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Understanding ADHD

This booklet can also be viewed as a non-printable pdf file and purchased from the online shop.

What is ADHD?
How common is ADHD?
What causes ADHD?
Do children grow out of it?
How is a diagnosis made?
What are the treatments?
What should I do if I’m worried?
Useful organisations
Websites
Further reading

‘I always worry when I go to pick John up from school. It seems every day some problem has arisen. I feel people think I’m just a bad parent.’

‘To try and get Manjeet to do her homework and hand it in, in a presentable form, can take all right. We often get comments from the school on how messy her work is, but she does try so hard.’

‘Ben is so unpredictable; one minute he will be in a good mood, and the next he will be shouting at his sister. When we have other children around, he will act very silly, and then boss them about.’

‘I don’t care what you call the problem, my child needs help.’

Children with attention deficit hyperactivity disorder (ADHD) have severe behaviour problems and learning difficulties, but with the right kind of help early on, these can be overcome. This booklet describes the behaviour and gives an overview of the various theories about ADHD. It suggests what can be done to help, and the practical steps that parents, teachers and other carers can take.

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What is ADHD?
Many parents worry about how their child is behaving, from time to time, but untamed behaviour is a normal part of growing up. The difference between this and ADHD is how extreme it is. A child who has ADHD always behaves in the same highly challenging way, wherever they are and whoever they’re with. Unless they get the special help they need, ADHD can be damaging to them, to their family, and to their future.

Children can be very young when problems start. Parents often describe their children as being ‘motor driven’. They will be restless, on the go the whole time, often very clumsy and always asking for attention. By the time they reach school age, teachers will find them very disruptive in the classroom, and exceptionally untidy, disorganised and forgetful.

One key sign of ADHD is that these children are always highly impulsive. They act and speak without thinking, saying and doing things they shouldn’t. They end up with a reputation for acting stupidly. Learning is very taxing for them, especially learning to write. Because they are so easily distracted, their work is always careless and full of mistakes. Teachers are likely to complain that your child never sits still, but flits around from task to task, never finishing anything or paying attention to what he or she is told.

Making or keeping friends can be a serious problem for these children because they are so bossy and talkative, often butting in, not listening to what anyone else has to say. They can also be very moody. Other children find them irritating and disturbing. As they grow older, the restlessness may turn into an inner jitteriness. Their frustration and dismay at what happens only makes their problems worse.

Most children misbehave occasionally. It doesn’t mean that there’s anything wrong. But if the behaviour has been going on for a long time, it could mean there is a problem, although not necessarily ADHD. If you are worried about your child, you are entitled to help, whether or not your child has ADHD.

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How common is ADHD?
It’s hard to judge how many children have ADHD, because different experts use different terms and definitions. This is very confusing for parents and everyone else involved. Figures from the USA suggest that between three and seven schoolchildren in every hundred could be affected, but others in the UK think the figure is more like one to three per hundred.

It seems that more boys than girls receive this diagnosis, but the reasons why aren’t clear. It may have something to do with society’s expectations about the way we should behave. In the USA, for instance, groups such as the National Association for the Advancement of Colored People have argued that more Black boys are included in the category than should be.

In the UK, a small study of hyperactivity found that Asian children, rated by their teachers as being as hyperactive as their white classmates, were actually less hyperactive in the classroom. Clearly, it’s difficult to arrive at a true picture, so ADHD should be seen as way of defining a set of behaviours that is still open to change, not as a cut-and-dried ‘illness’.

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What causes ADHD?
Nobody knows exactly why, and there may be a number of different factors at work. Inheritance can play a part, because a child with ADHD is four times as likely to have a relative who had the same childhood difficulties. Many doctors, particularly in the USA, believe that ADHD is caused by a shortage of the brain chemicals that help a child to concentrate, plan and carry out their activities, and control their emotions. But some experts think that it’s unlikely to be just down to these chemicals, and that other influences are at work on a child, from birth onwards.

It’s been suggested that stress may act as a trigger to the problem. There’s no doubt that stress in the family upsets parents’ relationships with their children, making children more disruptive.

Families with children diagnosed with ADHD very often show signs of being under stress, but this is hardly surprising. If you have a child with ADHD, your home may feel like a battleground, and your confidence as a parent is likely to be very low. In other words, it could be hard to tell what comes first, the stress or the ADHD.

Another theory is that certain foods and food additives, and exposure to lead could be responsible for children developing ADHD, but many experts are doubtful. It’s possible that some foods may make your child more irritable and frenetic, and it may be worth cutting out drinks or foods containing caffeine or a lot of additives. But it’s very important to consult a qualified dietician before trying any special diets you may be recommended.

Whatever the cause of the problems, parents should never feel to blame. What you need is an understanding of the problems you’re facing and help in dealing with them.

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Do children grow out of it?

People who were hyperactive as children do sometimes go on to have problems in adult life, which may involve drug or alcohol abuse and anti-social or criminal behaviour. However, many experts believe this is because they have other problems, as well as ADHD. Although it’s hard to generalise, because of all the different kinds of behaviours included under ADHD, it’s clear that many children do grow out of their problems. There’s no reason to assume that your child won’t.

The more help a child gets, right from the start, the more likely they are to go on to lead positive and successful lives. The longer hyperactivity or behavioural problems go on, the greater the chance of both school and family reacting against the child, and the child reacting against them. School and family environment have an enormous influence on the way a child grows up.

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How is a diagnosis made?
There aren’t any special DNA tests, blood tests or other laboratory tests for ADHD. Only a child mental health expert (a child psychiatrist, an educational psychologist or a paediatrician) can make the diagnosis, based on the DSM-IV (the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders), or the ICD-10 (its European counterpart). One aim is to rule out any other possible causes for your child’s behaviour, such as language or hearing difficulties, dyslexia, autism, Asperger’s syndrome, epilepsy or depression.

ADHD is the usual term (though it’s sometimes called Attention Deficit Disorder [ADD]), and describes the two different groups of symptoms: hyperactivity (behaviour problems) and attention deficit (learning problems). Most children have a mixture of both types of symptoms, but others have only one type or the other. The term is sometimes written AD/HD to reflect this (as in ‘and/or’). If your child isn’t particularly hyperactive, they may still be diagnosed as having ADHD, but it will be called ‘ADHD without hyperactivity’. Girls often have this diagnosis, while boys tend to have both aspects of the problem.

Whoever does the diagnosis will observe your son or daughter carefully and may give them tests to do (for example, psychometric tests and Continuous Performance Tests), which help build a picture of their mental processes. They will also collect as much information as possible from parents, teachers, playgroup leaders, social workers, health visitors and anyone else involved in looking after your child. They will take into account whether there are any other medical reasons for the behaviour, and what else might be going on in your child’s life.

Once they think they know what’s wrong, they will suggest the best available treatment for that particular child. Not all children will be offered the same treatment for ADHD.

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What are the treatments?
Ideally, you should get a package of treatments involving behaviour management, counselling or psychotherapy, special help at school, and, possibly, medication. Unfortunately, access to all these forms of help may be limited by lack of funding.

On top of any treatment your child is offered, it’s vital that you, as parents, get the help and support you need to learn skills that can help your child. This will make you feel more confident about coping, and will help reduce stress and conflict within the family.

Behaviour management
Children want to get their parents’ attention; it’s a powerful reward for them. Unfortunately, scolding, arguing or shouting are powerful forms of parental attention, even though they are negative. Because children with ADHD are very difficult to manage, they tend to get more negative attention, and so will continue to behave badly. This cycle, which is called negative behaviour reinforcement, needs to be broken.

To do this, behaviour management encourages parents to notice when a child is being good, and to reward them. Children benefit from being praised often, enthusiastically and clearly. They need to know why they are being praised. This is known as positive behaviour reinforcement.

At the same time, parents have to ignore bad ehaviour. Whining, arguing, tantrums and swearing are extremely trying, and most adults’ instinctive reaction is to tell the misbehaving child to stop. But when a child has ADHD, this will only add to the problem, so you will be taught when to simply ignore bad behaviour, by avoiding eye contact and discussion, and by moving away from the child.

You should try to avoid using ‘stop’ instructions, such as, ‘stop shouting’, and say something like, ‘please speak more quietly’, instead. You should also try taking time out if your child keeps refusing your request, which gives you all a chance to cool off.

Behaviour management techniques take time and great patience on everybody’s part. Parents often find they have just as much to learn as their children, and need plenty of support. But the techniques have been shown to be very effective, and a positive reinforcement cycle can soon gain momentum, once it’s established.

It’s just as vital to help your child gain more self-control, both at home and at school. Putting more structure into their daily life, to help them get better organised, is an important first step. It’s a great help to children to use things like alarm clocks to break homework into chunks, and lists of tasks they can tick off each day. Getting a good routine going is essential. At school, it’s important that they’re encouraged to take an active part in learning, helped to set their own pace, and provided with lessons that have the right content level, variety and interest. Educational psychologists are often the best people to advise parents and teachers on effective programmes for their children.

Social skills training
Social skills training teaches children how to mange their relationships better, by reading the hidden signals of communication. It teaches them to understand what impact their behaviour has on other people, so they can change it.

Counselling
Counsellors are trained to help children to talk through the reasons for their behaviour and its consequences. Children diagnosed with ADHD almost always feel bad about themselves. Counselling can help them to tackle this, gain more self-control, focus their attention, and find better ways of learning and organising themselves.

As a parent, you also need to look honestly at the way your family works as a whole. You may well find family therapy can give you all a chance to talk through the worries or problems that may be contributing to your child’s behaviour. GPs, family therapy centres or child and family consultation services can all be useful starting points for helping parents, as well as children.

Psychotherapy
Child psychotherapists are skilled at helping children to recognise and tackle their own distress. Some ADHD-diagnosed children can become very severely demoralised, anxious or depressed. A child psychotherapist can provide intensive and longer-term help for them.

Medication
There is some controversy about using drugs to treat ADHD. Some experts have said that it gives both the children and their families a breathing space from the troubled behaviour, and helps them to maintain a more loving relationship with their child. Others believe that children are being prescribed these strong drugs, which may have side effects, when it’s not needed. They fear that using it may mask emotional or other causes behind the behaviour, especially in very young children. They are now banned for children under five.

One of the most popular drugs, Ritalin, was virtually unknown in Britain at the beginning of the 1990s, but between 2001-2002, prescription rates rose by 22 per cent. Over a five-year period, the number of prescriptions for children rocketed by 102 per cent to 254,000 items.

There have been cases of these drugs being misused, with youngsters selling them to other people. The drugs used are methylphenidate (trade names, Ritalin, Concerta and Equasym) and dexamphetamine (trade name, Dexedrine), which are stimulants that act on the central nervous system. They are Schedule II controlled drugs, falling into the same category as barbiturates and methadone, and are related to amphetamines (‘speed’). It’s not known exactly how they work, but it’s possible that they top up the chemicals in the brain that help communication between brain cells.

Most studies are very clear that these stimulants shouldn’t be used as the first or only treatment, and most doctors agree that they should only be used when absolutely necessary.

The medication can’t cure the problem, but it can help the child to think more clearly, understand better and feel calmer and more in control of themselves. This means they can take proper advantage of the other help they are getting at home and at school.

The drugs can sometimes have unwelcome side effects, particularly at the beginning. Children may have less appetite, lose weight and have problems falling asleep. The medicine usually lasts for about three to five hours at a time, and when it wears off, there can be a rebound effect, with the problem behaviour returning in an extreme form. In about ten per cent of children, the drug can make them tearful and withdrawn. Reducing the dose often helps.

Doctors need to carefully calculate the right dose of the drug, and monitor the effect on each child. If one kind doesn’t work, they may suggest a different one. Some children take these stimulants for six months, others for much longer, depending on how helpful they prove.

When these stimulants aren’t suitable, don’t work or have unpleasant side effects, doctors may prescribe antidepressants. Sometimes, these may be useful when a doctor feels a child’s depression is more disabling than their ADHD-diagnosed problems, but they may also have side effects. (See Further reading further down.)

It’s hoped that other non-stimulant forms of medication may be available within the next couple of years. (For more information about the treatments mentioned, see Useful organisations and Further reading further down.)

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Useful organizations
ADDISS
10 Station Road, Mill Hill, London NW7 2JU
tel. 020 8906 9068, fax: 020 8959 0727
email: [email protected] web: www.addiss.co.uk
The national attention deficit hyperactivity disorder information and support service

The Association of Child Psychotherapists
120 West Heath Road, London NW3 7TU
tel. 020 8458 1609, fax: 020 8458 1482
email: [email protected] web: www.acp.uk.net
For information on child psychotherapists working in your area

British Association for Counselling and Psychotherapy (BACP)
BACP House, 35–37 Albert Street, Rugby CV21 2SG
tel. 0870 443 5252, fax: 0870 443 5161
minicom: 0870 443 5162
email: [email protected] web: www.bacp.co.uk
See website or send A5 SAE for details of local practitioners

The British Psychological Society
St Andrews House, 48 Princess Road East, Leicester LE1 7DR
tel. 0116 254 9568, fax: 0116 247 0787
email: [email protected] web: www.bps.org.uk
Publishes a directory of chartered psychologists

Hyperactive Children’s Support Group
71 Whyke Lane, Chichester, West Sussex PO19 2LD
tel. 01243 551 313, fax: 01243 552019
The HCSG offers access to local groups throughout the UK

United Kingdom Council for Psychotherapy (UKCP)
167–169 Great Portland Street, London W1W 5PF
tel. 020 7436 3002, fax: 020 7436 3013
email: [email protected] web: www.psychotherapy.org.uk
Umbrella organisation for psychotherapy in UK. Regional lists of psychotherapists are available free

United Kingdom Psychiatric Pharmacy Group
tel. 020 7919 2999
Helpline run by pharmacists to answer queries on psychiatric drugs

YoungMinds
102–108 Clerkenwell Road, London EC1M 5SA
tel. 020 7336 8445, fax: 020 7336 8446
parents information service: 0800 018 2138 (for any adult with concerns about the mental health of a child or young person)
web: www.youngminds.org.uk
A national charity committed to improving the mental health of all babies, children and young people

Youth Access
1–2 Taylors Yard, 67 Alderbrook Road, London SW12 8AD
tel. 020 8772 9900, fax: 020 8772 9746
email: [email protected]
Information on youth counselling