How is a diagnosis made?(shows reliance on DSM and ICD subjective checklists)
There aren’t any special DNA tests, blood tests or other laboratory tests for ADHD. Only a child mental health expert (a child psychiatrist, an educational psychologist or a paediatrician) can make the diagnosis, based on the DSM-IV (the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders), or the ICD-10 (its international counterpart). One aim is to rule out any other possible causes for your child’s behaviour, such as language or hearing difficulties, dyslexia, autism, Asperger’s syndrome, epilepsy, obsessive compulsive disorder or depression.
ADHD is the usual term (though it’s sometimes called Attention Deficit Disorder [ADD]), and describes the two different groups of symptoms: hyperactivity (behaviour problems) and attention deficit (learning problems). Most children have a mixture of both types of symptoms, but others have only one type or the other. The term is sometimes written AD/HD to reflect this (as in ‘and/or’). If your child isn’t particularly hyperactive, they may still be diagnosed as having ADHD, but it will be called 'ADHD without hyperactivity'. Girls often have this diagnosis, while boys tend to have both aspects of the problem.
Whoever does the diagnosis will observe your son or daughter carefully and may give them tests to do (for example, psychometric tests and Continuous Performance Tests), which help build a picture of their mental processes. They will also collect as much information as possible from parents, teachers, playgroup leaders, social workers, health visitors and anyone else involved in looking after your child. As a parent, you will probably be asked to complete a questionnaire about your child’s behaviour. Doctors or psychologists will take into account whether there are any other medical reasons for the behaviour, and what else might be going on in your child’s life.
Once they think they know what’s wrong, they will suggest the best available treatment for that particular child. Not all children will be offered the same treatment for ADHD.
What are the treatments?
Ideally, you should get a package of treatments involving behaviour management, counselling or psychotherapy, special help at school, and, possibly, medication. Unfortunately, access to all these forms of help may be limited by lack of funding. On top of any treatment your child is offered, it’s vital that you, as parents, get the help and support you need to learn the extra skills that can help your child. This will make you feel more confident about coping, and will help reduce stress and conflict within the family.
Children want to get their parents’ attention; it’s a powerful reward for them. Unfortunately, scolding, arguing or shouting are powerful forms of parental attention, even though they are negative. Because children with ADHD are very difficult to manage, they tend to get more negative attention, and so will continue to behave badly. This cycle, which is called negative behaviour reinforcement, needs to be broken.
To do this, behaviour management encourages parents to notice when a child is being good, and to reward them. Children benefit from being praised often, enthusiastically and clearly. They need to know why they are being praised. This is knownas positive behaviour reinforcement.
Parents may need to learn how best to handle bad behaviour – ignoring a child is not always the right thing to do, but for some behaviour it may be best. The vital thing for parents is to have a good behaviour strategy to start with, so that they know which forms of behaviour can be ignored and which are unacceptable and need to be tackled first.
It is important to maintain boundaries and discuss why some behaviour is unacceptable, as a child may not immediately understand why something is wrong. Then keep to the rules, so that your child doesn’t get confused. It is also very important to let them know when they are getting it right. You should try to avoid using 'stop' instructions, such as, 'stop shouting', and say something like, 'please speak more quietly', instead. You should also try taking time out if your child keeps refusing your request, which gives you all a chance to calm down.
Behaviour management techniques take time and great patience on everybody's part. Parents often find they have just as much to learn as their children, and need plenty of support. Behaviour techniques have been shown to be very effective, and a positive reinforcement cycle can soon gain momentum, once it’s established.
It’s just as vital to help your child gain more self-control, both at home and at school. Putting more structure into their daily life, to help them get better organised, is an important first step. It’s a great help to children to use things like alarm clocks to break homework into chunks, and lists of tasks they can tick off each day. Getting a good routine going is essential. At school, it’s important that they’re encouraged to take an active part in learning, helped to set their own pace, and provided with lessons that have the right content level, variety and interest. Educational psychologists are often the best people to advise parents and teachers on effective programmes for their children.
Social skills training
Social skills training teaches children how to manage their relationships better, by reading the hidden signals of communication. It teaches them to understand what impact their behaviour has on other people, so they can change it.
Counsellors are trained to help children to talk through the reasons for their behaviour and its consequences. Children diagnosed with ADHD almost always feel bad about themselves. Counselling can help them to tackle this, gain more self-control, focus their attention, and find better ways of learning and organising themselves.
As a parent, you also need to look honestly at the way your family works as a whole. You may well find family therapy can give you all a chance to talk through the worries or problems that may be contributing to your child's behaviour. It’s also a good chance to discuss how your child’s behaviour is affecting the rest of the family. GPs, family therapy centres or child and family consultation services can all be useful starting points for helping parents, as well as children.
Child psychotherapists are skilled at helping children to recognise and tackle their own distress. Some ADHD-diagnosed children can become very severely demoralised, anxious or depressed. A child psychotherapist can provide intensive and longer-term help for them. Note that overactive and disruptive behaviour can in itself be a sign of unhappiness in a child, rather than being a sign of ADHD.
Schools may play a crucial part in the management of your child’s ADHD. Additional in-class support may be available through the school’s special needs department. Behavioural techniques may be used but most importantly, the school will hopefully develop strategies to improve your child’s academic achievement, which will have beneficial effects on their self-esteem and consequently, their behaviour and engagement in lessons.
There is some controversy about using drugs to treat ADHD. Some experts have said that it gives both the children and their families a breathing space from the troubled behaviour, and helps them to maintain a more loving relationship with their child. Others believe that children are being prescribed these drugs unnecessarily and fear that using them may mask emotional or other causes behind the behaviour, especially in very young children. The long-term effects on the child’s brain, which is still developing, are not known.
Although stimulant drugs have been used to treat ADHD since 1937, one of the most popular drugs, Ritalin, was virtually unknown in Britain at the beginning of the 1990s, but between 2001-2002, prescription rates rose by 22 per cent. Over a five-year period, the number of prescriptions for children rocketed by 102 per cent to 254,000 items. Prescriptions for child and adolescent ADHD continue to rise. There have been cases of these drugs being misused, with youngsters selling them to other people. The drugs used are methylphenidate (Ritalin, Concerta and Equasym) and dexamfetamine (Dexedrine), which are stimulants that act on the central nervous system. They are Schedule II controlled drugs, falling into the same category as barbiturates and methadone, and are related to amphetamines ('speed'). It’s not known exactly how they work, but it’s possible that they increase the activity of the chemicals in the brain that are essential to communication between brain cells.
These drugs can sometimes have unwelcome side effects, particularly at the beginning of treatment. Children may have less appetite, lose weight and have problems falling asleep. These drugs may retard growth (which should be monitored). The medicine usually lasts for about three to five hours at a time, and when it wears off, there can be a rebound effect, with the problem behaviour returning in an extreme form. In about ten per cent of children, the drug can make them tearful and withdrawn. Reducing the dose often helps. Doctors need to carefully calculate the right dose of the drug, and monitor the effect on each child. If one kind doesn’t work, they may suggest a different one. Some children take these stimulants for six months, others for much longer, depending on how helpful they prove.
The National Institute for Health and Clinical Excellence states that these stimulants shouldn’t be used as the first or only treatment, and most doctors agree that they should only be used when absolutely necessary. The British National Formulary advises that the use of amphetamines should be discouraged as they may cause dependence and psychotic states. The drug safety and risk committee of the Food and Drug Administration (FDA) in America recommended in February 2006 that ADHD stimulant treatments should carry a black box warning of the risk of sudden death, following a report listing 25 sudden deaths in both adults and children, between 1999 and 2003. Some of these were patients with known heart disease, and the cautions for these drugs do include heart conditions.
The alternative to amphetamines is atomoxetine (Strattera) which is not a stimulant, but acts in a similar way to antidepressants and is much less likely to be abused as a street drug. Its effects last longer than those of the stimulants, so that it may need to be taken only once a day. Possible side effects include liver problems which are rare but serious, as well as loss of appetite and digestive problems and raised blood pressure. (For more information see Mind’s web-based factsheet, Drugs for attention deficit hyperactivity disorder) Methylphenidate and atomoxetine are not licensed for use in children under the age of six years; dexamfetamine is not licensed for children under the age of three years. Drug treatment should always be initiated by a specialist with expertise in ADHD.
When these drugs aren’t suitable, don’t work or have unpleasant side effects, doctors may prescribe antidepressants. Sometimes, these may be useful when a doctor feels a child's depression is more disabling than their ADHD-diagnosed problems, but they may also have side effects. There are, however, very few types of antidepressant that a doctor might prescribe to a child. The BNF for Children says that the tricyclic antidepressant imipramine may be prescribed for a child with ADHD, but this drug should not be given at the same time as a stimulant. For more detailed information see Mind’s booklet Making sense of antidepressants.
The medication can’t cure the problem, but it can help the child to think more clearly, understand better and feel calmer and more in control of themselves. This means they can take proper advantage of the other help they are getting at home and at school. Drug holidays are often built into the treatment plan so that the doctor has a chance to judge the continuing benefits of the medicine, and to allow growth to catch up if it is thought to have been retarded by the drug
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