Inattention, hyperactivity and impulsivity are common in the general population and may represent transitory or normative developmental patterns, but if this leads to impairment, these children may suffer from ADHD (DSM) or Hyperkinetic Disorder (ICD). ADHD and Hyperkinetic Disorder affect children throughout the world at a rate of about 3-5%.
ADHD has long been described in the medical literature. Heinrich Hoffmann (1809-1894), a German psychiatrist, was the first to describe children whose behavior was marked by impulsivity and hyperactivity. He named this behavioral problem “impulsive insanity” or “defective inhibition”.
Attention Deficit Hyperactivity Disorder (ADHD) is a diagnosis that is familiar to most people, even to those not involved in mental health assessment or treatment. As of 2003 an estimated 4.4 million children (ages 4 to 17 years old) in the United states had been diagnosed with ADHD which is equivalent to 7.8% of this age group (Center for Disease Control [CDC] 2005). Because of the prevalence and wide spread media coverage of ADHD and its associated features many people feel they “know” when a child has ADHD. Professionals in the field however realize that accurate identification of ADHD is not always obvious or straightforward. It is critical to have appropriate assessment tools based on both clinical work and research findings that contribute towards accurate diagnosis and treatment planning.
ADHD is common in all cultures, it can be serious: untreated it can lead to educational failure, accidents and unfair harsh punishments that may worsen the behaviour and outcome. It can also be severe as it can persist into adulthood with risk of: drop out from school, marriage breakdowns, unemployment, accidents, and other psychiatric disorders. Also it can be stigmatizing: Patients or their families may be blamed for the behaviours, suffering social exclusion. However, is treatable with several evidence based treatments.
There are certain behaviors and emotions that characterize ADHD in children which include cognitive, social, emotional, behavioral and sensory motor features.
Cognitive factors manifest as problem with executive functioning, memory deficits and variability in performance. Children with ADHD particularly those with the inattentive subtype, often show executive deficits during testing and in everyday life. These deficits include poor planning and strategy formation limited organizational skills, lack of self-inhibition (i.e. self-talk is often said aloud) and poor self-regulation of emotions (i.e. emotional lability). ADHD is also associated with deficits in working memory (i.e. the ability to remember information and process it at the-same time such as is required to complete mental calculations).
Attentional problems can mimic memory problems. A child must first pay attention to information before he or she can store it in memory. To retrieve information from memory, information must be stored in an organized manner which is problematic for many children with ADHD who lack strategy or organization in their lives. Even when a child with ADHD knows information he/she may not be able to recall it, unless specifically prompted by parent, teacher or any other significant person in the child’s life who is aware of his/her challenges. For example a child may not remember being assigned any homework until the parent asks, “which page did your teacher say to do for math homework tonight?”
Variability in performance is another cognitive feature of ADHD. For parents or guardians of children with undiagnosed ADHD, they often make mis-attributions about their children performance such as ‘you are just lazy’, ‘you are not smart’ and that’s because they just can’t seem to reconcile changes in performance. This variability is demonstrated in a number ways such as grades (e.g. getting As and Fs in the-same class), knowledge (e.g. knowing math facts one day and forgetting them the next day), and level of awareness (e.g. being on the ball one minute but out of it the next). Research has documented this variability using standardized tests that measure things such as reaction time. These variability often leads to comments such as “he can do better when he tries” or she’s just lazy. “I know she is capable of getting better grades “. This can be disheartening to a child with ADHD who is putting forth good effort, but getting inconsistent results.
Children or adolescents with ADHD often recall hearing mis-attributions about their challenges such as ‘’dumb’’, ‘’lazy’’, ‘’lacks effort or motivation’’. As a result, a child or adolescent with ADHD is at risk of developing poor self-concept, low self-esteem and depression. Secondary anxiety can also develop, as an impulsive child may be constantly worrying about making a mistake or disappointing teachers and parents. Anxiety disorders and mood disorders often co-occur with ADHD.
Children or adolescents with ADHD may have social deficits. Research shows that most children or adolescents with ADHD do not have social skill deficits; they have adequate knowledge of appropriate social behaviors. Instead ADHD is more often associated with social functioning deficits, which is the failure to apply social skills in appropriate situations and impulsivity can be manifested and in turn be perceived as social intrusiveness, since the child or adolescent with ADHD may impulsively enter a conversation or a game without stopping to consider whether it is socially appropriate to do so. These social functioning deficits can result in social isolation, as peers, parents and other people around the child may view these children as rude or lacking courtesy.
Features of ADHD can also be associated with behavioral problems, an active child or adolescent (e.g. hyperactive) has more opportunities to get caught doing the wrong thing. Consider for example a typical child who might misbehave in 1 of 10 actions if the number of actions is multiplied by 10 represent hyperactivity, then the child with hyperactivity will have 10 instances of misbehavior. When this hyperactivity is combined with impulsivity the child is more likely to act before thinking, which results in the child getting into trouble more often. Disruptive behavior disorders such as oppositional disorder (ODD) and conduct disorder (CD) have high rates of co-existing with ADHD.
Children or adolescents with ADHD tend to have impairments in motor coordination and are often described as “clumsy”. Fine motor skills (e. g. dexterity) can be deficient resulting in sloppy handwriting.
Children with ADHD often earn low scores on measures of adaptive functioning. Poor adaptive functioning is not due to lack of knowledge or ability in self-care, but rather the failure to independently apply self-care skills. The need for constant reminders results in low adaptive functioning scores when parents are describing a child’s self-initiated daily performance.
Although AADHD is often associated with negative features, it is also associated with positive traits, individuals with ADHD are often enthusiastic and energetic. They are often good at creative brainstorming and at developing ideas that are not limited by traditional boundaries. While ADHD can make traditional educational programs very difficult for child some adults with ADHD have been very successful in creating or finding positions that will maximize their strengths (and minimize their weaknesses). For example the founders of some large companies credit their success to “out of the box” thinking associated with ADHD in combination with very organized and structured support systems including spouses and staff(e.g. David Neeleman, the founder and CEO of jet blue airways ; paul Orfalea founder of Kinko’s; Gilman n.d.). It is important to support students with ADHD during their educational years, while helping them focus on their strengths as they move into adulthood.