ADHD (ATTENTION DEFICIT HYPERACTIVITY DISORDER) IN SCHOOL AGE CHILDREN (age 9-16)
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Unit 23 Health issues for specific groups
ADHD (ATTENTION DEFICIT HYPERACTIVITY DISORDER) IN SCHOOL AGE CHILDREN (age 9-16)
In my report, I will outline the facts about ADHD and new research among child psychiatrists and paediatricians, along with the current situation in the UK.
Introduction
Attention deficit hyperactivity disorder (ADHD), sometimes called attention deficit disorder (ADD) or hyper kinetic disorder (HKD) is a neurobiological disorder caused by an imbalance of some of the neurotransmitters found in the brain, called nor epinephrine and dopamine.
ADHD is one of the most common disorders of childhood and is characterised by symptoms of impulsivity and hyperactivity or inattention. The symptoms are not seen to the same degree in all people diagnosed with the disorder and healthcare professionals recognise that there are 3 main combinations of symptoms:
* Some people have predominantly hyperactive-impulsive type
* Some have predominantly inattentive type
* And some have a combined type - this makes up the majority of ADHD cases.
Hyperactive or impulsive behaviours may include; fidgeting, having trouble playing quietly, interrupting others and always being 'on the go'. Symptoms of inattention include; being disorganised, being forgetful and easily distracted and finding it difficult to sustain attention in tasks or play activities. Whilst ADHD behaviours occur to some extent in all of us, the difference between ADHD and normal behaviour is the degree of the problem and the difficulties it causes. Children with ADHD show this behaviour to a significantly greater extent and severity.
Children with ADHD may exhibit behaviours that cannot be explained by any other
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Psychiatric condition and are not in keeping with the child's age and intellectual ability. Mood swings and social clumsiness are common.
Parents and teachers may report that these children often misread the accepted social cues, saying or doing inappropriate things, Social problems often hit peak in primary school and start to ease in secondary school.
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According to medical guidelines, ADHD affects 5% of school aged children, and the male to female ratio in diagnosed ADHD prevalence is at least 4 to 1. The observed prevalence of ADHD in boys and girls is skewed by the fact that symptoms of hyperactivity and impulsivity are more common in boys, whereas girls with ADHD more commonly have inattentive symptoms.
Many girls remain undiagnosed as they may not be referred to a clinic, they may still be failing at school, and experiencing other problems due to their ADHD.
ADHD is strongly hereditary (or genetic) condition. If a family member has 1 child with ADHD, there is a 30-40% chance that another brother or sister will also have the disorder. If the child with ADHD has an identical twin, the likelihood that the twin will also have the disorder is about 90%.
Symptoms of ADHD
A child must have exhibited at least six of the following symptoms for at least six months to an extent that is unusual for their age and level of intelligence.
> Fails to pay attention to detail or makes careless errors during work or play
> Fails to finish tasks or sustain attention in play activities
> Seems not to listen to what is said to him or her
> Fails to follow through instructions or to finish homework or chores
> Disorganised about tasks and activities
> Avoids tasks like homework that require sustained mental effort
> Loses things necessary for certain tasks or activities, such as pencils, books or toys
> Easily distracted
> Forgetful in the course of daily activities
Hyperactivity
A child must have exhibited at least three of the following symptoms for at least six months to an extent that is unusual for their age and level of intelligence.
> Runs around or excessively climbs over things
> Unduly noisy in playing, or has difficulty in engaging in quiet leisure activities
> Leaves seat in classroom or in other situations where remaining seated is expected
> Fidgets with hands or feet or squirms on seat
Impulsivity
At least one of the following symptoms must have persisted at least six months to an extent that is unusual for their age and level of intelligence.
> Blurts out answers before the questions have been completed
> Fails to wait in lines or await turns in games or group situations
> Interrupts or intrudes on others, e.g. butts into others conversations or games, talks
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excessively without appropriate response to social restraint.
Key survey findings
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> Fidgets with hands or feet or squirms on seat
Impulsivity
At least one of the following symptoms must have persisted at least six months to an extent that is unusual for their age and level of intelligence.
> Blurts out answers before the questions have been completed
> Fails to wait in lines or await turns in games or group situations
> Interrupts or intrudes on others, e.g. butts into others conversations or games, talks
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excessively without appropriate response to social restraint.
Key survey findings
A recent survey was carried out amongst child psychiatrists and paediatricians in the UK.
* ADHD was rated as having as great an impact on a child's development as depression, Tourette's syndrome, anxiety or dyslexia. 80% of specialists surveyed rated ADHD as having the greatest or second greatest impact of these conditions on a child's development.
* 98% of those surveyed believed undiagnosed ADHD as having a serious impact on a child's academic progress
* 97% stated that children with undiagnosed ADHD are more likely to drop out of school several years earlier than their peers
* Over 90% said that undiagnosed and untreated ADHD:
* Has a serious impact on a child's relationships with parents, siblings and peers
* Can result in children feeling excluded from their peers, impacting their ability to make friends and leading to very low self-esteem due to their exclusion
* Can lead to a variety of social problems, such as difficulties finding and keeping friends and criminal behaviour such as stealing, shoplifting and vandalism.
* 85% said they believe that not treating childhood ADHD could lead to adult mental health problems such as depression and even suicide.
The recently published international Consensus statement, signed by 86 psychiatrists and psychologists also confirms that untreated ADHD can lead to 'impairments in major life activities' which can include increased teenage pregnancy, substance misuse, engaging in antisocial behaviour.
According to NICE guidance, the prevalence of ADHD is 5% of school age children. Also according to NICE, ADHD is currently under diagnosed in the UK. 1% of school age children meet the diagnostic criteria for severe combined type ADHD and should receive treatment, (this equates to approximately 100,000 children in the UK). However only 70,000 children are currently receiving medication for their ADHD. Over half (54%) of the child and adolescent psychiatrists and community paediatricians recently surveyed also stated that ADHD is currently under diagnosed in the UK.
The survey participants were asked what they thought the main barriers to effective identification and diagnosis of ADHD in the UK were. Reasons given included:
* Too few child and adolescent psychiatrists or paediatricians with an interest in mental health 85%
* GPs are unsure of which patients to refer 57%
* Parents are not aware of ADHD so don't go to their GP 53%
* For those aware of the problem, research conducted among children and parents on the subject of children's mental health found that the most common reasons parents gave for nor contacting any service about their child's health problems, included fear of being branded a failure or blamed 29%.
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The role of primary care in initial identification of ADHD and referral to secondary care specialists was highlighted by the experts surveyed.
* Over two thirds of specialists (72%) felt that G.Ps should have a key role in preliminary screening of patients who may have ADHD
* 88% felt that G.Ps would benefit from increased education to improve their understanding of ADHD and improve the level of accurate referral.
Through my research from various health practices and ADHD organisations within the North east of England I found it extremely difficult to determine how many children in any one area have ADHD.
The only statistics that I was able to provide was through cafamily based in Gosforth, Newcastle upon Tyne.
They currently have 1708 individual families with school aged children on their books with ADHD within the North East area.
It is vital that primary and secondary care work effectively together to manage ADHD. Improved education is key to improving the referral process and helping children with ADHD access secondary care specialists.
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Teachers were also highlighted as having a potential role in initially recognising ADHD in the classroom. 43% of medical experts surveyed believe that a major barrier to diagnosis of ADHD is that teachers are not aware and therefore do not realise that children should be referred to a medical professional.
It is possible that some of the children with ADHD excluded from school could still be in mainstream education had they been identified and treated earlier.
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Treatment and a way forward for children
ADHD is not simply about diagnosing the disorder and treating it with a single, or combined, therapy. The nature of the disorder, whether undiagnosed and untreated or recognised and managed by health services, requires greater input from a range of different sources to ensure continued support. The most critical points for a child are:
* Parents and the family network
* Education and schooling
* Social services and, where appropriate, the youth and criminal justice system.
Every individual must be given the opportunity to achieve his or her potential in learning and educational systems. For this to happen it is important that pupils with ADHD are identified as early as possible in their schooling so that they receive appropriate support.
Increased understanding of ADHD, plus help negotiating the routes through the statementing and diagnosis process for both parents and teachers, is essential to aid children with ADHD in receiving the educational support they need. This requires more effective joined up working - with guidance and advice between all the parties involved.
The DfES (department for education and skills) has recently produced guidance in the form of a Special Educational Needs (SEN) Code of Practice in order to try to improve the support provided to children with SEN within the education system. The Code states that Local Educational Authorities are required to build collaborative relationships with health services, parent groups, social services and voluntary organisations, utilising joined up working between agencies to ensure provision of integrated care for children with mental health problems.
The DfES provides guidelines for schools, but these policies do not translate into reality in practice. ADHD is a complex disorder and the lack of understanding around ADHD means that teachers would benefit from policies that provide more clear and definite guidance regarding ADHD in the classroom. Only then will the joined up thinking of the DfES promotes be translated into effective joined up working.
Treatment depends on a child's exact diagnosis. It should take into account any specific difficulties and those strengths that may aid their improvement.
It is not easy to live or cope with a child with ADHD. Both teachers and parents can follow the guidelines to manage the child's problematic behaviour but they may need specialist support and advice, e.g. from a psychologist.
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Management techniques for parents and teachers
* Create a daily routine for the child, e.g. homework schedules, bedtime and mealtime routines
* Be specific in your instructions to the child and make clear and reasonable requests, e.g. instead of telling the child to 'behave' suggest 'play quietly with your lego for ten minutes'.
* Set clear and easily understood boundaries, e.g. how much TV they may watch, and that rudeness is unacceptable
* Be consistent in the handling and managing of the child
* Remove disturbing or disruptive elements from their daily routine, e.g. remove siblings from the room when they are doing homework or turn off the TV
* Plan structured programmes aimed at gradually lengthening the child's concentration span and ability to focus on tasks
* Communicate with the child on a one to one basis and avoid addressing other children at the same time
* Use rewards, e.g. stickers, tokens or even money consistently and frequently to reinforce appropriate behaviour such as listening to adults and concentrating
* Use sanctions, e.g. loss of privileges, being sent to their room for unacceptable behaviour or overstepping of boundaries
* Discuss your child with their school or nursery and see if you can work together
Medication
Behavioural management techniques such as those above are always important, and for the mild attention deficit problems they are the treatment of choice. Research suggests that medication is the best treatment. The most common and effective medications are amphetamine - like stimulants, mainly methylphenidate (Ritalin) and dexamphetamine (Dexadrine). If there are coexisting conditions then these may also require medication.
Ritalin reduces hyperactivity and impulsiveness and helps to focus a child's attention. They become less aggressive, seem to comply with requests, and become less forgetful. Many parents say their child's behaviour has vastly improved as a result of Ritalin.
However, there is growing concern about the use of Ritalin to treat ADHD. Like amphetamines, Ritalin is classified as a class A drug. Many parents and professionals are worried about alleged side effects, including damage to the cardiovascular and nervous systems. Ritalin's manufacturers also recommend that even if Ritalin is effective it should be discontinued periodically to assess the child's condition,
Psychological treatments
In addition to the management techniques described, other forms of psychological treatment might include anxiety management, cognitive therapy, individual psychotherapy and social skills training.
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Educational management
This includes individual, or group, learning support for coexisting learning difficulties and educational underachievement.
Diet
Research suggests that diet is not a significant factor in ADHD for most children. Some children have particular food allergies that need investigation. Dietry changes need to be supervised by a doctor and nutritionist. In this approach all foods suspected of causing behavioural problems are removed from the diet then gradually reintroduced while the child's behaviour is monitored by the psychologist.
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The code of practice promotes effective partnerships between families and professionals in the field of special educational needs (SEN). Parents of a child with SEN often wish to, or are expected to participate in decisions taken about their child's education. In order to encourage the development of good working relationships within the local community, local authorities must be committed to this objective and ensure staff are in a position to foster such relationships/
Advantages
* The policy states that educating an SEN child in an ordinary school should be compatible with:
* He/she receiving the special educational provision that they require
* The efficient use of resources
* The movement to parental choice has been accompanied by regulations intended to require schools to produce information to parents
* Schools are required to produce a statement on their policy on special educational needs such as ADHD etc.
Disadvantages
* A school may feel that the academic performance of SEN pupils will reflect badly on its ability to produce good results
* Evidence is emerging that the threat to the integration of SEN pupils has materialised, the rate of exclusions has shot up over the last few years (ofsted report)
* Exclusions develop a cheap method of dealing with pupils who demand more in terms of resources
* Given that SEN pupils are in a vulnerable position, how is the law protecting the children from the effects of underfunding and segregation.
CONCLUSION
This report highlights the managemnet of ADHD and even though the disorder is undiagnosed and those who do manage to navigate the system successfully, it can take years to obtain a diagnosis, by which time the child may have been excluded from school. It is imperative that the management of ADHD is improved and that the call to action involves all parties. There needs to be joined up thinking in the way that healthcare professionals, education professionals and parents of children with ADHD
work to ensure that these children receive the support and attention that they need.
By Dawn Bewick
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Introduction and Evaluation of my designed leaflet
I have designed a leaflet to inform parents of ADHD and ways they can combat the problems that they have with their children in day-today living.
Leafleting is one of the easiest and most effective ways to inform parents about the issue of ADHD, it publicises and encourages parents to learn more about the health issue and problems that occur.
The leaflet that I have designed, highlights the real differences that parents can and do to make their children's life a lot easier as well as their own.
It is a very colourful leaflet with pictures which I believe makes it that bit more interesting.
If parents were to become more involved with their childrens needs , then I believe that a great number of children would be diagnosed as having ADHD, this leaflet would help parents to understand the needs of their child and seek help from the the right professionals, which would also prevent their child from being excluded from school.
The leaflet is very colourful with relevant diagrams, cartoons and pictures to interest the parent so that they don't just pick it up and think 'not another leaflet'. This was designed to attract the attention of the parents and teaching staff to make them aware of all the facts on ADHD.
The leaflet is not too long consisting of just three pages, so it should not be too boring or feel that the topic is dragging on and on. There is also a list of website addresses should the parent wish to investigate further.
The leaflet that I have designed is a quick way to get information across to parents and is designed to grab their attention. It also provides the parents with enough basic information to encourage them to ask for more and can also become a catalyst for discussion when they are handed out personally.
The front cover of my leaflet has to work like the headline of an advertisement, so it was designed to tell the world what information they need to be aware of and help that may be on offer.
The leaflet may also end up being read by many more people than the person it was handed to, widening its impact still further. I also believe that the leaflet is persuasive, interesting to read and catchy and memorable. By using bullet points it makes the leaflet easier to read.
The cartoon pictures help to get my message across as it is the first thing that will catch a person's eye and is also attractive and stands out, enticing people to pick it up.
It is easy to use so that people are guided through it without confusion about which section they should read, or look at, next.
Rationale
The rationale for the leaflet was that parents are regarded as the fundamental principle underpinning the successful treatment and care of their children who may suffer from ADHD. It aims to be a common point of reference for information and includes basic advice for parents and how they can help their children.
The leaflet provides answers to some of the most common questions and where to get help.
By Dawn Bewick
