11  Attention-Deficit/Hyperactivity Disorder

Mr. and Mrs. Wynne are concerned about their son, Marcus. He is a handful sometimes, especially in church, where he just cannot seem to keep still, or in the grocery store, where he loves to run up and down the aisles. They know that it’s important for him to be active, but Marcus is in the first grade now and his parents worry that his behavior might cause problems in school. They decide to meet with his teacher, Mrs. Collins.

They share their concerns with Mrs. Collins, and she explains that she has noticed that Marcus has difficulty regulating his attention during the day, like stopping one activity to shift his focus to another or finishing his classwork in the same time as the other students. Mrs. Collins has been keeping data on this, which shows that Marcus’s behavior is not improving over time. She encourages his parents to see their son’s pediatrician.

Mr. and Mrs. Wynne talk to Dr. Lee about Mrs. Collins’s observations and what Marcus is like at home. After talking extensively with Mr. and Mrs. Wynne, reviewing the data shared by Mrs. Collins, and spending time playing with Marcus, Dr. Lee tells Mr. and Mrs. Wynne that she is comfortable giving Marcus a diagnosis of attention-deficit/hyperactivity disorder (ADHD).

Mr. and Mrs. Wynne are surprised at first, then apprehensive. They have heard about children with this diagnosis and don’t want to put Marcus on any medications. Dr. Lee agrees that medication is not the right treatment at this time, and she encourages them to work with Marcus’s school to teach him how to regulate his own behavior and provide him with some tools that will help him in school and at home.

When Mr. and Mrs. Wynne tell Mrs. Collins about the diagnosis, she reaches out to one of her colleagues, Mr. Poivre, for suggestions on modifying the classroom activities and routines to help Marcus. On his advice, Mrs. Collins changes the class schedule to make it very predictable every day. She also adds a large visual timer on the SMART board so that everyone can see the red circle getting smaller and smaller to signify that time is almost up for an activity. Another idea she implements is to have the class return to a home base after each activity to review and to check what’s next on the schedule, then celebrate their finished task with a 2-minute dance party for everyone to get their bodies moving.

Mr. Poivre also gives Mrs. Collins some ideas to help Marcus specifically, like breaking down each assignment into smaller chunks and giving him a checklist so he can mark off when he completes each part. Marcus loves this, as it gives him a sense of accomplishment and helps him finish tasks almost as quickly as the other students.

Seeing how these changes help Marcus in school, his parents find some apps for visual timers on their phones and start to use checklists in the morning to help him get ready for school and in the afternoon for his homework and chores. They even discover how fun it is to have a few dance parties of their own at home, too!

As Marcus’s parents understand, all young children learn actively through moving and exploring the environment as well as manipulating and experimenting with objects to construct their own understanding about the world around them. All children get restless, have difficulty paying attention, daydream, or act impulsively at times, but as Mrs. Collins noted about Marcus, children with ADHD have difficulties with some of these behaviors more frequently than other children do (ED 2008). By age 4, most children begin to develop the ability to self-regulate—that is, to focus their attention on a person or an activity, control their emotions, and manage their behavior and impulses to be part of a group setting—but children with attention disorders have trouble with this skill.

ADHD symptoms can persist for a long time, sometimes into adulthood. Although working with medical professionals and families to figure out when there is a true attention problem can be challenging, it’s very important to identify a child who needs intervention. Early identification and support can help a child learn to manage his behavior and maximize his chances for success.

What Is ADHD?

ADHD is a medical diagnosis that impacts about 5 percent of the population (APA 2013); the CDC estimates that 11 percent of children ages 4 through 17 are affected (Visser et al. 2015). According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA 2013) there are three types of ADHD:

»  Inattentive ADHD is usually identified in children who are easily distracted or very inattentive. This type is what people commonly refer to as ADD (attention deficit disorder) since the child usually shows no signs of hyperactivity or impulsivity. A child with inattentive ADHD doesn’t seem to listen to directions or misses important details, or she is unorganized and unable to find her possessions or the materials she needs.

»  Hyperactive-impulsive ADHD is usually identified in children who are restless and reckless but not inattentive. A child with hyperactive-impulsive ADHD may fidget and have difficulty sitting still; he may constantly interrupt conversations and speak out of turn.

»  Combined ADHD describes children who demonstrate inattention, hyperactivity, and impulsivity. You may notice a child who is unable to remain seated for a long period of time, is forgetful, and has difficulty following through on a task or assignment.

Many children are diagnosed with ADHD when they are in the early primary grades, although signs often appear much earlier. As many as 40 percent of children who eventually receive a diagnosis of ADHD show signs by age 4, making ADHD the most common mental health disorder that is identified at that age (Visser et al. 2015).

ADHD is considered a health impairment under IDEA if it impacts a child’s educational performance. Some children who don’t qualify under IDEA but need extra help in the classroom might receive services under Section 504 of the Rehabilitation Act of 1973 (Public Law 93-112). This law defines disability more broadly than IDEA and prohibits any program that receives federal funding assistance from discriminating against people with disabilities. ADHD is not a learning disability (Cortiella & Horowitz 2014). Chapter 12 discusses learning disabilities.

Possible Reasons for ADHD

ADHD is not a problem caused by lenient or ineffective parents or schools or by too much screen time. Children with ADHD do not just need consistency or a firm hand and consequences to “get over” their ADHD and improve their behavior.

ADHD is a biological condition (APA 2013). While there is no single cause, there is a strong genetic component to ADHD, which means that it often runs in families. Some environmental factors, such as exposure to maternal smoking and drinking in utero or to pesticides or lead during infancy, may play a role in the development of ADHD in some children (APA 2013). Premature birth may also put a child at risk. Research is ongoing to help determine how biological and environmental factors might work together to cause the condition.

Impact of ADHD on Development and Learning

Attention disorders impact the way children interact with their environment and peers and can inhibit the way they learn. Sometimes the child is labeled a troublemaker or a problem kid. A child who struggles with inattentiveness and distractibility may have trouble hearing and following directions or focusing on an activity or lesson and completing it. He may constantly misplace things—his shoes, his homework—causing frustration for himself and others. His impulsiveness can lead to interrupting others, having difficulty taking turns, lashing out at others, or getting into unsafe situations. All of this can aggravate adults and peers, and a child with ADHD often has trouble gaining the acceptance of others, resulting in low self-esteem (Mayo Clinic 2016a). Because children with ADHD often act younger than their age, they may find it difficult to form friendships with their same-age peers; many gravitate to children who are younger than they are.

Identifying ADHD

When a child has a difficult time transitioning from more active times of the day to less active times, is always on the go and can’t settle down, or exhibits other behaviors outside the norm, some adults assume that it must be ADHD. There are other conditions with similar symptoms, however, and a medical doctor—who must do a full evaluation to determine whether a child has ADHD—usually explores and rules out other possible conditions before diagnosing ADHD. These include undetected seizures, hypothyroidism, trauma, learning disabilities, problems with motor or communication skills, and psychological or behavioral disorders like anxiety and bipolar disorder (Bhatia 2016; NIMH 2008).

A diagnosis of ADHD should follow a thorough medical exam and complete review of medical history, a checklist rating of the symptoms, and input from parents and teachers about the child’s behaviors at home and school. The child’s symptoms must cause impairment across more than one setting; if the child has difficulty only at school or only at home, there is likely something else occurring (Subcommittee on ADHD 2011).

The American Academy of Pediatrics (AAP; Subcommittee on ADHD 2011) discourages pediatricians from diagnosing ADHD in children younger than 4 years old. This is largely because it is difficult to distinguish between a very active toddler or preschooler and one who has ADHD (MacDonald 2015). However, signs of ADHD can appear early, and parents, teachers, and doctors often go back to review those early signs and symptoms when considering an initial diagnosis of ADHD. Although the AAP offers guidelines for diagnosing children as young as age 4, many doctors will not do a full evaluation for ADHD until the child is school age (Subcommittee on ADHD 2011).

ADHD symptoms in preschoolers. The following signs, if present for more than six months, may indicate that a 3- or 4-year-old may have ADHD (Kennedy Krieger Institute 2012):

»  Delays in physical development: Unable to hop on one foot

»  Risk taking: Shows little or no fear in dangerous situations, sometimes resulting in serious injury. Befriends strangers easily, with no fear or caution.

»  Short attention span: Cannot play for longer than a few minutes, leaves the activity quickly, or refuses to participate in lengthier activities. Unable to sit without squirming, frequently needs to move.

»  Difficulty making similar-age friends: Louder and noisier than other children they are playing with. May show aggressive behavior when playing with peers.

ADHD symptoms in school-age children. Teachers are often instrumental in identifying a child’s symptoms, such as the following (Bolyn 2015):

»  Inattention: Needs daily reminders to complete his classwork. Has a hard time concentrating on an activity that he does not enjoy.

»  Being impulsive: Interrupts others when they are talking and has a hard time following rules. Makes decisions and acts without thinking things through first.

»  Being hyperactive: Has a hard time staying still all day; constantly in motion, like tapping her feet or wiggling in her chair.

Treatments and Therapies for ADHD

Both medical and nonmedical treatments are used to help children with ADHD. Professionals in many different fields may be involved in a child’s treatment, including physicians, psychologists, social workers, therapists, and educators.

Medication

For many years, a common treatment for ADHD symptoms has been the use of prescription stimulant medications. These increase levels of chemicals in the brain, particularly dopamine, which are often lower in children with ADHD (Cleveland Clinic 2013). Between 70 and 80 percent of school-age children diagnosed with ADHD take a stimulant medication, such as Ritalin or Adderall (Visser et al. 2015). Nonstimulant medications are also available.

Many families and teachers have found that these medications give short-term help to school-age children, enabling them to sit still and concentrate better in school. However, there is no long-term evidence that academic achievement and behavior are changed by taking medication for ADHD, and many children experience significant side effects like loss of appetite and insomnia (Visser et al. 2015). Strategies that focus on helping a child change her behavior, on the other hand, can give her skills that will benefit her long term.

Nonmedical Treatments for ADHD

Nonmedical strategies focus on ways to change the environment, routines, and expectations to accommodate children’s needs, rather than trying to make children fit into the current structure of the classroom or home.

»  Behavioral supports. A system of positive behavior supports, which includes a solid structure of predictable schedules, routines, and expectations, is often the most effective short- and long-term strategy for young children. You might give a child a report card each day that shows how well he met his goals, like finishing his homework or speaking only when it’s his turn. When he meets his goals, he gets a reward.

»  Social skills supports. Intentionally teach the specific social and emotional skills children may not have yet. You can manipulate how routines or activities are done so that, for example, two students must collaborate as a way to practice problem solving (Lentini, Vaughn, & Fox 2005). When children learn to understand their own and others’ emotions, handle conflicts, problem solve, and develop relationships with peers, their challenging behavior decreases and their social skills improve (Fox & Lentini 2006).

»  Supports at home. Parents can help their children regulate their behavior by having clear rules; using praise and rewards when children follow the rules and providing clearly understood and reinforced consequences when they don’t; providing predictable routines; helping children manage their time and possessions; and giving simple instructions. When teachers and families share information about how a child is doing and use similar strategies at home and school, the child is more likely to be successful.

Children with ADHD often hear what they’re doing wrong. Remember to build on children’s abilities and give them positive encouragement when they’re doing well!

Sensory Processing Issues

You probably know at least one child who can’t seem to get enough of jumping or swinging or bouncing, who is always moving some part of her body, who has to touch everyone and everything, who often gets hurt but seems unaffected by pain. Or a child who can’t stand wearing his blue shirt with the itchy tag, who hears every background noise that no one else pays attention to—the air conditioner humming, fluorescent lights buzzing—and is driven crazy by it.

Many of these children have sensory processing issues. They react strongly to information coming in from their senses—touch, sight, hearing, smelling, and tasting, plus the vestibular (sense of balance/dizziness) and proprioceptive (knowing your body position and where your body is in space) senses—in ways most children don’t. They may be oversensitive, seeking to avoid stimulation because it’s overwhelming, or under-sensitive, craving an experience that gives them that stimulation. They may be both.

What Are Sensory Processing Issues?

The brain receives all kinds of messages from each of the senses, and the brain interprets these messages to help us make meaning from them. Children who have sensory processing issues often aren’t able to filter out less important information, or they have trouble organizing information coming in from multiple senses at once (Kranowitz 2016). Some children process all of the information equally until they become overloaded with sensory messages and are unable to make sense of any of them.

Children may have problems processing information from just a few senses. For example, a child who does not like to eat certain foods because of the texture may have no problems with balance or noisy environments. Reactions are sometimes inconsistent, extreme one day and mild the next (Kranowitz 2016; Leigh 2016).

Many children with delays or disabilities, including those with ASD and ADHD, experience sensory processing issues (Palmer 2014; Reynolds, Lane, & Gennings 2009), and these issues are recognized as a symptom of these disorders. They can also occur in children with no diagnosed disability, although they are not considered a disability under IDEA or a separate disorder in DSM-5. However, these issues can greatly affect children’s learning and behavior, making it difficult for them to feel secure, concentrate, and socialize.

What Does a Sensory Processing Issue Look Like?

Sensory issues are different for each child. Children who are very sensitive to stimulation may show defensive behaviors like these:

•  Refusing certain food textures

•  Showing distress when their diaper or clothing is changed

•  Not wanting other people to touch them

•  Being extremely bothered by bright lights and loud sounds, like sirens or a vacuum cleaner, or even subtler sounds like a refrigerator hum

•  Avoiding or becoming uncomfortable in large, noisy groups

•  Balking at transitions to a different activity or place

•  Avoiding elevators, amusement park rides, or even car rides because they get motion sickness easily

Children who are under-sensitive to stimuli may compensate for their need for more stimulation by seeking it out. With these children, you might see behaviors such as the following:

•  Wanting to be swaddled, have heavy blankets, or tight pajamas for sleeping

•  Needing to be rocked, bounced, or have their back rubbed to get to sleep

•  Frequently touching things or people, not understanding boundaries

•  Wanting and giving tight hugs

•  Fidgeting with something in their hands; trouble sitting still

•  Seeking out thrill rides, wanting to go fast, spin, or be upside down; not getting dizzy (Child Mind Institute 2017b; SPD Support 2017)

Because sensory processing issues are not considered a separate disorder, identifying the problem and finding help can be difficult for families. Occupational therapists are generally the ones to evaluate a child and may provide a diagnosis of sensory processing disorder based on assessment tools, observations of the child’s functional activities, and conversations with the child’s family and teachers.

Strategies for Therapy and the Classroom

An occupational therapist may design a therapeutic approach—known as sensory integration therapy—to help a child learn to integrate and regulate sensory information. The therapist works with a child on activities like spinning, bouncing, and deep pressure that is calming. Although no studies prove that sensory integration works for children, many families do see improvement with therapy (Child Mind Institute 2017c).

Here are a few things teachers and families can do to help children be more comfortable and successful in the classroom and at home:

•  Keep things active by letting children move whenever possible.

•  Provide security items (blanket, stuffed toy) to help a child learn how to self-regulate in situations that are overstimulating or otherwise causing anxiety (Passman 1977). Let older children keep something in their hands to fidget with.

•  Provide sensory spaces—places in the room where a child can remove herself from overwhelming sensory stimulation. Make a quiet, cozy area with carpeting that makes the child feel more enclosed and reduces stimulation.

•  Make sure the child’s chair fits her, and she can put her feet flat on the floor and rest her elbows on the desk. Some children may need seating options that let them move more, like bouncy balls.

•  Check that overhead lighting is not flickering or buzzing and that noises from the heater and air conditioner are not distracting a child.

•  Have a strategy for large groups, like the lunchroom and assemblies. They may be overwhelming to some children. It may be okay for the child to miss a one-time event or sit near the door or on a quieter side of the room with just a few friends.

•  Use visual schedules to help children prepare for transitions (Child Mind Institute 2017a).

It is important to understand each child’s sensory needs to help her develop the necessary self-regulation and self-soothing skills for home and school. Close collaboration between the child’s family, therapist, and teacher will help provide the support the child needs.

Strategies for the Classroom

Here are some strategies that can help a child with ADHD make positive behavior changes in the classroom:

»  Identify exactly what a child has difficulty with. Can she start an activity just fine, but has trouble following through with it? Does she get distracted by too many materials in her work or play space? Provide supports in those areas where she most struggles.

»  Follow a routine. A structured, predictable routine helps children with ADHD know what to expect. This supports their self-regulation skills.

•  Post a visual schedule for the routines and activities of the day.

•  Have a simple, consistent routine for each part of your day. When a child comes into the classroom each morning, he knows what to do. When a child is done with his classwork, he knows where to put his work.

•  Add a home-base routine to the schedule. For example, when a lesson or an activity is completed, have everyone meet back at the rug or other central location before moving to the next activity.

»  Get organized. Children with ADHD often have problems deciding what’s important and how to prioritize tasks. These skills are part of what is called executive function.

•  Have a place for everything and make sure everything is in its place. A clear system of organization around the classroom makes everything run smoother and helps children be more independent.

•  Use colors to show what is important. For example, folders that are red must go home each day.

•  Give older children a master binder with everything color coded, and teach them how to write down homework assignments.

»  Give directions one at a time. If there’s more than one step to a task, try making each one a separate task so the child has a sense of accomplishment as she finishes each task.

»  Allow plenty of time. Children with ADHD often need more time to complete routines and activities than other children do. Make sure children are not rushed through their routines. Give them plenty of time and advance notice before transitions to make changing activities as smooth as possible.

»  Identify the steps in a process. Children with inattention or impulsivity often skip steps in a process. Teach the child the steps she needs to complete—for example, what to do before leaving at the end of the day. A visual checklist is helpful for teaching these skills.

»  Provide a place to be alone. Sometimes children need to de-stress, and teaching them how to do this for themselves is invaluable.

•  Give children a safe, private place to calm down when needed.

•  Teach the child to use this space when he feels overwhelmed. Do not treat the space as punishment.

»  Set a good example. Keep things positive for the child, and have a set of “dos” that you teach the child instead of always telling her what not to do.

•  Try not to let the child see you stressed and anxious. Show her what you expect her to do in as relaxed a manner as possible.

•  Model the need to take a step back and de-escalate your own feelings.

Supporting Movement and Play with Active Children

Large motor play and movement are not just good for the heart and muscles; they’re also good for the brain. Even light physical activity, such as dancing to music in the classroom or going for a walk outside, can trigger the brain to release the neurotransmitter dopamine—the same intent as the prescription stimulant medications used to treat ADHD (Hamblin 2014; Hillman et al. 2014). Purposely adding physical activities to a child’s day can make her more aware of her own body and how to regulate her movements, which can have a calming effect (Hamblin 2014; Kranowitz 2016).

Here are some additional ideas:

•  Set up obstacle courses where children can go over, under, around, and through objects, focusing on balance and coordination skills. Use bubble wrap in your obstacle course so children can jump on it and pop it!

•  Play games that require following directions and regulating movement, like Twister or Simon Says.

•  Encourage children to throw and catch a ball with you or each other. This engages both the body and the brain, developing a child’s focus and organizational skills.

Summary

Attention disorders are real medical issues, but medication is not always the best solution for young children. Nonprescription interventions—including behavioral, social, and home supports—are usually most appropriate. Changing some routines and activities of your day so children can move and engage their muscles and brains also helps them learn to regulate their own behavior and actions.

Even with supports in place, working with children who display attention issues can be challenging. Remember that children are not acting a certain way on purpose. Helping them learn how to regulate their own behavior will make all the difference to you and them.