These summaries start with a reference to the management of very young children and the likely concerns over medication.
There follows a mention of the possible confounding of sleep problems linked to medication or to the ADHD itself.
Next, there is a reminder of the potential value of computer-based working.
The issues of the long term nature, and of possible changes in ADHD symptoms over time, or of later onset of symptoms, are discussed.
The final section briefly describes a different perspective upon ADHD where a self- regulation deficit is seen as the critical element.
In response to questions about how to manage very young children with ADHD, within which there is an implied concern over the use of medication, Manos (2006) acknowledges the dilemma whereby the need for intervention may be pressing but the existing knowledge and experience about the effects of stimulants are limited, and there is potential for greater variability of responses and unpredictable behavioural and cognitive side effects.
There is a probability that early intervention will be associated with a greater chance of favourable outcome, but no clear pattern has been identified as the appropriate course for pre-school children.
Reference is made to Rappley et al (1999) who highlighted the range of approaches that continued to be pursued with this age group. Further, in their sample of 223 children of 3 years or below all diagnosed with ADHD, it was observed that 44% experienced problems co-morbid with the ADHD, and that almost as many had health problems or had experienced injuries of one kind or another. More than half of the children were receiving medication of which 22 different forms were identified; but only about 25% were the subject of psychological advice and intervention.
Manos notes that psychological consultation and help for the parents in applying appropriate management strategies may be commonly recommended as the first line of intervention for the children and families, but observation shows that the use of medication has increased markedly over the recent past.
This is attributed to the relative ease of organising such intervention and of access to a range of medications alongside the realisation that psychological interventions are expensive and adherence to regimes not always achieved.
The point is repeated, however, that severe ADHD in this age group is particularly problematic because these young children do not have the ability to use or respond to language as a means of moderating behaviours, with the implication that behavioural interventions will be of limited usefulness. The children are unlikely to make the connection between rules, their own actions, and the consequences of breaking the rules, so that psychosocial intervention will not have a significant impact.
Meanwhile, the confidence in the accuracy of a diagnosis of ADHD will be lessened with the younger age of the children in question. This is, to a considerable extent, because short attention span, high activity levels, and impulsiveness are quite typical of children in the pre-school age group.
However, the child who may well justify a diagnosis of ADHD will show chronic motor restlessness; non-compliance; a vigorous and persistently high activity level; and destructiveness of play. The parents are unable to relax their vigilance because of the probability of emotional outbursts of an intense level; and the children often show delays in their achievements of milestones such as toilet training, consistently sleeping in their own beds, and age appropriate motor and language skill acquisition.
In his own study, Manos examined the issue of side effects in a sample of 4-5 year old children with ADHD who had no previous experience of medication.
Support was gained for the short-term effectiveness and the safety of psycho-stimulant medication for this age group with behavioural ratings showing improvements across home and pre-school group settings. There were no signs of side effects differentiable from those which can be observed among older children, and any observed effects appeared more common during the baseline and placebo periods.
Irritability and reduced appetite were frequently reported, but it was recognised that irritability may well be part of the original problem.
In other words, it was concluded that pre-schoolers do benefit from psycho-stimulants and side effects are no greater a problem than with older age groups, but it is of great importance that the diagnostic process is pursued very carefully to ensure that the diagnosis is accurate. It is also necessary to monitor events carefully, given that little is known about the effects of medication upon the biochemistry of the brain, especially during the critical formative periods of early childhood.
Meanwhile, the guiding question concerns whether the benefits from the medication significantly influence the management of the ADHD and improve the quality of life both for the child and the parents.
One of the issues that would need to be monitored among children and young people with ADHD is whether insomnia is to be attributed to the effects of ADHD itself or of the medication used as an intervention.
The advice from Robb (2006) is that the important requirement is the taking of a history with regard to bedtime routine and sleep habits, including whether the child shares a room, snores, or has a television or radio or computer game console in the bedroom.
It is reported that for individuals not receiving medication, the issue is about the avoidance of going to bed or of settling down to sleep, and there may be a constant leaving of the bedroom to ask for a drink or something to eat or a favourite toy, or whatever. Once the child is settled in bed, it is likely that (s)he will rapidly go to sleep and remain asleep through the night.
Where there is sleep disruption attributable to medication, the onset of sleep may be inhibited and there will be observable changes in the pattern of sleep and sleep difficulties.
Some medication (Atomoxetine) can be associated with insomnia but also with hypersomnia with the individuals feeling they need to sleep longer or to take a nap in the day.
Stimulant medication can lead to insomnia and problems with the onset of sleep and these symptoms will increase as the dosage is increased; but, once asleep, the individuals are likely to sleep well for the rest of the night. The onset may be more delayed if there is use made of a short acting stimulant in the afternoon as well as a long-acting stimulant in the morning.
Approaches to avoid medication-related insomnia include the switching to a stimulant which has a shorter duration of effectiveness (8-10 hours rather than 12 hours).
Pre-schoolers would benefit from short-acting stimulants, and school students who need an afternoon dosage should be given the lowest dosage possible.
In addition, one would remove from the bedrooms any toys or games or equipment which might interfere with sleep routines, such as a television or computer or mobile ‘phone.
A reminder is offered by Rabiner (2005) that many students with ADHD show under-achievements in basic skills, notably Mathematics, and there are general weaknesses in conceptualising, basic fact retrieval, and the effective use of problem-solving strategies.
There is converging evidence, however, that these students can do better when the tasks are structured to match their existing attainment levels and when they gain frequent feed back about their performance, especially if there are tangible rewards linked to good efforts. It is also helpful if the material can be presented in a range of different ways thus to maintain the interest and an optimal level of stimulation.
The problem is that it can be difficult to match this aspiration in a typical classroom where there the teacher may be confronted by various levels and types of need; and the use of computer programmes can be very valuable in providing the appropriate multi-sensory stimulation for, and demands upon, the students with ADHD.
Reference is made to the work of Mautone et al (2005) who worked with a small group of 8-9 year olds with ADHD and significant delay in the development of Maths’ skills.
As part of the time routinely set aside for Mathematics (a total of 10-15 minutes on 3 occasions each week for between 10 and 20 weeks), these students were given access to a computer programme (“Maths Blaster” – Knowledge Adventure) which can be adjusted to suit the starting level for any given learner. Each activity was presented in a game-format with points to be earned, and gradual moving through levels, from correct responses. Each response was also linked to feed-back, including a reminder and the correct answer when errors were made. Reaching a given number of points was marked by being allowed access to a video game for a few minutes before the next task was presented.
The monitoring involved pre-and post intervention assessment of skill levels, as well as observing the extent of on-task behaviour during routine class-work in Mathematics.
Results indicated that each student had made significant gains and greater than would have been expected from the routine teaching input; and there was consistent improvement in the extent of time that the students were purposefully on-task during the normal class-work periods.
Rabiner’s commentary suggests that the success of this kind of working is a matter of the immediate and frequent feedback on performance along with the opportunity to practise given skills to mastery level.
It is acknowledged that the sample size was small, that the students were quite young, and long term maintenance of the skills has yet to be assessed, but the current conclusion points to the value of computer working with students with ADHD and the legitimacy of regular access to this facility as part of the day to day input.
Larsson et al (2005) describe ADHD as a condition which can impact upon individuals from a pre-school age, through childhood and adolescence into adulthood, and it is noted that the core symptoms can persist throughout this period placing those concerned at increased risk of other and later adjustment problems, albeit with individual variation in the severity of the symptoms which remain observable.
There has tended to be an assumption that the childhood and adult forms of ADHD have a common genetic basis, although the current authors report a lack of studies about how genetic and environmental influences interact to bring about stability or change over time.
A review of what data are available from family, adoption, and twin studies suggests that symptoms of ADHD are aggregated in families and that the genetic influence is very strong; although one particular twin study (Nadder et al 2002) has suggested the probability that new genetic influences may begin to operate as the individuals concerned move from childhood into adolescence.
The study by Larsson et al evaluated the developmental pathway of a sample of students with ADHD, with base-line measures taken at age 8-9 and repeated measures taken at age 13-14 years.
In common with previous evidence, they found relatively high stability of ADHD symptoms over this 5-year period.
It is recognised that some children largely “recover” from ADHD over time, while others only begin to show significant symptoms at a later age; and the implication proposed by the current authors is that changes between childhood and adolescence, particularly the onset of new or additional symptoms, is a matter of further genetic effects - perhaps part of a developmental trajectory linked to puberty with particular impacts upon neurotransmitter systems - and, to some extent, of new environmental effects that come into play as the individuals get older.
In particular, and with regard to socialisation, reference is made to the decreased influence from parenting (and, presumably, the associated greater influence for the better or worse from peer behaviour and attitudes, from teachers, and significant others). However, it is also noted that the individual could be at risk for more severe or more persistent symptoms if parents display symptoms related to ADHD.
Nevertheless, the developmental trajectory is not yet understood, and reference is made to some studies (such as that of Faraone et al 2000) which have suggested that persistent ADHD is a highly heritable form of the condition.
The current data support the general pattern in earlier studies to the effect that there is a relatively strong continuity of ADHD symptoms although the number of cases reaching a given cut-off point of severity declines with age. It is further argued that the continuity reflects the same genetic effects in operation from childhood onwards.
The current authors also argue that their data offer support for the view that the way in which some children show gradually reducing symptoms over time while others begin to how greater problems in adolescence reflects the pattern whereby higher levels of inattention and impulsiveness are observed among older individuals whose onset of symptoms and diagnosis of ADHD occurred after the age of 7 years.
What matters, they conclude, is the early identification of children at risk such that support for the children and their parents can be offered as soon as practicable.
Two further short reports contain features of relevance to this present topic.
Firstly, Oner et al (2005) have shown, via tomography studies, that cerebral blood flow among samples of individuals with ADHD tends, among younger cases, to favour the right hemisphere. There is a prefrontal asymmetry.
However, with time and increased age (from around 7 years to around 13 years) there is a shift and left hemisphere dominance, as indicated by the rate of cerebral blood flow, is gradually established …. presumably with implications for the greater influence of language or logic-based control strategies and a likely lessening of symptoms in many cases.
Secondly, and perhaps partially explaining why some individuals maintain or even increase ADHD symptoms over time, one notes the work of den Bergh et al (2005) who have indicated the significance of antenatal maternal anxiety (with controls in place for post-natal anxiety and for parental socio-economic level).
High levels of such anxiety appear to be correlated not only with infant temperament or childhood disorders, but also with impulsiveness in adolescence.
Neuro-behavioural development appears altered, and self regulation by children and young people with ADHD appears less probable, in the case of those individuals where antenatal maternal anxiety was atypically high; and the implication is for targeting early support towards those families where this characteristic has been identified.
(A related piece of evidence emerges from the work of Kendall et al (2005) who found that family management of the problems associated with ADHD is inhibited when the behaviours are towards the severe end of the spectrum, when there is family conflict [and, presumably, some lack of consistency of handling], and when there is a significant element of maternal distress.
The authors suggest that it is the issue of maternal distress which is most critical and that it may act as the mediating link between the problem behaviour of the children and adolescents and the development of conflicts within the family. The implication is for the critical importance of the mothers in the management of ADHD, and for the need to ensure adequate support for them when the ADHD is first diagnosed.)
It is recognised that there may be much information and research about ADHD in childhood and adolescence, but rather less about the condition as the individuals enter young adulthood.
However, evidence is gradually accumulating to the effect that a significant number of college students remain affected by ADHD and that they experience academic disadvantages, gain lower grades, and may also demonstrate lower self esteem and inhibited social skills.
The work of Shaw-Zirt et al (2005) has examined these issues among a sample of college students diagnosed with ADHD compared with a control sample matched on age, gender, and entry level attainments.
They sought information about symptoms when the participants were children as well as about current symptoms, and found that nearly all their target sample currently met criteria for ADHD and had presented significant problems earlier, but had gone through childhood and adolescence without any therapeutic intervention.
In respect of all three aspects of functioning studied – adjustment to college, self esteem, and social skills – the target group were found to be generally poorer or more disadvantaged than the controls.
The students in question saw themselves as achieving more poorly (despite cognitive abilities on a par with those of controls) and to be performing less well in terms of social and emotional aspects. There was a feeling of being less strongly connected with the college.
With regard to social skills, the results were somewhat difficult to clarify given some gender differences in that the target group of female students reported a more positive picture than did the male students, although females with ADHD compared with females without ADHD reported greater difficulties in social relationships and more negative experiences.
The authors’ further analysis suggested that the apparent sequence began with the ADHD symptoms and difficulties which led to a lowering of self esteem which, in turn, led to poor adjustment. There was less evidence that poorer social skills were responsible for the greater adjustment weaknesses.
The conclusions drawn by the authors highlighted the discrepancies in terms of who is identified with ADHD at an appropriately early age with the resulting imbalance over the allocation of resources and support; but also recognised that, whatever may have gone before, there is likely to be a significant number of individuals entering further and higher education still experiencing problems linked to ADHD and for whom support services need to be maintained.
A different way of conceptualising ADHD is explored by Barkley (2005) and has been summarised by Rabiner (op.cit).
It is Barkley’s view that the core deficit in ADHD is a lack of self control such that problems with inattention are secondary. The further implication is that those individuals with the inattentive form of the condition but without the hyperactivity or impulsiveness should not be linked with those who have the combined form of the condition.
The two conditions are separate and not simply different presentations of the same basic condition.
Normally, a child’s control over behaviour gradually shifts from a response to external measures (reminders and sanctions and rewards from family and significant others) to self control via internalised rules and standards.
The older child can anticipate reactions and consequences of maladaptive behaviours, and is likely to inhibit such behaviours without the threat of some punishment.
The child with ADHD lacks this capacity, but Barkely argues that the failure to develop self-regulation is based upon biological factors rather than upon any lack of appropriate management and parenting.
The core deficit in self-regulation leads on to further developmental anomalies such as a weakness in working memory (with implications for problems in being able to recall past events and manipulate the details in order to make predications about current events); in internalisation of speech (and a lack of one important element of self-guiding); in a sense of time (and to weaknesses in planning how to complete a task and in general organisational workings); and in goal-directed behaviour (with implications for a failure to maintain a clear goal in mind and to take the steps towards it, and for limited persistence and effort).
Barkley holds that this conceptualisation of ADHD does not assume any lack of skill or knowledge on the part of the individuals; instead, the lack of self-regulation prevents the application of the knowledge. It is the immediate goal of getting one’s own way and not sharing or cooperating that gets in the way of longer-term goals such as making and maintaining a positive peer relationship.
Intervention, therefore, should focus upon these existing skills and knowledge and help the individual to apply them in the appropriate context via frequent external cues and reminders. In the example above, the intervention could focus upon reminders about how to behave during incipient social interactions, perhaps having the child review a short set of social rules immediately before playtime or a shared activity.
There is a further word of caution in that the effectiveness of prompts and reminders will be limited if the child’s motivation (for the longer term outcomes) remains lacking, hence the need for external rewards and mini-privileges to be used regularly and to match positive efforts made in order to counter the appeal of the alternative behaviours that the child might pursue.
Immediacy of reward and feedback is important such that longer-term objectives and chains of behaviour need to be split into small steps each with its own reward.
The further implication is that this kind of intervention needs to continue beyond the child’s apparent mastery of the desired behaviours, albeit with the reassurance that maturity of behaviour can be gradually achieved and less reliance placed upon external sources of motivation. In all this, medication can be a valuable adjunct to the behavioural intervention in reducing negative and impulsive actions and making it easier to find opportunities for reward and positive feedback.
The final implication is for the initiation of an intervention as early as possible in order to establish routines before the maladaptive behaviours become fixed and before the development of secondary issues such as peers’ wariness or actual avoidance of the child in question.
* * * * * *
Barkley R. 2005 ADHD and the Nature of Self Control. New York : Guildford Press
den Bergh B., Mennes M., Stevens V., van der Meere J., Borger N., and Lagae L. 2005 ADHD deficit as measured in adolescent boys with a performance task is related to antenatal maternal anxiety. Pediatric Research 59(1) 78-82
Larsson J-O., Larsson H., and Lichtenstein P. 2005 Genetic and environmental contributions to stability and change of ADHD symptoms between 8 and 13 years of age. Journal of the American Academy of Child and Adolescent Psychiatry 43(10) 1267-1275
Manos M. 2006 Treating severe ADHD in very young children. Medscape Psychiatry and Mental Health 11(1)
Mautone J., Dupaul G., and Jitendra A. 2005 The effects of computer-assisted instruction on the mathematics performance and classroom behaviour of children with ADHD. Journal of Attention Disorders 9 301-312
Nadder T., Rutter M., SilbergJ., Maes H., and Eaves L. 2002 Genetic influences on the variation and covariation of ADHD and oppositional defiant disorder /conduct disorder symptomatologies across informant and occasion of measurement. Psychological Medicine 32 39-53
Oner O., Oner P., Avsev A., Kucuk O., and Ibis E. 2005 Regional cerebral blood flow in children with ADHD : changes with age. Brain Development 27(4) p.279
Rabiner D. 2005 Attention Research Update : December 2005 (www.helpforadd.com)
Rappley M., Mullan P., Alvarez F., Eneli I., Wang J., and Gardiner J. 1999 Diagnosis of ADHD and use of psychotropic medication in very young children. Archives of Pediatric and Adolescent Medicine. 153 1039-1045
Robb A. 2006 Insomnia in children with ADHD. Medscape Psychiatry and Mental Health 11(1)
Shaw-Zirt B., Popali-Lehane L., Chaplin W., and Bergman A. 2005 Adjustment, social skills, and self esteem in college students with symptoms of ADHD. Journal of Attention Disorders 8 109-120
© Mike Connor 2006.
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