AD/HD: Helping Your Child
by Warren Umansky, Ph.D. and Barbara Steinberg Smalley
Warner Books, 2003
Ordering Information: Amazon.com
by Warren Umansky, Ph.D. and Barbara Steinberg Smalley
Warner Books, 2003
Ordering Information: Amazon.com
AD/HD: WHAT IT IS AND ISN’T
Click here for ordering information.
Robert, a third-grader, walks to school most days. His school is no more than a five-minute trek from home, yet even when Robert leaves on time, he is often thirty minutes late.
His classmates don’t like Robert very much. They say he’s bossy and claim he’s always picking on them. Robert has problems in the classroom as well. He spends the majority of his time under or near his desk rather than sitting down and working. His handwriting is sloppy, his work is messy, and his assignments are frequently left unfinished. He’s constantly losing things and can’t seem to keep up with the class when they are reading aloud. And rarely does he have the right materials out to complete a given task.
At home, Robert is equally disorganized. His parents say he is extremely messy and has to be repeatedly reminded to complete simple chores. In the neighborhood, Robert has few friends his own age. When he plays with them, a fight typically ensues over sharing, hurt feelings, and so forth. Consequently, Robert plays mostly with children who are older or younger than he is.
Robert was recently diagnosed as having Attention Deficit/ Hyperactivity Disorder (AD/HD)—and he’s far from alone. AD/HD is thought to affect some 3 percent to 5 percent of today’s school-age children in the United States. And while this disorder seems to have emerged from nowhere to become a near epidemic over the last decade, it’s hardly new.
In fact, AD/HD has been recognized since the early 1900s, and is one of the most widely researched of all childhood disorders. Over the years, however—and to reflect researchers’ growing advances in concept and theory about this disorder—AD/HD has assumed many aliases.
In the 1930s, for example, children who exhibited AD/HD-like symptoms were described as having “Minimal Brain Damage.” In the 1960s, that label changed to “Minimal Brain Dysfunction” and was considered relatively rare. By the 1970s, however, it was called “Hyperkinesis,” and up to two hundred thousand children were thought to have the disorder.
In the late 1980s, the term Attention Deficit Disorders (ADD) was coined, and affected children were categorized as having ADD with or without hyperactivity. The current name, Attention Deficit/Hyperactivity Disorder—or AD/HD—was first used in 1994.
What Is AD/HD?
The American Psychiatric Association redefined AD/HD in 1994 to describe three subtypes:
1. AD/HD Predominantly Inattentive. Jill, eleven, fits this category. Though bright and intelligent, she has trouble paying attention to details, and, as a result, tends to make careless mistakes on classwork and homework. Her teachers often reprimand Jill for gazing out the window instead of listening to directions. But Jill can’t help it. A chirping bird outside distracts her from the math problem in front of her.
2. AD/HD Predominantly Hyperactive-Impulsive. Eight-year-old Sam falls into this subtype. He’s always tapping his pencil, squirming in his seat, or otherwise fidgeting in class. His teachers often send notes home saying, “Sam can’t stay seated or quiet and often blurts out answers instead of waiting to be called on.” At home, when friends come over, Sam has trouble waiting his turn while playing games, and he’s constantly interrupting his mom when she’s on the phone.
3. AD/HD Combined Type. A child who falls into this category is inattentive as well as hyperactive and impulsive—like Robert, whom you read about earlier. One of the reasons Robert is often late for school—even when he leaves on time—is that he might spot a frog along the way and decide to chase it for a while. Once he is in school, his teacher calls out Robert’s name several times a day because he is often under or near his desk rather than sitting down working. Robert rarely finishes his assignments in the classroom, because he can’t seem to pay attention long enough to complete them. And when his class is reading aloud, he has trouble keeping up with them, because his mind wanders. At home, his parents say Robert is a whirlwind. He rarely sits still, even when eating. His parents must also repeatedly remind him to do his chores and stay focused on his homework.
People used to think that AD/HD was the result of some type of brain damage, but scientists now know that’s not true. Granted, the exact causes of this disorder remain a mystery; nevertheless, cutting-edge research using computerized imaging technology and other sophisticated diagnostic tools is revealing fascinating clues to why some youngsters’ brains have a propensity to AD/HD, while others do not.
Scientific evidence suggests that the level of neurological activity is quite different in certain parts of the brain in individuals with AD/HD compared to those who do not have the disorder. Differences have also been found in the size of various parts of the brain. Furthermore, at least in some cases of AD/HD, these central nervous system differences appear to have a hereditary component. We will talk more about the causes of AD/HD in Chapter Three.
Some researchers have described AD/HD as an inhibition disorder. That is, children are unable to put the brakes on useless movements, can’t control their distractibility and inattention, and can’t overcome their tendency to daydream. It is this inhibition theory that puts AD/HD in a family with certain other disorders, such as depression, obsessive-compulsive disorder, and tics.
What It’s Not
AD/HD is a biological, not an emotional disorder, though it can cause its victims to experience emotional problems at home, in school, and in social settings. Neither is AD/HD a learning disability, although many children with AD/HD also have learning disabilities. Nor is AD/HD caused by poor parenting or inadequate teachers, although a disorganized home life and school environment can make its symptoms worse.
Some suspect diet as the culprit, but extensive research offers proof positive that too much sugar, aspartame (brand name: NutraSweet), food additives, food coloring, and food allergies do not cause AD/HD, either. Nor does watching too much television or playing too many computer or video games, although these may reflect an environment that lacks good supervision and may nurture the development of AD/HD-like characteristics in a child.
What is true is that many children with AD/HD also suffer from other conditions, including depression, anxiety, enuresis (bedwetting), and tics. And for the frustrated parent and the unhappy child, sorting out which symptoms are biologically based, which are learned behavior, which are controllable or not controllable, and which are severe enough to interfere with the child’s success presents a significant dilemma.
Of course, not all youngsters who misbehave, who have trouble paying attention in school, or who have difficulty making friends have AD/HD. In fact, a host of physical, emotional, and situational problems can masquerade as AD/HD. Which is why it’s imperative that a child be properly diagnosed before being treated.
With no virus or bacteria to look for, no X-rays to take or blood tests to administer, how is a diagnosis for AD/HD made? Usually it involves input from a team of professionals—and from the child’s parents.
First, a medical doctor performs a thorough physical exam—which often includes neurological tests—to rule out any physical causes (such as vision problems or hearing loss) for the difficulties a child is experiencing. Many physical and medical problems, such as thyroid dysfunction, may cause behavior that mimics AD/HD. (See Chapter Two for other maladies that can masquerade as AD/HD.)
Once physical causes are ruled out, a psychologist may beconsulted. She may begin by taking a comprehensive history from the child’s parents and consulting with the child’s teachers. In addition to asking questions about a child’s level of achievement, as well as social and emotional functioning, the psychologist looks for signs of family crises (death, job loss, divorce, a recent move) that can trigger behavior problems that can be mistaken for AD/HD.
Gathering input from teachers and other caregivers is equally essential, as symptoms that appear only at school or at home may indicate that the problem is not AD/HD, but something related to a specific setting.
Classroom and home behavior is most often evaluated using checklists such as the ones shown on pages 7 and 8 for checklist. These checklists allow professionals to get a better idea of a child’s typical behavior—particularly behavior that may not be obvious from observation. Two different checklists are presented. One lists problem behavior while the second states positive behavior. There are many commonly used checklists for parents and teachers that incorporate one or both of these formats.
Naturally, documenting a child’s behavior in different settings is an important part of the diagnostic process. In fact, for a correct diagnosis to be made, a child must exhibit symptoms in at least two different settings. Thus, the psychologist will frequently observe a child at school as part of the data-gathering process.
So, what does the psychologist look for in the school setting? A number of characteristics that can support a diagnosis of AD/HD, as well as ideas to help the child improve his or her performance in the classroom. For example, the psychologist might note how a child’s seat placement contributes to distractions and how it affects his ability to copy material from the chalkboard or get assistance from another child or the teaching staff. The psychologist will likely observe how much time the child spends paying attention to assigned work versus the amount of time spent daydreaming or working on other, unassigned tasks. She might observe how the child gets along with his peers, as well as the types of children he gets along with best—or worst.
The psychologist will likely monitor how successful the child is at paying attention to and completing independent work, and compare that to his performance in class discussions or in small groups. She will also note the frequency and intensity of the child’s problem behavior—and how the teacher responds to the child.
The problem is that a child with AD/HD may show different behavior in different settings, at different times of day, with different people, and when different levels of challenge are presented. Therefore, relying on the report of one observer or formulating an impression of a child from an isolated observation may offer only a narrow view of the child’s problem. For a diagnosis to be accurate, it is important to compare and contrast a child’s performance under a number of conditions and to analyze observations from various individuals. For this reason, the psychologist may observe a child several times, on different days.
Can the diagnostic process move forward without the input of a psychologist? Yes, it can. But some professional must take the lead in gathering information and documentation to help the physician make a diagnosis and to help parents and teachers respond to the child’s needs. The parents’ professional partner may be a private or school psychologist, another mental health professional, a supportive teacher or school administrator, or even a friend who has traveled the same path.
When evaluating a child for AD/HD, professionals rely on a profile of characteristics that tend to differentiate children who might have AD/HD from those who do not. This profile is then compared with a list of criteria to make an official diagnosis.
Where do these criteria come from? They are listed in a manual that is published and revised periodically by the American Psychiatric Association. Professionals use this manual to diagnose specific psychiatric and psychological diseases and disorders, and in its most recent edition—Diagnostic and Statistical Manual—IV (DSM-IV)—the three types of AD/HD we discussed earlier are listed.
Here are details of the three subtypes of AD/HD:
AD/HD Predominantly Inattentive
A diagnosis of this subtype of AD/HD requires that at least six of the following symptoms have been present for at least six months; they must interfere with normal functioning in social, academic, and occupational skills; they must be present in at least two different settings; and they must be inconsistent with the child’s developmental level:
1. Often fails to give close attention to details or makes careless mistakes in school work, work, or other activities.
2. Often has difficulty sustaining attention in tasks or play activities.
3. Often does not seem to listen to what is being said to him or her.
4. Often does not follow through on instructions and fails to finish school work, chores, or duties in the workplace (not due to oppositional behavior or failure to understand directions).
5. Often has difficulty organizing tasks and activities.
6. Often avoids, expresses reluctance about, or has difficulty engaging in tasks that require sustained mental effort, such as school work or homework.
7. Often loses things necessary for tasks or activities (such as school assignments, pencils, books, tools, or toys).
8. Is often easily distracted by extraneous stimuli.
9. Often forgetful in daily activities.
AD/HD Predominantly Hyperactive-Impulsive
What was once called ADD with hyperactivity has been renamed AD/HD predominantly hyperactive-impulsive type. For a diagnosis to be made of this condition, at least some of the following symptoms must have been present before seven years of age; at least six of the symptoms must have been present for at least six months; they must interfere with normal functioning in academic, social, and academic skills; they must appear in two or more settings; and they must be inconsistent with the child’s developmental level:
1. Often fidgets with hands or feet or squirms in seat.
2. Leaves seat in classroom or in other situations in which remaining seated is expected.
3. Often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).
4. Often has difficulty playing or engaging in leisure activities quietly.
5. Is always “on the go” or acts as if “driven by a motor.”
6. Often talks excessively.
7. Often blurts out answers to questions before the questions have been completed.
8. Often has difficulty waiting in lines or awaiting turn in games or group situations.
9. Often interrupts or intrudes on others (for example, butts into others’ conversations or games).
AD/HD Combined Type
Diagnosing this mixed subtype of AD/HD requires that a child meet the criteria for both inattentive and hyperactive-impulsive subtypes. Moreover, at least some of the symptoms must have been present before seven years of age; they must appear in at least two different settings (at school, at home, in recreational or social settings); they must clearly impair social and academic functioning; and they must not be due to other specified developmental or psychiatric disorders.
If you are a parent, it is important that you be well-prepared in providing documentation of your child’s behavior, that you be able to describe his behavior and performance in various situations, and that you consider other factors that may be causing your child to perform as he does. Professionals will use the symptoms listed above—together with other information from physical exams and reports from teachers and observed behavior—to determine if your child has AD/HD.
What’s Normal, What’s Not
All children are overly active some of the time. Many also have short attention spans and may act without thinking. Several factors, however, distinguish youngsters with AD/HD from those who do not have this problem.
First, it’s true that many of these behavior patterns are developmental in nature. In other words, they appear in children at certain ages, but youngsters typically outgrow them. In children with AD/HD, however, many such behavior patterns persist. These youngsters either do not outgrow the behavior or the behavior disappears for a while, then returns.
Second, children with AD/HD often exhibit more such behavior than do children without the disorder. During a typical child’s early years, for example, the majority of parents deal with a few of these behavior patterns. But parents of children with AD/HD deal with far more such behavior and for a much longer period of time.
Finally, parents can usually control a majority of undesirable behavior in children who do not have AD/HD by using good behavior management strategies. Youngsters with AD/HD, however, tend not to respond to most behavior management strategies or show great inconsistency in their response. A harsh reprimand, time-out, or restriction, for example, may be enough for most children to be convinced to straighten up. But these approaches are not likely to have long-lasting effects on a child with AD/HD.
Describing the Child with AD/HD
Children with AD/HD are not all the same. They may exhibit some characteristics frequently and others less frequently or not at all. Yet, having a clearer understanding of which behavior may be a consequence of AD/HD may help parents to better understand their child and to be less frustrated by their behavior. In a slight departure from the list of specific symptoms presented earlier, consider these descriptions, which characterize the kinds of behavior one most often sees in children with AD/HD:
Fidgets, Squirms, or Seems Restless
Children with AD/HD are often described as “always on the move.” In the classroom, they are the toe tappers or the ones who are constantly fiddling with other objects on or in their desks. They may chew on their collar or gnaw pencils. At home, during mealtime, they may toy with their silverware or food. Children with AD/HD also often demonstrate new and creative ways of sitting in a chair: on their legs, with legs propped up on a desk or table, or half-standing and half-sitting.
Has Difficulty Remaining Seated
Teachers report that children with AD/HD are frequently out of their seats for a variety of reasons. They need a drink of water. They need to sharpen a pencil. They need to go to the bathroom. In fact, teachers agree that it’s not unusual to find a child with AD/HD wandering around the classroom for no apparent reason.
At home, a youngster with AD/HD usually eats on the go because he has a difficult time remaining seated for an entire meal. Homework time also suffers, because the child is unable to sit still long enough to complete his assignments. And when it comes to enjoying activities that require participants to sit for any length of time—such as concerts, lectures, and church or synagogue services—parents often resign themselves to the fact that they cannot take their child along. If they do, they spend excessive amounts of time reminding him to remain seated and stay quiet.
Is Easily Distracted
Children with AD/HD lose their concentration very easily if there are sounds or movements around them. Consequently, in school they have difficulty focusing on independent seatwork if, for example, a reading group nearby is making noise, the classroom gerbil is exercising, or a child sitting next to them is wearing a watch with a loud ticking noise. That’s because many youngsters with AD/HD are simply unable to disregard distractions like these.
Homework becomes a chore, as well, when the television or stereo is on in a nearby room, or when people are coming and going near the homework area. Oddly enough, however, children with AD/HD may appear freer from distraction when playing video games or watching television. This is likely due to the multisensory nature (sound, color, and constant action) of these activities. Consequently the ability to pay attention to these activities is not sufficient to rule out a diagnosis of AD/HD.
Has Difficulty Waiting His Turn
Many children with AD/HD can’t wait in line as well as other youngsters of the same age. Some may try to force their way to the front of the line. Others fidget or constantly touch other children or things while waiting their turn, or they may gyrate or dance around in line.
Blurts Out Answers
Children with AD/HD would make ideal quiz show contestants, and they may excel at classroom drills where quick answers are rewarded. But in a structured classroom setting, these children often stand out as being impatient and uncooperative. Unable to muster the self-discipline needed to hold back an answer until they are called upon, children with AD/HD will call out an answer as soon as they think they know it.
Moreover, in some instances, their comments may be totally unrelated to the specific class activity or discussion. This probably occurs because of the associations the child makes in response to a question. For example, the question, “What is the capital of Montana?” may get the child thinking of the family trip to Montana last year, the plane landing in Helena (the capital), their horseback riding excursion at Yellowstone, and the park ranger they stopped to talk to. When the child answers, “the park ranger,” there is no way for the teacher to know that the child’s reply springs from having the answer, though her thoughts have speeded right past the appropriate response.
Has Difficulty Following Directions
Children with AD/HD usually fare better when dealing with a single set of instructions. In fact, many become totally lost when they are given several instructions at one time. Say a parent tells a child to put on her pajamas, brush her teeth, and come back for a “goodnight kiss.” Five minutes later, the child is wandering around aimlessly or engaged in her room playing with her CD player, not having even begun to do what she was told. The same pattern occurs in school. When students are given numerous directions for several worksheets at a time, the child with AD/HD may either remember instructions for the first worksheet but not remember others, or remember instructions for the last worksheet. Consequently, these children frequently appear to be out of touch with what is going on in the classroom. They also have difficulty remembering what they are supposed to do for homework or which books to take home. Even if they write down assignments, the information may often be garbled or wrong.
Has Difficulty Sustaining Attention
A classic sign of AD/HD is the number of incomplete papers the child brings home from school. Children with AD/HD have difficulty completing assignments, and the appearance of their papers is usually a good indicator of the disorder. They may complete the first few problems on a page, but the remainder of the page is blank. Or their papers will look as if they rushed through the work in an attempt to get everything finished without regard to quality or correctness.
On the flip side, some children with AD/HD are so meticulous that they may do their work over and over until it is perfect. But this extra time devoted to perfection often prevents them from completing other important tasks on their to-do list.
Shifts from One Uncompleted Task to Another
Parents of youngsters with AD/HD often describe their children as having difficulty playing by themselves or as moving from one play activity to another without devoting much attention to any of them. Teachers agree. They describe students with AD/HD as very impulsive in learning centers and as likely to discontinue working at a project before its completion. Furthermore, these children often leave remnants of their activities around their desk, the classroom, or the house.
Even when warned to calm down, children with AD/HD have a tough time maintaining a quiet state. They are also easily aroused by other children. As a rule of thumb, the louder and busier an environment is, the louder and busier the child will be. In fact, many parents with just one child who live in a relatively quiet home often have a difficult time believing that their child with AD/HD is as busy and loud in the classroom as the teacher says he is. But after further probing, these parents usually come up with similar descriptions of how their child typically behaves with them outside the home, such as at restaurants or at the mall.
A child with AD/HD is often described as being very talkative and asking questions that are repetitive or that make little sense, “Like an out-of-control tape recorder that is locked on playback at a faster speed than normal,” according to one parent. Some parents may be quick to defend such behavior: “She’s perky, just like her mom,” or, “He’s all boy.” But when it interferes with a child’s success and is combined with other symptoms of AD/HD, it is reason for concern and action.
Interrupts or Intrudes on Others
Parents often describe their children with AD/HD as interrupting them constantly when they are on the telephone or when they are talking to their spouses or friends. Efforts to stop this annoying behavior are generally futile, they say—to the point that parent-child shouting matches frequently ensue. Moreover, because of this tendency not only to interfere with what others are saying but also to try to impose their will on others, children with AD/HD are often unpopular in groups.
Does Not Seem to Listen
Because children with AD/HD have trouble focusing visually and sustaining visual attention on an individual or an activity, people often assume that the child is not listening. On the contrary, many youngsters with AD/HD are still able to comprehend what is going on around them. In fact, teachers and parents are often surprised that the child is able to answer questions or repeat what has been said to him. Children with severe AD/HD, however, may not absorb what is said. In addition, many children with AD/HD may have a limited working memory, so that they cannot retain verbal directions long enough to carry them all out.
Loses or Forgets Things
Children with more severe cases of AD/HD often are so poorly organized that they never seem to know where papers, pencils, articles of clothing, or other belongings were left. They often come home without the books they need for homework, for example, or may not be able to find a shoe they just had in their hand! Nor is it unusual for them to forget to relay important written or verbal messages to their parents from their teachers—or vice versa—or to spend hours doing their homework, then lose their papers before school the next day or forget to turn them in.
Engages in Physically Dangerous Activities
Because youngsters with AD/HD tend to be impulsive, they often act before thinking. For instance, they might run out into a street after a ball without looking, jump from heights without considering potential danger, or ride a bicycle at breakneck speed without considering what is in front of them.
More Clues and Characteristics
Parents and teachers report other behavioral patterns they see at home, in school, and in the community:
Works Better One-on-One Than Independently or in Large Groups
If your child has AD/HD, you may find that homework goes much more quickly if you sit with him while he does it. Left alone to complete his homework—or classwork—a child with this disorder will more than likely be up and down, fidget, daydream, stare out the window, and not finish the work. Even sitting with your child may require constant redirection and hours of dealing with inefficient work skills. However, the fact that your child can do the work if you sit with him indicates his ability to master the material.
Plays Better with Older or Younger Than with Same-Age Children
Parents of children with AD/HD often worry about their child playing almost exclusively with much younger or much older children. Actually, there’s a good reason why this happens. Youngsters with AD/HD are often bossy or pick on other children and, while they may get away with bossing around younger children, same-age peers won’t put up with such a demanding playmate. Older children also tend to be more tolerant of this type of behavior, or the child with AD/HD may control his behavior better among older children for fear of being rejected and losing the status of being able to play with them. In any case, the child is likely to be alienated from his peers and to have more relationships with younger and older children.
A child with AD/HD may also play successfully with just one child. In group situations, however, conflicts are likely to occur. That’s because in most social situations, children with AD/HD have difficulty reading social cues. They simply don’t recognize when others are sending nonverbal messages that say, “You’re coming on too strong,” or, “Back off.”
Has Difficulty Copying Words from the Chalkboard or Book to Paper
The process of transferring information requires looking, retaining in working memory what was seen, then unloading that information onto paper. This can be a difficult process for children with AD/HD, since fleeting attention limits the amount of information that can be stored in memory from a single glance. Even when information is stored, it may be done in a faulty manner, or there may be errors (spelling mistakes, reversing information, adding or deleting information) in transferring the information from memory to paper. For youngsters with AD/HD, transferring information accurately requires many more glances at the source material, but these children are likely to tire of this quickly and may very well just write down what they think they saw.
Knows Material Well While Studying, Then Performs Poorly on a Test
There are few situations more frustrating to parents than when, the night before a test, their child appears to know the material very well, yet the next day takes the test and scores a 42. What went wrong? During studying, the child’s attention is focused with the help of a parent. During a test, however, many more distractions are present in the classroom, and the child is on his own staying focused and recalling information. And often he can’t. In addition, the test may take place as long as twenty hours after the child has studied for it, so many distractions have intervened since then.
Spelling tests are frequently an exception because a teacher typically calls out a word, then waits for each child to finish writing it. For this reason, many children with AD/HD perform better on spelling quizzes than they do on other kinds of tests. Moreover, teachers often help children organize the way they study spelling: writing the word several times on Monday, alphabetizing them on Tuesday, using them in sentences on Wednesday, and reviewing them on Thursday before the test on Friday.
Nevertheless, once children start to daydream or become distracted in the midst of a spelling test, they have a hard time regaining their place and often leave out many words or don’t complete the last parts of the test.
Responds Inconsistently to Appropriate Incentives
What often stymies parents and teachers about children with AD/HD is the consistency of their inconsistencies. For example, on one occasion, a child might work quickly at cleaning up his room in order to go swimming with his friends. In a similar situation at a different time, however, his parents may find him in his room playing instead of cleaning up. And if asked, “Don’t you want to go swimming?” his face might light up as if to say, “Why, of course! Why would you ask such a silly question?” But he also would have to be reminded again about what he needs to do before he can go swimming.
Shows Evidence of Poor Self-Esteem
The way a child feels about himself is reflected in the look on his face, his body language, his motivation to participate in various activities, and the things he says. Indeed, many children with AD/HD look sad and choose not to participate in extracurricular activities. Often this is related to feelings of inadequacy and fear of more failure. More distressing to parents, however, is a child’s claims that he is stupid, that nobody likes him, that he hates his parents, or that he’d rather be dead.
An analysis of these statements is complicated. The child who knows that he understands his school work, but continues to make poor grades, thinks he is stupid in spite of what others tell him. This is particularly true when he sees other children getting better grades than he does, even when he is sure that he knows more than they do. Similarly, if the children he wants to play with reject him, his perception is that “nobody” likes him, even when an adult assures him that he does have close friends. From the child’s perspective, it’s a pretty lousy life. And, if a child shuts down his engine in the early grades due to lack of success, it is very difficult to get it restarted again later.
Is Significantly More Active Than Children of the Same Age
This characteristic identifies children with the hyperactivity component of AD/HD. In young children, hyperactivity may be manifested in constant movement from one place to another, only a few hours of sleep at night, restless sleep, and an inability to sit in one place for more than a few seconds. Hyperactivity tends to decrease as a child approaches adolescence; however, it is typically replaced by more subtle excess movements. As a child gets older, for example, hyperactivity may be characterized more by excessive fidgeting and restlessness. Furthermore, older children often learn to compensate through internal controls, either as a consequence of improved neurological organization or because of increased motivation due to peer pressure or other social or tangible incentives.
Demonstrates Poor Penmanship
Penmanship is a skill that requires a plan for what one wants to write, an understanding of how to put that information on paper, and an ability to transfer that plan to paper. Many children with AD/HD have a great deal of difficulty mastering one or more of these steps. While formulating a plan for what they want to write, for example, they may become distracted and unable to maintain in memory the complete content of what they want to put on paper. Or they may have missed the instructions regarding how it is supposed to go down on paper. Finally, the attention required to the details of putting something down on paper may be so poor that neatness is compromised. Consequently, writing that may start off looking good while attention is high can quickly deteriorate as the child proceeds with the writing task. Letters may become less legible, and the spacing, size, or positioning of the letters and words may be poor. In short, the child may be able to concentrate on the neatness or the content, but not both simultaneously.
Lies or Makes Up Stories
Parents and teachers often report utter frustration with children who have AD/HD because they lie about obvious events. For example, the teacher may see a child take an object from another child’s desk and put it in her desk. When confronted, the child denies that she took it and tends to blame someone else or shrug her shoulders. Many children with AD/HD will deny that they have homework, that the teacher told them about a test, or that they took something from school that did not belong to them, for example. While this kind of behavior is characteristic of many young children, appropriate consequences typically cause the behavior to disappear. When the behavior persists in a child with AD/HD, however, it is probably related to the child’s impulsiveness. In other words, a youngster with AD/HD will act on an idea that comes to mind without becoming conscious of it. For example, he may see a nice pencil sharpener on another child’s desk and say to himself, “I sure wish I had that pencil sharpener.” The next thing the child knows, it is in his hand or on his desk, and he never is aware of the process of taking it from the other child’s desk!
It is this same lack of conscious monitoring of behavior that causes children with AD/HD to blurt out embarrassing and outrageous statements or to be reported for having their hands all over other children. As a consequence of AD/HD, the child does a poor job monitoring his own behavior and, therefore, may be totally unaware of what he says or does in many instances.
About two-thirds of children with AD/HD also exhibit one or more other conditions. Many of these are worrisome to parents—and rightfully so. Later in this book, however, we will talk about treatment approaches for AD/HD as well as these coexisting conditions, which should provide more optimism that good outcomes are possible with early diagnosis and prevention.
The most common coexisting psychological conditions with AD/HD are: oppositional defiant disorder (ODD) and conduct disorder (CD), learning disabilities, mood disorders (including depression and bipolar disorder), anxiety disorder, and tics.
The child with ODD argues with adults, blames others, refuses to follow rules, gets angry easily, and frequently annoys others. ODD is found in about 40 percent of children with AD/HD.
Conduct disorders affect about one-quarter of children with AD/HD and are characterized by behaviors usually associated with juvenile delinquency: destroying property, lying and stealing, truancy, and hurting people and animals. Because symptoms often worsen as the child gets older, early identification and treatment is critical. The combination of AD/HD and CD is particularly troublesome, in that children with these untreated coexisting conditions have a very high risk of social and emotional problems in later years. They also are twice as likely to have reading problems than children who have only AD/HD.
As many as half of children with AD/HD also have a learning disability—usually defined as a significant difference between two or more areas of achievement (such as reading, math, or writing) or between an area of achievement and intelligence. The problem is, it’s often difficult to determine whether this is a separate problem or one directly related to AD/HD.
Reading disabilities are usually the first to show up, with delays usually occurring in the first and second grades. That’s because unlike simple math skills—where children can use their fingers or objects to solve problems—reading requires that a child recognize letter symbols, learn their names and corresponding sounds, and be able to retrieve and combine them on demand. Actually, the foundation for learning to read begins to form well before a child enters kindergarten. The typical child takes notice of shapes, letters, and words and shows an early curiosity about them. The young child with AD/HD, however, may not focus long enough to construct that solid foundation of prereading skills.
Math difficulties, on the other hand, don’t usually surface until the introduction of word problems and multiplication and division. That’s because these skills require more complex mental calculations and information retrieval than simple addition and subtraction, which a child may have accomplished using his fingers, stroke marks, or objects.
Regardless of subject, only after successful treatment to control the symptoms of AD/HD can one determine if the child has a true learning disability or simply has a learning problem related to the AD/HD.
Mood problems are common, as well, in children with AD/HD. Many of these youngsters appear sad much of the time or show frequent and dramatic swings in mood. Much like learning disabilities, depression may also be a separate problem (it does tend to run in families), or it could be related to the symptoms of AD/HD. For example, a child who is bossy and impulsive is not likely to have many friends. And if being a social outcast is accompanied by disappointing report cards, conflicts at home, and low self-esteem, it’s easy for a child to feel sad, rejected, and unsuccessful. As a result, he may say that nobody likes him, or that he would rather be dead.
As a child suffering from AD/HD or depression—or both—gets older, he may be more and more reluctant to participate in group activities. He may also have trouble sleeping or eating and show little enthusiasm for activities he once enjoyed. Some teenagers react to all this by adopting different styles of dress; others might undertake body piercing or even begin cutting themselves.
As many as one in five children with AD/HD also has bipolar disorder. At younger ages, this disorder is characterized by rapid mood changes with no clear reason. The child may act sad and irritable or be combative and aggressive. Unlike adults, in whom cycles of depression and mania can last for days or weeks, children cycle much more rapidly. While mania can be very debilitating as a child gets older, the combination of AD/HD and mania is particularly problematic and can interfere with success in every aspect of life.
About one in ten children with AD/HD also has an anxiety disorder together with AD/HD. While most individuals experience some anxiety and nervousness in particular situations, a child with an anxiety disorder worries excessively, has many unwarranted fears, and feels stressed out or tense much of the time. Some children experience panic attacks, characterized by difficulty breathing, dizziness, a pounding heart, sweating, and fearfulness. Not surprisingly, children with anxiety disorders and AD/HD have more problems in school, at home, and in the community than children who have only AD/HD.
A small number of children with AD/HD also have tics or Tourette’s syndrome. Tics are nonpurposeful movements—such as neck stretching, eye scrunching, and lip licking—that occur over and over, and that the child cannot control. Tourette’s syndrome is a combination of tics and uncontrolled vocalization, such as sniffing or throat clearing. Stress and fatigue may increase the frequency of the tics.
Some children with AD/HD have obsessions and compulsions, as well. Obsessions are persistent unpleasant thoughts or feelings that interfere with the ability to function normally. Compulsions are ritualistic activities children feel they must engage in before moving on to another activity or continuing with what they were already doing. For example, some youngsters may feel compelled to wash their hands repeatedly after touching a certain object, are driven to follow a certain pattern of behavior before leaving the house, or must place objects in a particular order before feeling at ease. Others must have their food arranged in a certain way on their plate, or they must eat foods in a certain order.
Some children with AD/HD may have a very low tolerance for loud noises or other stimuli. For example, their socks must fit a certain way, or they may be unable to wear shirts with labels that rub against their skin “the wrong way.”
Many youngsters with AD/HD are persistent bedwetters, a condition called enuresis. While only about 10 percent of children in the normal population continue to wet the bed at night beyond the age of six, this problem tends to be over-represented in the population of children with AD/HD. Moreover, the most common behavior approaches used to curb bedwetting—reducing fluid intake after dinner, having the child empty his bladder before he goes to bed and again before his parents turn in—yield little consistent success in children with AD/HD. Even use of the popular bell and pad method is only moderately successful for these youngsters and may only add to the stresses the child and his family are experiencing. With this method, a special pad is placed under the sheet. When it is wet by urine, a bell connected to the pad rings. This awakens the child, who can then get up and complete urinating in the toilet.
As mentioned earlier, many children with AD/HD also show signs of depression that may be related to feelings of despair brought on by inability to meet their own—or others’—expectations. It is painful for parents to see their children so unhappy. It is even more painful for the child to live a life characterized by feelings of helplessness and hopelessness. That’s why careful diagnosis of AD/HD is necessary. It can help determine if a child’s depression has resulted from a specific event—such as a parental divorce, death of a family member, or a serious fight with a best friend—or from more global factors such as continual underachievement as a result of symptoms of AD/HD.
Lisa’s story is an excellent example. Lisa is a fourth-grader who consistently makes A’s and B’s on her report card and who rarely has her name put on the board for misbehaving. Lisa is also a popular child with lots of friends. For the past week or so, however, Lisa has made low D’s on the majority of her tests and has failed to turn in her homework most mornings. Her name has been put on the board at least twice every day for talking back to the teacher, and on the playground she has been repeatedly reprimanded for pushing and yelling at her friends.
Lisa’s teacher tried talking to her, but Lisa insisted that nothing was wrong. When the teacher threatened to call Lisa’s parents, the child became defiant. “Fine,” she said. “I don’t care. They’re not home anyway!”
When her teacher called Lisa’s parents to schedule a conference, a baby-sitter reported that they were indeed out of town. Lisa’s grandmother—with whom the child had been very close—had just died, and Lisa’s parents had gone out of town for two weeks to attend the funeral and to help take care of Lisa’s grandfather.
Once the teacher approached Lisa about her grandmother’s death, Lisa burst into tears and apologized for misbehaving and not doing her work. The school counselor spent several hours with Lisa over the next few weeks and Lisa soon returned to her old self.
Children with AD/HD are a diverse group. They are affected by biological, hereditary, and environmental factors that researchers are still trying to unravel. Many children have problems beyond AD/HD, which may have further dramatic impact on their successful performance in school, at home, and in the community—both in the near and long term.
It’s up to parents to be alert to the first signs and symptoms of AD/HD—and experts agree these may show up as early as infancy and toddlerhood in the form of frequent temper tantrums, severe separation anxiety, constant refusals to go to sleep, and other unruly behavior. Yet, sadly, studies show that most youngsters go a full decade before they are properly diagnosed with this treatable disorder.
Successful treatment of AD/HD requires that a team of professionals work
together, which can be overwhelming for parents.
But the good news
is that early diagnosis, intervention, and treatment have been shown to
help these youngsters overcome their
problems and achieve success
in all areas of their life.
Excerpted from AD/HD: Helping Your Child by Warren Umansky, Ph.D. and Barbara Steinberg Smalley. Copyright © 2003 by Warren Umansky, Ph.D. and Barbara Steinberg Smalley. All rights reserved. Posted with permission of TWBookmark.com. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.