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Josh is an 8-year-old 3rd grader whose parents are very upset with their son's behavior. His teachers complain that Josh talks all the time in school, and he can never wait his turn when standing in line for any activity. He can't seem to stay seated and seems to be always bothering other students. Josh's mother feels like her son is giving her a nervous breakdown. He doesn't listen to any of her demands, and seems to ignore or forget her requests.
Karen is a 4th grade student. She doesn't bother anyone and sits quietly in her seat. Her teacher is very concerned because she never completes any of her homework. In fact, when her mother asks her, she often states that she doesn't remember that her teacher has even given her any homework.
Doug is 15 years old. He has been having trouble in school most of his life. He states that he can't seem to stay focused on what the teacher is lecturing about and he easily gets distracted. Often, he stares out the window in his classrooms. At home, Doug's mom complains that her son is extremely disorganized and loses and misplaces his books and other things. His room, she notes, is a total wreck. Lately, Doug has begun to argue with a lot of his teachers and is hanging out with a wild group of kids. His father noted that Doug already smokes a pack of cigarettes a day.
What do all of these kids have in common? If you answered ADHD, known as Attention Deficit/Hyperactivity Disorder, then you answered correctly.
But what is ADHD?
Attention Deficit Hyperactivity Disorder (ADHD) is a condition that becomes apparent in some children in the preschool and early school years. It is hard for these children to control their behavior and/or pay attention. It is estimated that about 5 percent of children have ADHD. This means that in a classroom of 25 to 30 children, it is likely that at least one child will have ADHD.
The primary characteristics of ADHD are inattention, hyperactivity, and impulsivity. These symptoms appear early in a child's life. A child who "can't sit still" or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a "discipline problem," while the child who is passive or sluggish may be viewed as merely unmotivated. But, over a course of time, it is usually the schoolteacher who will report to the parent(s) that the child is having some difficulty in the classroom or with his or her peers.
According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders2 (DSM-IV-TR), there are three patterns of behavior that indicate ADHD. There is the predominantly hyperactive-impulsive type (that does not show significant inattention); the predominantly inattentive type (that does not show significant hyperactive-impulsive behavior) sometimes called ADD-an outdated term for this entire disorder; and the combined type (that displays both inattentive and hyperactive-impulsive symptoms).
What Is hyperactivity-impulsivity like?
Hyperactive children always seem to be "on the go" or constantly in motion. They dash around touching or playing with whatever is in sight, or talk incessantly. Sitting still at dinner or during a school lesson or story can be a difficult task. They squirm and fidget in their seats or roam around the room. Or they may wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive teenagers may feel internally restless. They often report needing to stay busy and may try to do several things at once.
Impulsive children seem unable to curb their immediate reactions or think before they act. They will often blurt out inappropriate comments, display their emotions without restraint, and act without regard for the later consequences of their conduct. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they're upset. Even as teenagers, they may impulsively choose to do things that have an immediate but small payoff rather than engage in activities that may take more effort yet provide much greater but delayed rewards.
What is inattention like?
Children who are inattentive have a hard time keeping their minds on any one thing and may get bored with a task after only a few minutes. If they are doing something they really enjoy, they have no trouble paying attention. But focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.
Homework is particularly hard for these children. They will forget to write down an assignment, or leave it at school. They will forget to bring a book home, or bring the wrong one. The homework, if finally finished, is full of errors and erasures. Homework is often accompanied by frustration for both parent and child.
Getting your child diagnosed
One thing for sure is that if ADHD is suspected, the child needs to receive a thorough examination and appropriate diagnosis by a well-qualified professional.
Diagnosing ADHD should be done by a competent physician such as a pediatrician, child neurologist or child psychiatrist. Non-medical professionals such as clinical psychologists, clinical social workers, and educational psychologists can also evaluate children suspected of having ADHD.
Whatever the specialist's expertise, his or her first task is to gather information that will rule out other possible reasons for the child's behavior. Among possible causes of ADHD-like behavior are the following:
A sudden change in the child's life-the death of a parent or grandparent; parents' divorce; a parent's job loss, moving to a new community such as moving to Israel
Undetected seizures, such as in petit mal or temporal lobe seizures
A middle ear infection that causes intermittent hearing problems
Medical disorders that may affect brain functioning
Underachievement caused by learning disability
Anxiety or depression or bipolar illness.
To assess whether a child has ADHD, specialists consider several critical questions: Are these behaviors excessive, long-term, and pervasive? That is, do they occur more often than in other children the same age? Are they a continuous problem, not just a response to a temporary situation? Do the behaviors occur in several settings or only in one specific place like the playground or in the schoolroom?
The behaviors must appear early in life, before age 7, and continue for at least 6 months. Above all, the behaviors must create a real handicap in at least two areas of a person's life such as in the schoolroom, on the playground, at home, in the community, or in social settings. So someone who shows some symptoms but whose schoolwork or friendships are not impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active on the playground but functions well elsewhere receive an ADHD diagnosis.
The child's teachers, past and present, are asked to rate their observations of the child's behavior on standardized evaluation forms, known as behavior rating scales, to compare the child's behavior to that of other children the same age.
ADHD is a Neurochemical Disorder
Experts today believe that ADHD is a neurochemical disorder. Calling the problem an attention deficit disorder is actually misleading since most ADHD children can concentrate just fine in activities that interest them, albeit computer games, or interesting conversations or sports. It seems that where these kids get into trouble is in the area of staying focused and on-task when the demand or activity, like listening in class, is mundane or not stimulating. Disruptive behavior, hyperactivity, and daydreaming, are in fact, the child's way to compensate for the under stimulation of neurochemicals that are responsible for attention and staying on task. It's kind of paradoxical that what ADHD children do to make themselves feel more normal is at the same time behaviors that get them into trouble with their parents and teachers. Both parents and teachers complicate the matter when they get angry at the child who exhibits hyperactive-impulsive behavior or doesn't listen and is spacey since these ADHD kids are supersensitive to criticism and disapproval. In other words, they are very likely to become oppositional if their problem is not understood more empathically.
Then they get labeled as a troublemaker, or in the case of an inattentive child, a lazy student. There is a need for parents and teachers to understand the biochemistry of ADHD so that they don't blame the child for his/her behavior but instead try to join forces to get the child the help he or she needs.
Treatment for ADHD
Treatment for ADHD for kids consists of behavioral and psychosocial counseling, parental education and guidance, and the use of medication to correct the neurological imbalance that causes ADHD symptoms. There are numerous things that can help this child at school. Certainly giving the child a seat in the front of the classroom can help, and working with the child's teacher to make sure the child is doing what he or she needs to do in school. Smaller size classrooms are certainly preferable for this child over larger groups. Personal positive attention will also help the ADHD child.
Researchers have also found that more breaks in the time expected for children to sit and listen to lectures combined with aerobic activity, even as little as 5-10 minutes can be enough stimulation to get the ADHD child more attentive.
Parents need help to learn not to personalize the child's disruptive and non-compliant behavior and to see the problem as one that is a parental challenge instead of an unfair burden. I strongly encourage the parent to plan special fun activities with the child to strengthen the parent-child bond. By the way, ADHD seems to run in families and may be transmitted genetically so it is not uncommon for there to be one parent of an ADHD child with the disorder. I strongly recommend counseling for the child and the parent to develop the skills that are social and organizational skills that are lacking.
It has been shown in numerous studies that stimulant medication provides significant benefit to between 70 and 80% of children with ADHD. The most commonly prescribed medications used to treat ADHD are Ritalin (short acting and long acting Ritalin SR), Adderal, Dexedrine, Adderal XR, Concerta, Strattera. Available evidence suggests that stimulants work by correcting a biochemical condition in the brain that interferes with attention and impulse control.
What benefits can stimulant ADHD medication produce?
The effects produced by stimulant medication occur quickly, and parents and teachers often observe an improvement in the child almost right away. The beneficial effects of stimulant medication treatment can be dramatic. Attention to class work can improve to the extent that the child is no longer distinguishable from classmates; activity level can decline to within normal limits and impulsivity can be substantially reduced. Even associated difficulties such as disruptive behavior and peer relationship problems sometimes show dramatic improvement. Interactions between parent and child and between the child and his or her siblings have also been shown to improve. Academically, many children show clear improvements in the quantity and quality of the work they complete.
What kinds of side effects are associated with stimulant medication?
As with any medication, stimulant medication used in treating ADHD can produce adverse side effects in some children. These can include: sleep difficulties, stomachaches, headaches, appetite reduction, drowsiness, irritability, nervousness, and excessive staring among others. In rare cases, stimulant medication can lead to nervous tics, hallucinations, and bizarre behavior.
The list of possible side effects can be scary to parents considering the use of medication for their child, but it is important to emphasize that the vast majority of children with ADHD experience no adverse effects. Based on the findings from many carefully controlled studies, physicians have concluded that when properly employed stimulant medication is safe and the side effects are minimal. When side effects do occur they are frequently short lived and often disappear when the dosage is reduced. Despite these data, however, it is obviously important for parents to discuss their questions and concerns with their child's physician.
Dr. Mike Gropper is an American trained psychotherapist and marital therapist, and the director of SmokeQuitters [www.smokequitters.co.il.]
Contact him at Golan Center, Ahuza 198, Ra'anana, (09) 774 1913, or Shalom Mayer Center, Diskin Street 9A, Kiryat Wolfson, Jerusalem, (02) 563 6265, firstname.lastname@example.org
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