RESOURCES AND SUPPORT FOR ADHD
ADHD Information and Support Service (ADDISS) provides information and resources about Attention Deficit Hyperactivity Disorder to anyone who needs assistance.
ADHD Resources website offers free and carefully chosen articles helpful to adults with ADD/ADHD and to parents of children with ADD/ADHD, links to other ADHD-related websites, and more.
INFORMATION ABOUT ADHD
This information was extracted from a series of factsheets from the Royal College of Psychiatrists for parents and young people.
What are attention-deficit hyperactivity disorder and hyperkinetic disorder?
Many children, especially under-fives, are inattentive and restless. This does not necessarily mean they are suffering from ADHD or hyperkinetic disorder. The terms `attention deficit', `attention-deficit hyperactivity disorder', `hyperkinetic disorder' and `hyperactivity' are used by professionals to describe the problems of children who are overactive and have difficulty concentrating.
The terms attention deficit disorder (ADD) or attention-deficit hyperactivity disorder (ADHD) are used in the USA. The official term in the UK is hyperkinetic disorder.
What are the signs?
Children with ADHD/hyperkinetic disorder:
- are restless, fidgety and overactive
- continuously chatter and interrupt people
- are easily distracted and do not finish things
- are inattentive and cannot concentrate on tasks
- are impulsive, suddenly doing things without thinking first
- have difficulty waiting their turn in games, in conversation or in a queue.
This type of behaviour is common in most children. It becomes a problem when these characteristics are exaggerated, compared to other children of the same age, and when the behaviour affects the child's social and school life. Often the signs will have been obvious since the child was a toddler.
What causes ADHD/hyperkinetic disorder?
We do not know exactly what causes these disorders, but genetic factors seem to play a part. The disorders can run in families, with boys more often affected than girls.
Where can I get help?
There is no simple test for ADHD/hyperkinetic disorder. Making a full diagnosis requires an experienced specialist assessment, usually done by a child psychiatrist. The diagnosis is made by recognising patterns of behaviour, observing the child and obtaining reports of their behaviour at home and at school.
Your general practitioner will be able to offer you advice and support and will usually refer you to a specialist. A child and adolescent psychiatrist will undertake a thorough assessment and offer treatment. Some clinical psychologists and paediatricians also have special experience and skills in managing this problem. Effective treatment will include advice and support for the parents.
Some medications such as methylphenidate may reduce hyperactivity and improve concentration (see Factsheet on stimulant medication). Medication produces a short-lived improvement after each dose, but is not a permanent cure. It creates a period when the child can learn and practise new skills. Children often say that medication helps them to get on with people, to think more clearly, to understand things better and to feel more in control of themselves. Not all affected children need medication. Those who do often need educational support as well.
Changing diet and avoiding additives
There is a small body of evidence about the effect of diet on some children. A few may be sensitive to certain foods. If parents notice that specific foods worsen hyperactivity, these may be avoided. It is best to discuss this with a dietician.
Do children grow out of it?
Children who receive specialist treatment tailored to their needs may benefit considerably. Some problems with restlessness, attention and lack of control might continue into adult life. However, with help, most hyperactive children will have settled down by the time they reach their mid-teens. They will have been able to catch up with their learning, improve their school performance and make friends.
STIMULANT MEDICATION FOR ADHD AND HYPERKINETIC SYNDROME
This factsheet is from a series of factsheets from the Royal College of Psychiatrists.
What are stimulant medications?
They are medications that affect the action of certain chemicals in the brain. In adults, they have the effect of making people more alert, active and awake. This is why they are called stimulants. In children, they can increase attention and reduce hyperactivity, and are used as one part of the treatment for hyperkinetic disorder and attention-deficit hyperactivity disorder (ADHD).
Medication should be prescribed only after your child has been fully assessed by a specialist. Stimulant medications may be worth trying if your child has serious difficulties with:
- concentration - can't concentrate for very long, doesn't seem to listen, is forgetful, disorganised, takes ages to start things and then rarely finishes them, is easily distracted
- activity levels - is overactive, climbs on things all the time, talks all the time, is very loud and noisy
- impulsivity - can't wait for things, interrupts a lot, acts without thinking.
They may have big problems:
- at school - poor concentration, can't complete a task, disruptive in class
- at home - on the go all the time, can't follow instructions, poor concentration, forgetful
- with friends - difficulty taking turns or sharing, getting into fights.
How stimulant medication works
Stimulants seem to affect parts of the brain that allow us to control how we pay attention and organise our behaviour.
What are its effects?
The child's behaviour becomes calmer, more focused and less impulsive. However, medication does not work for everyone. It is also important that the child has adequate help with learning in the classroom, and with controlling behaviour.
Why does medication help?
Stimulant medication creates a `window of opportunity' when children can be focused and concentrate better. They can therefore learn better at school. Some children say that when they are taking the medication, they can think more clearly, and find it easier to understand requests from parents and teachers. School work becomes more interesting and enjoyable, and they make more friends.
Parents and teachers can do a lot to help a child to make these changes. Your understanding and support (practical and emotional) are crucial. Practical and effective ways of helping a child to improve behaviour include:
- praising good behaviour
- making clear simple requests - one at a time
- praise for effort as well as achievement
- rewards for good behaviour
- brief periods of time away from other people when their behaviour becomes too much.
Which stimulant medications are used?
The stimulant medication most commonly used in the UK is methylphenidate. When it works, the effect begins within 30 - 60 minutes. The exact amount of each dose needs to be carefully monitored and adjusted by a specialist. There are also long-acting forms that last up to 12 hours.
What are the side-effects?
As with any effective treatment, there might be side-effects, such as reduced appetite and staying awake later than usual. Side-effects are less likely if the dose is increased gradually when the tablets are started. Some parents worry about addiction, but there is no good evidence to suggest that this is a problem.
The most common side-effects are:
- reduced appetite
- staying awake later.
Because of the effect on appetite, the child's height and weight should be measured regularly. Giving medication with meals may help.
Less common side-effects to look out for include:
- being `over-focused', quiet and staring _ this may be a sign that the dose is too high
- anxiety, nervousness, irritability or tearfulness
- tummy pains or feeling sick
- headache, dizziness or drowsiness
- tics or twitches.
How long should the medication continue?
Medication may need to be continued for several years. Some children will be able to stop completely as teenagers, others may be able to stop even sooner. Some may still need medication as adults. There are no known harmful effects from using these medications over several years.
Treatment will be monitored by a specialist and will be reviewed regularly. Medication may need to be adjusted. Physical health checks and repeat prescriptions may be provided by your general practitioner.
If stimulants don't work, your specialist may suggest one of a number of alternatives, such as atomoxetine (Straterra).
PHARMACEUTICAL COMPANY INFORMATION
- MEDIKINET XL, Flynn Pharma, Flynn ADHD resources
- EQUASYM XL, Shire, Shire ADHD information and support
- CONCERTA XL, Janssen-Cilag, Janssen information about ADHD
- STRATERRA, Atomoxetine, Lilly, Lilly information about Straterra and ADHD
What drugs do and don’t do on their own
Taken from the book ‘Parenting the ADD child. Can’t do? Won’t do?’, by David Pentecost and Jessica Kingsley
Likely to change substantially:
abilities and traits
Likely to change to some extent
Unlikely to change much:
Ability to pay attention
Ability to listen
Ability to play constructively
Ability to focus on tasks
Ability to listen to what you are saying
Ability to follow through tasks
Severe aggression and spitefulness
‘chip on the shoulder’
About courses for parents (NICE guidance for parents and carers, 2008)
The aim of the course is to equip parents with the necessary skills so that they can help to improve their child’s behaviour.
A course is about 8–12 sessions and usually takes place in a group with other parents. The course will help parents to understand their own and their child’s feelings and behaviour. It is a chance to meet other people in a similar situation, help one another and share experiences. There will be activities and ‘homework’ so that anything new can be practised at home.
Ask your GP for local parenting skill workshops / groups, as resources vary locally. Parenting courses with support with behaviour management can be found at the Early |nterventions Hubs (Oxfordshire), or try Triple P parenting, Webster Stratton Parenting courses within your county council.
CLASSROOM STRATEGIES TO HELP A CHILD WITH ADHD
Consider the following:
- Position in the classroom
- Tools to do the job
- Delivery of information
- Learning styles inventory
- Use of visual reminders
- Options for safe haven
The most effective classrooms include:
- Structure: clear rules, routines, directions, and expectations
- Salience: use of cues, prompting, and repetition of instructions
- Consistency: in limit-setting, use of prudent feedback
- Motivation: frequent positive feedback and consequences
- Interesting lessons: that capture imagination and curiosity
- Check work before they move on to the nexT
- Have routines for dealing with tasks and write them on a checklist.
- Ask the children to tick off as they complete each part.
- Allow for regular movement breaks - stretch, walk, take a message etc.
- “ ‘Ello, ‘ello…’”
- Repeat what you say several times. This will give the drifters several chances of getting the message.
Setting up a classroom
- Seat the pupil away from distractions.
- Close to the front of class or teacher’s desk.
- By peers who are good workers.
- Away from window, pencil sharpener, mobile, door, paint drying…
Display your classroom rules
- Then you can just point when you want to praise someone’s behaviour.
- Traffic light system to indicate the acceptable noise level.
- Display the class timetable and stick to it. This will give children a chance to think about forthcoming events.
- Rules should not be “Don’t…”
- Rules should say what children should do.
- Limit the time between lessons.
- Rehearse rules for these times.
- Warn children when a session is coming to an end.
- Engage pupils in activities while they are waiting for others to finish.
- Have a calm down time after breaks/lunch time etc.
Cut down and ‘chunk’ work
- Limit the amount of work on each page to only a few problems or activities so it doesn’t seem so overwhelming and cluttered.
- Cover up portions that are not needed.
Time and tests
Allot extra time to complete tests and homework. They shouldn’t be penalised for attention lapses or their difficulty sustaining extra effort during complex learning tasks.
Make use of technology
- Allow pupils to use computers to present work.
- Allow pupils to tape record some lessons.
- Use flow charts and mind maps.
- Allow notes to be photocopied and annotated.
- Use apparatus where possible rather than always pencil and paper tasks.
- Teach maths using games and coins.
- Measuring through building something.
- Decide how long the child is able to attend.
- Create a structure to the session.
- Involve the child with the planning of the session; the child may be more motivated to attend and participate.
- Constraints on the child’s behaviour may often be necessary for learning to take place.
- The child must experience success. The purpose is primarily to teach them to attend to the task, therefore initial activities must be short, simple and within their ability.
- Be consistent with your expectations and consequences for the breaking of rules.
- Teaching should proceed in small steps; gradually extend the duration and complexity of the stimuli the child is expected to attend to, and move towards a more normal environment.
- Sit beside him and engage in parallel play. Begin to extend the child’s play by demonstration without interfering in what they are doing. They may respond in one of the following ways:
- They may not appear to notice, but begin to imitate your actions.
- They may stop their play and watch you with interest.
- They may destroy your game.
In any case, contact has occurred and you have caught the child’s
- Be certain that the child can foresee an end to the task. When teaching new skills it is often hard for them to concentrate whilst the whole thing is being taught. Try to backward-chain i.e. start with the last component and work your way back. Thus the child sees an immediate end result and gets praise.
Verbalisation and Cueing
- Be careful about the type and amount of verbalisation used during an activity, because sometimes it can be too distracting.
- Focus on positive behaviour, e.g. say “Look at the paper” rather than “Don’t look over there”.
- Keep verbal instructions brief and simple, draw attention to one feature at a time.
- Non-verbal cues can alert the child to salient features of a task, e.g. point with a finger.
- When the child can tolerate the adult and begin to imitate, small modifications to their own play can be made:
- Push the correct puzzle in front of him
- Add another brick to their train or tower
- Then move towards giving simple verbal instructions immediately ahead of your actions.
Improving attention in the classroom
Establishing control and focus of attention
- Present the child with the chosen activity materials and allow them a few minutes exploratory play.
- Before giving any verbal instructions, ensure the child is sitting still and not fiddling with the toys.
- Call their name, establish eye contact and deliver a short, simple instruction.
- The next step is to gain the child’s attention while they are actively engaged in the task. Call their name, say “look”, “listen”, but don’t give any instruction until you have established eye contact.
- Instructions must be related to the task.
- Remember the child may be even more absorbed in these active games and at first you may have to physically quieten him before you can get his attention. Gradually decrease the amount you have to do to gain eye contact.
- Keep instructions very short to begin with e.g. “copy me”, “do this”.
- Accompany with appropriate gestures.
- Slowly teach the child to listen and take in what you say without stopping what he is doing.
- Stand by the child without speaking until he is aware of you, and then give the instruction.
- If the child continues to look at you, encourage him to stick at what he is doing with remarks such as “don’t look up, that’s very good”. Repeat the instruction if necessary.
- Stand by the child occasionally, while commenting on his activity. He thus cannot look at you without turning around.There is a need for consistency, calm and structure
- Boundaries need to be clear. The need to know where he is sitting, and who is looking after him or her, is also important for the child. Changes in classroom and teachers will cause anxiety for the child. They need to know the plan for each day, and the need for repetition (so that e.g. each Monday is the same) is important.
- Try to make up a timetable for the holidays as well so that there is structure there too.
- When the child first comes in at the start of the day, they need time to settle down, to allow them to feel in control. This is especially true after a busy time in the playground.
- Make sure that the child is in a good line of eye contact so that he can
- receive visual cues as well as auditory commands.
- Break down instructions into small bits, and repeat each stage for the child if necessary.
- Help the child to be organised – different colour pens for different parts of their work, see-through pencil cases so that they can see if they have all the contents.
- Try to sit the child next to the quieter children – noise will only stimulate the child to be noisier.
- Praise, praise and praise – they need to know that they are praised for trying, not just for doing well. Beware however that too much praise can lead to over stimulation.
- Use a timer to show how long a task will take or, set the timer to when the task should be completed by before the buzzer goes off.
- Always gain good eye contact before giving instructions. Ask the child to repeat them back to you. Don’t forget to keep the words you use to a minimum.
Activities to promote the transfer of attention
- Transfer to a child’s classroom may be affected by:-
- Increasing amount of environmental distraction. The primary school child may be placed in a very stimulating environment.
- The large class and open layout increases the number of people present in a given situation.
- Attention control work can be carried out in a small group after one-to-one has been successful. Initially it may be necessary to increase the help given to the child, as their attention will probably not be as good as in a one-to-one situation. The prompts can gradually be faded out.
- The child should now be able to work alongside another child doing the same activity.
Increase tolerance by either:-
- Including them in a small group of children at a similar level of attention.
- Try seating the child in a partitioned area of their own, later remove the partition and have the child with their back to the class.
- Include the child in normal activities and prompt them should their attention lapse.
- Gradually fade involvement.
- Find out what activities the child is expected to get on with by himself in class and practice these in individual sessions.