior to be mindful of and discuss with her clinician. Again, the more accurate you can be in describing what is happening, the more accurately your clinician can diagnose and recommend a plan of treatment.

1.5 Stress-free ways to prepare your child for life with ADHD

Once the ADHD diagnosis has been made, your provider will recommend a treatment plan. This plan may include:

Medication
Individual and/or family therapy
Psychosocial skills training
A combination of these interventions

There will be lots of new things to learn and do. Your child is going to rely on you to help them as they learn new ways of navigating their world. At the same time, you will be learning how to modify your parenting approach to accommodate your child’s needs.

Modifying does not mean that basic rules and expectations don’t apply. A diagnosis is not an excuse for inappropriate behaviors. What it does mean is learning to modify your child’s environment to maximize success and foster confidence.

When a child receives a diagnosis such as ADHD, treatment is a family process. Every family member is impacted in some way and it takes every family member working together to manage it successfully.

Create Structure

Structure means establishing and maintaining a daily routine. Knowing what is coming up helps to keep anxiety in check and creates consistency. Establish simple routines for mealtimes, playtime, homework, bedtime, etc. Give your child specific tasks such as setting the table or laying out her clothes for the next day.

Have a Set Bedtime

Sleep is sometimes difficult for children with ADHD. Poor sleep can exacerbate their symptoms. Establish an evening bedtime ritual such as a bath or story and a firm ‘lights out’ time.

Break Things Down

Children with ADHD can easily become overwhelmed with too many instructions or tasks. Be specific in what you say. Break instructions or information down into smaller pieces. Instead of saying, “Go brush your teeth, put your shoes on, grab your book bag and meet me at the door”, you may have to break the steps down to one or two at a time.

Make It Visual

Consider using a big, colorful calendar, cute checklists or behavior charts to help your child remember to do things. Even young children can benefit from visual cues such as pictures or symbols.

Create Quiet Spaces

Children with ADHD are often quite distractible. Create quiet spaces for homework, reading or just relaxing. Ideally, this is an electronics-free zone as electronics can overstimulate and exacerbate impulsivity.

Practice ‘Stop, Think and Go’ Style Activities

Learning to control impulses is a key skill for some children with ADHD. Children’s games such as pick-up-sticks, Simon Says, Red Light-Green Light, and Jenga rely on those skills to be successful. Do homework with your child. Ask questions that require a thoughtful response.

Help Your Child Be Organized

Organization is key for children with ADHD. Use a homework planner. Pack her book bag together the night before. Have a designated pace for homework and establish a routine for picking up and putting away personal belongings.

Manage Behavior

Learn effective behavior management strategies. Ideally, you want to encourage positive behaviors. Reward with praise such as “I like how you put your books away when you finished.”

Sometimes your child will break the rules. Be flexible but consistent in holding them accountable. Mistakes are often perfect teachable moments.

1.6 Terms to Know

As you begin to work with your treatment team and coordinate services for your child, you will be coming into contact with a host of professionals and education specialists. Sometimes, it may feel like they’re speaking another language. In some ways, they are. They are each speaking the language of their individual professions.

Learning the key terms associated with ADHD treatment and wrap around services will help you to understand what is being discussed and ask questions so that you are understood.

There are many terms associated with ADHD and mental health treatment in general. This list is by no means all-inclusive but includes some of the key terms you will need to know:

Accommodations: These are changes that are made in the school-setting for children with special educational needs. These accommodations may include things like extra time for assignments or tests, special seating, small group testing or the use of assistive technology.

Behavior Therapy: This is a type of therapeutic intervention teaches clients new skills that replace negative behaviors with positive ones. It is based on principles of learning.

Behavioral Contract: An agreement between the child and an adult (usually a teacher or parent) designed to change a specific behavior.

Classroom Behavior Management: This is a broad term that refers to strategies used in the classroom to manage student behaviors.

Co-Existing Condition: Also referred to as a “co-morbid” condition, it is the presence of two or more health or mental health conditions occurring at the same time.

Cognitive Restructuring: A therapeutic process that involves changing self-defeating ways of thinking.

DSM-V Diagnostic and Statistical Manual of Mental Disorders: This manual classifies and establishes standard diagnostic criteria for mental health disorders. The DSM-V is used by mental health professionals and insurance companies for diagnosis and for insurance purposes.

Distractibility: The inability to sustain attention to a task; being easily drawn off task.

Executive Function: Cognitive skills that control critical thinking and self-regulation including flexibility, focus, organization, planning, self-awareness, self-control and memory. ADHD can affect executive functioning.

Free Appropriate Public Education (FAPE): Sometimes referred to as “504”, FAPE is a provision under Section 504 of the Rehabilitation Act of 1973 and stipulates that all children and students are given the right to have a free appropriate public education. Appropriate education is considered to be the provision of regular or special education services that are designed to meet individual needs of students with special needs as adequately as the needs of regular students.

Hyperactivity: Increased movements, excessive fidgeting, impulsivity

Hyperfocus: Intense mental concentration or fixation on an activity or topic

Impulsivity: Acting before thinking about the outcome or consequences

Inattention: Inability to hold one’s attention on a task or object

Individualized Education Plan (IEP): A document that delineates the special needs child’s educational goals and the accommodations or interventions that will be used to support those goals.

Non-stimulant Medication: A type of medication that has been approved to treat ADHD for those patients who cannot tolerate or have had poor response to stimulant medications or who have co-morbid conditions that preclude the use of stimulant medications.

Self-Regulation: The ability to successfully manage one’s behavior with appropriate choices

Stimulant Medication: A type of medication that stimulates the production and activity of certain neurotransmitters that brain functions associated with ADHD. These medications are the most commonly prescribed medications for ADHD.

Target Behavior: A specific behavior that is chosen to increase or to decrease as part of a behavioral intervention.

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