WHAT IS ADHD?
· A complex and heterogeneous behavioral disorder, with a neurobiological basis, which appears in childhood and is identified when the child is around seven years old, whose causes are mainly genetic and environmental.
· It has a chronic character and follows a persistent behavioral pattern of a lack of attention skills and/or hyperactivity and impulsivity.
· It appears with an intensity and frequency greater than normal, interfering significantly not only in the child’s performance but in other daily activities too (López-Ibor A. et al, 2002)
· Low self-esteem, depression and/or anxiety can appear associated with ADHD in children.
· On some occasions it also appears associated with learning difficulties: dyslexia, dysgraphia, dysorthography and dyscalculia, as well as other comorbidities such us: Defiant disorder, antisocial behavior, tics, etc.
In people with ADHD there have been found anomalies in the chemical functioning of the brain (neurotransmitter activity: dopamine and adrenalin) and in the structural level ( volumetric anomalies in brain, cerebellum and caudate nucleus) of some brain areas (prefrontal lobe and the areas related to it)
· There is a general agreement that ADHD is a dysexecutive disorder characterized by:
- Difficulties in the pre-attention system.
- Difficulties in sustained attention.
- Difficulties in verbal fluency.
- Difficulties in inhibition and self-regulation processes.
- Difficulties in working memory
- Difficulties in cognitive flexibility.
- Difficulties in social and emotional skills.
WHAT ARE EXECUTIVE FUNCTIONS?
Executive functions have been described as cognitive processes that allow us to control and regulate our behavior in order to achieve a given aim.
Goldberg, Luria,s disciple, uses in his book «The executive brain» the metaphor or the «orquestra conductor» to explain how the frontal lobe is the anatomic structure that coordinates the information and other functions that receives from other brain structures in order to achieve an aim.
ADHD is a failure in the activation or not of executive functions in the brain, mainly in RESPONSE INHIBITION. This failure affects four main executive capacities:
Non-verbal working memory: to be able to look back and see or recuperate visual information of previous actions and its consequences. Implies self-awareness, sense and use of time and space.
Verbal working memory: it is the voice of our brain that allows us to reflect and apply self-instructions that help us regulate our action.
Emotional self-regulation: to be able to control, adjust and moderate our emotions. It includes regulation of motivation.
Planning and problem solving directed to action: innovation capacity directed to an aim, planning our response and choosing the best one, facing problem solving, planning our life and thinking about future.
We could say that in terms of brain functioning is as if the child/young person with ADHD had a «Ferrari» with «bicycle breaks»
WHAT CAUSES IT?
In people with ADHD there have been found anomalies in the chemical functioning of the brain (neurotransmitter activity: dopamine and adrenalin) and in the structural level (volumetric anomalies in brain, cerebellum and caudate nucleus) of some brain areas (prefrontal lobe and the areas related to it).
Environmental aspects such as acquired biological factors, traumatic brain damage or encephalopathy, high level of exposition to zinc or lead, intrauterine exposition to alcohol, nicotine, drugs or certain medication or prematurity or law weight at birth can modulate ADHD during prenatal, perinatal or postnatal period
Psychosocial aspects are not considered critical in etiology of ADHD but play an important role in the evolution of it and specially they become an important opportunity for intervention. We are referring to context family aspects such as: stress, marital problems, psychopathologies in the parents, etc.
In the same way, children that suffer other factors related to bonding when in foster care, institutions or adoptions and stressful situations such as low socio-economic situation are more likely to develop ADHD, although it is not clear if it is due to prenatal influence or lack of stimulation or the combination of both.
DOES IT HAS A CURE?
Rather than talking in terms of cure we should address this in terms of “how does ADHD evolve?”
From this perspective, there is not a unique prognosis in relation to the evolution of ADHD. Recent studies with adults have identified three different groups:
- The ones that function as well as others without a previous history of ADHD
- The ones that suffer from important psychopathologies.
- And the largest group of those with concentration difficulties, impulsivity and difficulties in social functioning.
Those difficulties are more often related to:
- academic achievement
- problems in interpersonal interaction and sentimental relationships
- problems at work
- higher risk of suffering driving accidents
- self-harm risk
- drug abuse and higher risk of delinquency
Generally speaking it could be said that symptoms of ADHD persist in 80% of adolescents, one third complying diagnostic criteria. In adulthood, between 30-65% of the patients will still have the disorder or clinically significant symptoms of it.
WHAT ARE THE SYMPTOMS?
WHAT DO WE “SEE” IN CHILD WITH ADHD?
Illustration 1 ATTENTION DEFICIT
Illustration 2 HIPERACTIVITY
Illustration 3 IMPULSIVITY
These symptoms are variable in intensity but NOT necessarily simultaneous
CLASSIFICATION SYSTEMS OF ADHD
Currently there are two international classification systems for diagnosis of ADHD in children and adolescents:
- Following DSM-V, ADHD characterizes are:
A. Persistent pattern of attention deficit and/or hyperactivity-impulsivity that interferes in the functioning or the development, characterized by (1) attention deficit and/or (2) hyperactivity and impulsivity :
Note: Symptoms are not only a manifestation of oppositional behavior, defying, hostility behavior or failure in the understanding of tasks and instructions. For adolescents and adults (above 17 years old) five symptoms or more are required for diagnosis.
CRITERIA 1: ATTENTION DEFICIT
CRITERIA 2: HYPERACTIVITY & IMPULSIVITY
DSM V: ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)
- These symptoms are variable in intensity but NOT necessarily simultaneous
ASSESMENT OF ADHD
We need to remember in the degree of the difficulty to adapt that the child with ADHD shows, the importance of:
ASSESMENT OF ADHD: COMORBIDITY
- Comorbidity occurs in more than half of the cases.
- We need to get information about the following aspects:
- . Specific learning difficulties
- . Oppositional defiant disorder or conduct disorder
- . Emotional symptoms
- Up to a 60% of the children suffer a neuropsychiatric condition associated with ADHD, the most common are:
- Comorbidity in ADHD is understood as a severity indicator.
- In many cases it explains the lack of response to treatment.
- Multidisciplinary treatment should have specific intervention areas to treat ADHD and to treat the comorbid difficulties.
- Early and thorough treatment of ADHD could prevent the appearance of comorbidities.
HOW CAN WE HELP?
DEALING WITH ADHD: KEY IDEAS FOR COMPETENT PARENTS
MULTIMODAL TREATMENT OF ADHD
The treatment of a child with ADHD should be multimodal, this is, should include the intervention of: doctors, therapists, teachers and parents. In this model doctors and therapists intervene to control the main symptoms (hyperactivity, attention deficit and impulsivity) and the psychological, psyschopedagogical and family intervene to solve behavioral and learning difficulties and the maintain the welfare of the child.
Parents need to be trained on how to act with their child as the base for any successful intervention. Specifically, parents need to learn about:
· Cognitive therapy: to be able to identify and modify inappropriate cognition that affects emotions and behavior to be able to change them into positive cognition. The most frequently used techniques are:
- Self-control techniques
- Response inhibition techniques
- Problem solving techniques
· Training in Social Skills: quite often people with ADHD have difficulties to relate to other people (family, friends, teachers, partners, workmates, etc.). This happens because they have not developed enough basic social skills such as: assertiveness, verbal and non-verbal communication skills, negotiating skills and problem solving skills, etc.
If a person has not developed appropriate social skills frequently develops inadequate behavior, different to the one that is socially expected, causing rejection, mockery, etc.
When specialists talk about basic social skills they refer to: smiling, saluting, making favors, answering, helping, cooperating, sharing, joining play, initiate/maintain/finish a conversation, expressing/receiving emotions, defend rights and assertiveness, identify and solve problems.
· Training in relaxation techniques and anxiety control: often ADHD is accompanied by motor agitation and anxiety. These techniques help them canalize excess of energy and calm a general state of nerves and anxiety and at the same time promote positive emotions, improve communication skills and family atmosphere.
Some of the techniques used are:
- Breathing and relaxation exercises
- Body expression and psychomotor activity
- Sport and social activities
KEY IDEAS TO PROMOTE A BETTER ENVIRONMENT AT HOME AND DEAL IN A POSSITIVE WAY WITH THE CHILD DIFFICULTIES
USSUAL PROBLEM AREAS AT HOME
a - SCHOOL-HOMEWORK-STUDYING
- Children with ADHD can work better if they are allowed to move.
- It is important to establish a routine, including extra-school activities.
- Organizing and planning with them their work is essential.
- Establishing short periods of work and allowing a rest but not doing another activity such as watching TV for a while, because it will be very difficult to get them to sit down and work again.
- Value, encourage, reinforce each step, everything they do right. Don´t think you are overvaluing their effort because for them keeping at the task is a greater effort than we imagine.
- Guide in a directive style the most difficult tasks, establishing a routine that is always the same, it will give them security and will help them to learn the importance of organization and order.
- Look for a personal support teacher if needed to avoid family conflict when you cannot keep calm and the situation becomes too stressful for both of you.
b- ROUTINES AND HABITS
“We talk about automatization of behavior for those children that have extreme difficulty to do it because of their poor development of internal language (internal guide of behavior). In this case it is necessary to EXTERNALISE INFORMATION using: signs, boards, visual watches, calendars, notefiles, alarms…”
We refer to two different types of movement:
- Motion movement: they stand up, jump, swing the chair, etc.
- Static movement: when they are moving hands or playing with an object or making noises WHILE they are working.
Children with ADHD usually need this second type of movement while they are working, it does not distract them. But they are usually told not to do it because IT DISTURBS US not them. It drives us nuts!”
- Movement while working can even help concentration if does not imply stopping what they are doing.
- Movement leaving the work activity has to be conducted and limited teaching them the right moments to do it –i.e. finish and then stand up or go for a walk- or make it have a purpose – i.e. can you get up and switch the computer on cause we will use it for the next activity.
From there we could:
- Control the environment to reduce distractors.
- Isolate the child from visual and auditorial distractors for short periods while doing a task that requires concentration (headphones, facing the wall, etc.).
- Using alarms and visual notes that remind them to get back to the task, to stop being distracted.
- Fragment long tasks into small parts and adapt to their attention capacity.
¿What can we do?
- Prevent and avoid useless conflicts. Reducing conflict helps keeping a better atmosphere and attitude.
- Once there is an “explosion” we have to WAIT for the emotion to calm down and KEEP AT A DISTANCE FROM THE EMOTION, do not enter conflict, do not confront, do not try to talk or reason…
- Once calm we can: be emphazetic; express our point of view; ask for a change; analyze alternatives for other occasions; help them visualize themselves solving the problem without loosing control; etc.
- After bad behavior we need to apply consequences (distance, taking away a privilege…)
- When they apologize and express regret don´t rush into forgiveness, don´t minimize what happened by saying things such as “it wasn´t so bad” “don´t worry” “don´t think more about it” or “think about something else or something nice”. We need to teach them to normalize the emotion, accept it and understand it, but NOT TO avoid it or minimize it. More so when they have hurt others or have been totally out of order.
- We need to teach them to regulate their behavior and emotions. If the child has great difficulty at managing either we should consider seeking for specialized therapeutic help.
“It is important that the child has something to hold onto, something that pulls of him to be able to do…”
- Value, praise, believe in them, while they are doing their tasks.
- Offer them a gratifying task immediately after they have done one that it is hard or they don´t enjoy.
- Help them develop a positive self-esteem, to feel “proud of themselves” and be aware that the child with ADHD quite often is under a great deal of criticism and negative messages from the minute they get up. We need to make very visible what they do right, even when they try and only manage partially to succeed, so that they develop self-confidence and a sense of self-worth.”
- Use positive feedback and reinforcement: immediate, continuous, frequent and visible. Reinforce WHAT THEY ARE CAPABLE OF, not only what they have managed to do in a giving moment.
LIMITS AND NORMS
- It is necessary to prioritize limits and say NO only for important things.
- In the long run limits help them develop autonomy and emotional self-regulation because they expose them to frustration in a controlled way.
- Norms should be few, clear and with unavoidable consequences.
- The child and particularly the adolescent can and knows how to negotiate norms, and feel more willing to follow them.
- They should be written and in a visible place, to compensate their working memory difficulties.
The problem is to stop doing them because this moment usually becomes a fight, a tantrum, out of proportion reaction. What can we do then?
- DO NOT let the child do them before studying/homework, because it is very difficult for them to stop having fun to do something boring or hard.
- Play time has to be regulated because they do not perceive time and they do not regulate their behavior accordingly.
The most effective consequences are the ones that are unavoidable and occur immediately after they behave wrongly.
- They will be more effective if there is enough positive feedback and reward, this is, if we value what they do rightly and they have developed a positive self-esteem.
- It is very important to warn them about the consequences of their inappropriate behavior and they have these agreements on writing. And they will need this way of regulation for a long time before they manage to control their behavioral difficulty.