Attention deficit hyperactivity disorder (ADHD) affects about 2–5% of school age children. It is a complex behavioural disorder typified by problems paying attention, excessive activity and difficulties in exercising self-control. Young children with ADHD often have problems in settings such as early years services, nursery classes or at school where their difficulties in paying attention may result in poor achievement and disruptive behaviour. Martin Hodgson describes the background to the condition and reviews support options for early years providers.
The symptoms of ADHD tend to be noticed at an early age. They fall into two categories:
Hyperactivity and impulsiveness.
Most children with ADHD will show both of these, to some degree. However, some may display one and not the other.
The main signs of inattentiveness include:
short attention span
being easily distracted
making careless mistakes
appearing forgetful or losing things
being unable to stick at tasks
appearing to be unable to listen to or carry out instructions
constantly changing an activity or task.
The main signs of hyperactivity and impulsiveness include:
inability to sit still, especially in calm or quiet surroundings
constantly squirming or fidgeting
being unable to concentrate on tasks
excessive physical movement such as inappropriate running or climbing
being unable to wait in turn
trouble quietly playing or engaging in leisure activity
acting without thinking
interrupting conversations or answering questions before they are finished
having little or no sense of danger.
All children go through phases where they are restless or inattentive, or even badly behaved, and many signs of impulsiveness and boisterousness may be normal in toddlers. However, in ADHD the symptoms are seen as more severe and can cause significant problems in a child’s life. The effect can be most clearly seen at nursery or school where performance and social functioning may become a serious concern and the child begins to fall behind in their development.
Symptoms often lessen in adolescence and 1 in 3 children with a diagnosis of ADHD can grow out of their condition and not require any treatment when they are adults.
The exact cause of ADHD is unknown. ADHD may run in families and it is believed that in some cases genetic factors may be involved, modified by environmental factors. For instance, premature birth, low birth weight, or a mother drinking alcohol or smoking during pregnancy are all associated with the development of ADHD traits although the evidence is not conclusive.
ADHD is more common in children with learning difficulties but can occur in those with any intellectual ability. Research involving brain scans has suggested that certain areas of the brain may be smaller or larger in those with ADHD.
Boys are three times more likely to suffer from ADHD than girls. There is no evidence that ADHD is the result of poor parenting although the parents of children with ADHD can be taught to better manage their child’s behaviour.
Parents who suspect that their child might have ADHD should see their GP. The GP will not be able to diagnose ADHD but will discuss their concerns and refer them for a specialist assessment if necessary. The GP will want to know about:
how the symptoms affect the day-to-day life of the child and the family
where the symptoms occur
any family history.
The GP may advise a period of observation to see if symptoms improve. They might also suggest a parent training or education programme.
Where the GP believes that further assessment is required, they will refer the child to a specialist, usually a child psychiatrist or paediatrician. A referral is more likely where symptoms are having a serious impact on day-to-day living.
Diagnosis is hard, especially in very young children, and great care should be taken in getting a diagnosis right. A child psychiatrist or paediatrician will generally diagnose ADHD if a child displays six or more symptoms of inattentiveness, or six or more symptoms of hyperactivity and impulsiveness. The symptoms must have started to show before the age of 12 and the child must have been displaying symptoms continuously for at least six months in at least two different settings. These guidelines rule out symptoms that are just part of a difficult phase or may be accounted for by another condition.
Most cases are diagnosed when children are 6–12-years-old.
Official guidance on the diagnosis and management of ADHD has been published by the National Institute for Health and Care Excellence (NICE). CG72Clinical Guideline specifically covers treatment options for pre-school children.
ADHD is closely related to a number of other conditions which may need to be excluded during diagnosis. Some children may display one or more of these in addition to ADHD:
autistic spectrum disorder (ASD)
Specific learning disabilities such as dyslexia, language problems and difficulties with handwriting are commonly associated with ADHD. A disorder known as oppositional defiant disorder (ODD) is also recognised where a child displays a pattern of angry or irritable behaviour toward people in authority.
Help and treatment
ADHD is treated using a mixture of medication and therapy. The aim will be to help the child achieve his or her potential and live as normal a life as possible. The majority of children who receive specialist treatment will benefit significantly.
Therapy options for young children usually consist of programmes designed to help parents learn specific ways of talking to their children which are effective in improving their attention and behaviour. Parents learn more about behaviour management and about improving family relationships. Some children will be offered psychotherapy and family therapy.
Behaviour therapy can be used with ADHD. This consists of using rewards to encourage a child to learn new behaviours.
Medication for ADHD is prescribed to help a child to concentrate, to be less impulsive and to feel calmer. Medication is prescribed by specialists and monitored by the child’s GP. Not all children with ADHD will need medication.
There is no evidence of a link between food and ADHD. However, some parents report an improvement in their child’s condition when certain foods are avoided. These include caffeine, chocolate, fizzy drinks, cordials and artificial colourings. Food options can be discussed with a dietician.
Having a child with ADHD can be exhausting and stressful for parents who are often encouraged to seek help from local and national support groups. Each area also has a child and adolescent mental health service (CAMHS) which includes specialist nurses and psychologists.
There is a general lack of understanding in society about ADHD and some parents feel blamed by others and accused of failing to control their child. The National Attention Deficit Disorder Information and Support Service (ADDISS) provides further information about ADHD and can help with contacting local support networks.
ADHD in early years settings
In an early years setting, parents should be encouraged to inform staff about any conditions such as ADHD and about any treatments a child may be receiving.
Parents are the “experts” in the care of their child and early years staff should be as supportive as possible. The special educational needs co-ordinator (SENCO) for the service should be involved and staff should discuss options with the parents. An individualised support plan for managing the child’s behaviours should be drawn up which is regularly reviewed with the parents and, where possible, with healthcare professionals involved such as CAMHS nurses. Behavioural parenting plans should be supported and any medication or diet regimes followed.
Staff may find certain general approaches helpful with most children with ADHD:
give simple specific instructions
stand close and talk to children slowly and calmly
set clear boundaries
give praise when a child has done what is required
watch children carefully for signs of frustration and boredom and intervene at an early stage
break tasks into small time spans, such as 15–20 minutes
give children time and activities to spend their energy.
Providing adequate support to build confidence and help in developing social interactions is a key approach. Effective communication between early years staff and parents is also vital to ensure that a consistent approach is taken, especially where a child exhibits very challenging behaviour.
The ADDISS website contains a wide range of information about ADHD. ADDISS provides training and support for parents, sufferers and professionals in the fields of ADHD and related learning and behavioural difficulties.