Michael Connor Chartered Educational Psychologist. Surrey EPS

Although "Attention Deficit Disorder" has only recently become a familiar term, the frequency with which children are so-described is already considerable.

Systematic investigation of this condition can be traced to the 1940's when the emphasis was upon motor and overt behavioural symptoms and the children affected were described as hyperactive. Terms such as "Brain Injured Child Syndrome" or "Minimal Brain Dysfunction" continued to focus upon motor restlessness, and it was not until the 1970's that the problem of attention as well as hyperactive behaviour was given recognition.

According to a relatively early definition, the issue is…."a child's frequent failure to comply in an age appropriate fashion with situational demands for restrained activity, sustained attention, resistance to distracting influences, and inhibition of impulsive responses."

While this definition goes back to 1980, it is still very apposite in highlighting that there are at least two, and probably, three aspects of Attention Deficit Disorder, viz: Inattention; Hyperactivity; and Impulsivity.

It is now recognised that children who are diagnosed as having attention deficits may be further classified into subtypes, namely, hyperactive, normally active, and hypoactive, so that the emphasis has now focused upon the matter of attention rather than upon hyperactivity.

These subtypes are reminiscent of the work of Luria (1961) who referred to the "excitatory" and the "inhibiting" types of individual. Meanwhile what is critical, is to remain aware that hyperactivity will almost certainly be linked with a marked limitation of attention and concentration . . . . Attention Deficit Disorder with Hyperactivity (ADHD), but that attention difficulties or deficits will not always be linked with hyperactivity . .. . Attention Deficit Disorder (ADD).

Some children may have very real problems with attention and concentration but may not be perceived as experiencing these disadvantages. Instead they may be regarded as difficult or disruptive. The symptoms may have a disruptive effect, but it would be unreasonable to describe the children themselves in that way. One significant implication of this is that where there are attentional difficulties which inhibit the progress of a given individual but which do not have an impact upon the rest of the class, (s)he may not be identified as having any problem. Relevant here is the description by Tom Ravenette of the "disturbed" compared to the "disturbing" individual where the former may have no less disadvantage than the latter, but may not be recognised as requiring some intervention and support.

The criteria for a diagnosis of AD(H)D will include not just a number of symptoms but will need to take account of their persistence over time and of their severity.

The most recent Diagnostic and Statistical Manual of the American Psychiatric Association indicates that one would look for a minimum number of diagnostic features under the tripartite heading .... for example

Inattention : Does not seem to listen to what is said ; Has difficulty in organising tasks ; etc..

Hyperactivity: Often talks incessantly ; Frequently leaves his/her place during activities where remaining seated is expected ; Often acts as if " driven by a motor " and cannot remain still ; etc..

Impulsivity: Blurts out answers before the question has been completed ; Often has difficulty in waiting in lines or in taking turns in games or in group activities ; etc..

As a result of observations and assessments, ideally involving more than one setting (home and school), the AD(H)D diagnoses may be further classified as "primarily hyperactive" or " primarily inattentive", and it is possible that the marked difference between incidences for boys and girls may reflect the greater probability that boys more commonly fall into the former category, and girls into the latter which is less readily identified.

In respect of the severity of symptoms, one may refer to Mild, which involves a pattern of short attention span in only one setting, and, albeit with some impairment of function, there is no marked threat to the child's progress in school or to his/her social functioning.

The Moderate description still involves problems in one setting rather than all-pervasively ; however, there is some interference with both scholastic and social functioning. Where there is a Severe problem, the child is seen as inattentive or disorganised in more than one setting, may not acquire appropriate work habits; and has difficulty in participating in any form of quiet play or activity for any useful period of time.

There is no single source of AD(H)D. Rather, the condition may be linked to genetic factors, neurological damage or dysfunctions, dietary conditions or exposure to certain food additives, parental handling style, environmental toxins, or to factors which are not recognised or even recognisable. Evidence is available which suggests that, in some cases, one can distinguish differences in neural structure or functioning, when comparing AD(H)D cases and controls; and, in particular, the focus is upon the frontal lobes, basal ganglia, and brain stem. Meanwhile, further evidence suggests that there may be some imbalance in the production of neuro-transmitter substances among children diagnosed as AD(H)D.

The aetiological picture is confused by the finding that the effects of AD(H)D within a family can be bi-directional. Mothers of children with attentional difficulties appear to handle them in a way clearly differentiable from the handling style of control parents, but the maternal style may be as much a consequent as a cause of the child's particular behaviour.

In regard to the extent of these problems, epidemiological data suggest that the generalised (multi-setting ) form of AD(H)D is quite rare with an incidence less than 2% of the population as a whole. Difficulties which are observed in only one setting (either home or school) may be more common. However, it is generally acknowledged that one may be underestimating the incidence given the lack hitherto of specific criteria, or the subsuming of AD(H)D within the much broader categories of emotional/behavioural difficulties or (specific) learning difficulties.

It may also be the case that, until very recently or perhaps even now, a diagnostic category such as AD(H)D has not been regarded as a means of gaining access to special or additional support or of pinpointing action, so that other diagnostic categories have been preferred for their possibly greater instrumental effectiveness.

AD(H)D and specific learning difficulties do overlap and may easily co-exist or be confounded. This is illustrated by descriptions of symptoms such as .. . "may fail to pay close attention to detail". . . "frequently makes careless mistakes in school work" ... "may have difficulty in planning how to organise tasks" . . . etc., which have been applied to AD(H)D but which could equally be descriptive of aspects of specific difficulties. Meanwhile the child with attention difficulties or deficits is at risk of inhibited progress or of school failure, and of poor or non-existent social relationships, hence the desirability of early intervention before lowered expectations, negative labelling, impaired self esteem, or any other secondary difficulties come into play and a form of vicious circle is established.

It has been argued that attentional "bias" may be a better diagnostic term than "deficit" on the grounds that there is not necessarily an all pervasive lack of attention and that many or all children seen as AD(H)D can still focus upon certain tasks without being distracted when the task is of their choosing or matches their interests at the time. Attention may not be adequate in those other situations where the task does not match the child's interest or mood.

In any event, the child with the attentional bias or deficit or difficulty (plus hyperactivity?) will indeed selectively attend to novelty and to that which is immediate. Greater problems will be observed when the tasks are complex and unstructured, and those which are well practised will rapidly lose their appeal and be linked with a marked lack of sustained attention.

Errors will increase during the latter stages of tasks or during the latter part of the school day; and the children affected will be the more at risk when verbally presented material is lengthy, detailed, or complicated, and when they need to work against a background of classroom "buzz".

The matter of identification of the AD(H)D children will involve consultation with teachers (specifying what and where the difficulties are, the educational history, the impact of existing interventions, etc.) ; consultations with the parents (developmental histories, parental experiences and expectations, etc.); and interviews with, and observations of, the children including a quest for any signs of anxiety, low self esteem, impaired social relationships, and current attainments compared with informed expectation.

Use may be made of a number of psycho-educational tools, such as rating scales (Rutter, or Connors, for example) curriculum based measures; time sampling; etc,; and one would wish to gain a picture of the child at home and at school.

To match the complexity of aetiology, interventions will probably require more than one strategy.

Educational approaches involve task analysis, short term goals, a variety of different tasks, maximal reinforcement for completed assignments, etc..

Behavioural approaches involve a high level of positive (and, ideally, tangible) reinforcement for positive periods of behaviour, token systems, positive feedback, short and sharp reprimands for off-task behaviour, social skill training, etc..

These approaches are enhanced if . .. a. they are initiated before problems and attitudes are entrenched, and b. the school and family work together consistently in monitoring and reacting to the child's performance.

A third approach may, with the input of the child's G.P. or the Community Paediatrician/Consultant/ Psychiatrist, involve the use of a psychostimulant drug of which the most well known is Ritalin (Methylphenidate). It is still the case that this approach is subject to some controversy or, at least, debate among those who favour the use of medication and those who feel it to be inappropriate.

In sum, the medication does appear to have a very positive impact among many (but not all) children for whom it is prescribed in terms of suppressing behavioural symptoms and enhancing general functioning. It may provide a breathing space for the child, the family, and the teacher(s) during which educational and behavioural approaches can be initiated. However, the medication does not in itself "cure" the condition, nor can it have a direct impact upon unlearnt scholastic skills which must still be taught. Further, opinions vary concerning the possibility of negative side effects such as "tics" or sleep disturbance.

Thus, while many children do gain great benefit from Ritalin or its equivalent, others may not show improvement, and the question remains as to when the dosage will be reduced or discontinued. There may be a risk that the medication is seen as the total treatment rather than as part of a wider package, or that it may serve to postpone the educational or behavioural interventions.

It appears desirable or necessary to ensure liaison among teaching staff, parents, educational or clinical psychologists, and medical specialists so that consistency is observed and a balanced intervention arranged.

In conclusion, it must be acknowledged that AD(H)D is a very real condition which brings about considerable disadvantages for the children themselves, and, in many cases, for their peers, parents, and teachers. It is regretted that, rather akin to what happens in the case of other conditions, such as Dyslexia, the diagnostic label may be applied rather too widely or loosely with the risk that some cynicism may be evoked when mention is made of attention deficit.

There is, nevertheless, a wide spectrum of need applying to the AD(H)D children. In some cases, there will be a requirement for only a small amount of support during a finite period of their education; in other cases, there will be a need for consistent and intensive help over a prolonged period. The use of the medically-oriented term "Attention Deficit Disorder" should not obscure the desirability of multi-modal interventions which concern the child's "intrinsic" strengths and weaknesses and the learning environment, and which will involve educational, behavioural, and medical input in particular combinations and forms to suit given circumstances and needs. Whatever the content of the individual educational plan agreed, one would wish to emphasise the significance of early intervention, and observable consistency among all those working with the child.


M.J.Connor Spring 1996

This article is reproduced by kind permission of the author.

© Mike Connor 1996.

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