What Are the Symptoms of ADHD?
By, Laurie Laird
ADHD is not like a broken arm, or strep throat, it does not have clear physical signs that can be seen in an x-ray or a lab test. ADHD can only be identified by looking for certain characteristic behaviors and these behaviors vary from person to person. Scientists have not yet identified a single cause behind all the different patterns of behavior–and they may never find just one. Rather, someday scientists may find that ADHD is actually an umbrella term for several slightly different disorders.
At present, ADHD is a diagnosis applied to children and adults who consistently display certain characteristic behaviors over a period of time. The most common behaviors fall into three categories: inattention, hyperactivity, and impulsivity.
- People who are inattentive have a hard time keeping their mind on any one thing and may get bored with a task after only a few minutes. They may give effortless, automatic attention to activities and things they enjoy. But focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.
For example, Lisa finds it agonizing to do homework. Often, she forgets to plan ahead by writing down the assignment or bringing home the right books. And when trying to work, every few minutes she finds her mind drifting to something else. As a result, she rarely finishes and her work is full of errors.
- People who are hyperactive always seem to be in motion. They can’t sit still. They may dash around or talk incessantly. Sitting still through a lesson can be an impossible task. Hyperactive children squirm in their seat or roam around the room. Or they might wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive teens and adults may feel intensely restless. They may be fidgety or they may try to do several things at once, bouncing around from one activity to the next.
- People who are overly impulsive seem unable to curb their immediate reactions or think before they act. As a result, they may blurt out inappropriate comments or run into the street without looking. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they’re upset.
Undifferentiated Attention Deficit Disorder
In this form of ADD the primary and most significant characteristic is inattentiveness; hyperactivity is not present. Nevertheless, these children still manifest problems with organization and distractibility, and they may be seen as quiet or passive in nature. It is speculated that undifferentiated ADD is currently under diagnosed, since these children tend to be overlooked more easily in the classroom. Thus, children with undifferentiated ADD may be at a higher risk for academic failure than those with attention deficit hyperactivity disorder.
Can Any Other Conditions Produce These Symptoms?
The fact is, many things can produce these behaviors. Anything from chronic fear to mild seizures can make a child seem overactive, quarrelsome, impulsive, or inattentive. For example, a formerly cooperative child who becomes overactive and easily distracted after a parent’s death is dealing with an emotional problem, not ADHD. A chronic middle ear infection can also make a child seem distracted and uncooperative. So can living with family members who are physically abusive or addicted to drugs or alcohol. Can you imagine a child trying to focus on a math lesson when his or her safety and well-being are in danger each day? Such children are showing the effects of other problems, not ADHD.
In other children, ADHD-like behaviors may be their response to a defeating classroom situation. Perhaps the child has a learning disability and is not developmentally ready to learn to read and write at the time these are taught. Or maybe the work is too hard or too easy, leaving the child frustrated or bored.
Tyrone and Mimi are two examples of how classroom conditions can elicit behaviors that look like ADHD. For months, Tyrone shouted answers out in class, then became disruptive when the teacher ignored him. He certainly seemed hyperactive and impulsive. Finally, after observing Tyrone in other situations, his teacher realized he just wanted approval for knowing the right answer. She began to seek opportunities to call on him and praise him. Gradually, Tyrone became calmer and more cooperative.
Mimi, a fourth grader, made loud noises during reading group that constantly disrupted the class. One day the teacher realized that the book was too hard for Mimi. Mimi’s disruptions stopped when she was placed in a reading group where the books were easier and she could successfully participate in the lesson.
Like Tyrone and Mimi, some children’s attention and class participation improve when the class structure and lessons are adjusted a bit to meet their emotional needs, instructional level, or learning style. Although such children need a little help to get on track at school, they probably don’t have ADHD.
It’s also important to realize that during certain stages of development, the majority of children that age tend to be inattentive, hyperactive, or impulsive–but do not have ADHD. Preschoolers have lots of energy and run everywhere they go, but this doesn’t mean they are hyperactive. And many teenagers go through a phase when they are messy, disorganized, and reject authority. It doesn’t mean they will have a lifelong problem controlling their impulses.
ADHD is a serious diagnosis that may require long-term treatment with counseling and medication. So it’s important that a doctor first look for and treat any other causes for these behaviors.
What Can Look Like ADHD?
Underachievement at school due to a learning disability
Attention lapses caused by petit mal seizures
A middle ear infection that causes an intermittent hearing problem
Disruptive or unresponsive behavior due to anxiety or depression
Can Other Disorders Accompany ADHD?
One of the difficulties in diagnosing ADHD is that it is often accompanied by other problems. For example, many children with ADHD also have a specific learning disability (LD), which means they have trouble mastering language or certain academic skills, typically reading and math. ADHD is not in itself a specific learning disability. But because it can interfere with concentration and attention, ADHD can make it doubly hard for a child with LD to do well in school.
A very small proportion of people with ADHD have a rare disorder called Tourette’s syndrome. People with Tourette’s have tics and other movements like eye blinks or facial twitches that they cannot control. Others may grimace, shrug, sniff, or bark out words. Fortunately, these behaviors can be controlled with medication. Researchers at NIMH and elsewhere are involved in evaluating the safety and effectiveness of treatment for people who have both Tourette’s syndrome and ADHD.
More serious, nearly half of all children with ADHD–mostly boys–tend to have another condition, called oppositional defiant disorder. Like Mark, who punched playmates for jostling him, these children may overreact or lash out when they feel bad about themselves. They may be stubborn, have outbursts of temper, or act belligerent or defiant. Sometimes this progresses to more serious conduct disorders. Children with this combination of problems are at risk of getting in trouble at school, and even with the police. They may take unsafe risks and break laws–they may steal, set fires, destroy property, and drive recklessly. It’s important that children with these conditions receive help before the behaviors lead to more serious problems.
At some point, many children with ADHD–mostly younger children and boys–experience other emotional disorders. About one-fourth feel anxious. They feel tremendous worry, tension, or uneasiness, even when there’s nothing to fear. Because the feelings are scarier, stronger, and more frequent than normal fears, they can affect the child’s thinking and behavior. Others experience depression. Depression goes beyond ordinary sadness–people may feel so “down” that they feel hopeless and unable to deal with everyday tasks. Depression can disrupt sleep, appetite, and the ability to think.
Because emotional disorders and attention disorders so often go hand in hand, every child who has ADHD should be checked for accompanying anxiety and depression. Anxiety and depression can be treated, and helping children handle such strong, painful feelings will help them cope with and overcome the effects of ADHD.
Of course, not all children with ADHD have an additional disorder. Nor do all people with learning disabilities, Tourette’s syndrome, oppositional defiant disorder, conduct disorder, anxiety, or depression have ADHD. But when they do occur together, the combination of problems can seriously complicate a person’s life. For this reason, it’s important to watch for other disorders in children who have ADHD.
What Treatments Are Available?
For decades, medications have been used to treat the symptoms of ADHD. Three medications in the class of drugs known as stimulants seem to be the most effective in both children and adults. These are methylphenidate (Ritalin), dextroamphetamine (Dexedrine or Dextrostat), and pemoline (Cylert). For many people, these medicines dramatically reduce their hyperactivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as handwriting and ability in sports. Recent research also suggests that these medicines may also help children with an accompanying conduct disorder to control their impulsive, destructive behaviors.
Unfortunately, when people see such immediate improvement, they often think medication is all that’s needed. But these medicines don’t cure the disorder, they only temporarily control the symptoms. Although the drugs help people pay better attention and complete their work, they can’t increase knowledge or improve academic skills. The drugs alone can’t help people feel better about themselves or cope with problems. These require other kinds of treatment and support.
For lasting improvement, numerous clinicians recommend that medications should be used along with treatments that aid in these other areas. There are no quick cures. Many experts believe that the most significant, long-lasting gains appear when medication is combined with behavioral therapy, emotional counseling, and practical support. Some studies suggest that the combination of medicine and therapy may be more effective than drugs alone.
Use of Stimulant Drugs
Stimulant drugs, such as Ritalin, Cylert, and Dexedrine, when used with medical supervision, are usually considered quite safe. Although they can be addictive to teenagers and adults if misused, these medications are not addictive in children. They seldom make children “high” or jittery. Nor do they sedate the child. Rather, the stimulants help children control their hyperactivity, inattention, and other behaviors.
Different doctors use the medications in slightly different ways. Cylert is available in one form, which naturally lasts 5 to 10 hours. Ritalin and Dexedrine come in short-term tablets that last about 3 hours, as well as longer-term preparations that last through the school day. The short-term dose is often more practical for children who need medication only during the school day or for special situations, like attending church or a prom, or studying for an important exam. The sustained-release dosage frees the child from the inconvenience or embarrassment of going to the office or school nurse every day for a pill. The doctor can help decide which preparation to use, and whether a child needs to take the medicine during school hours only or in the evenings and on weekends, too.
Nine out of 10 children improve on one of the three stimulant drugs. So if one doesn’t help, the others should be tried. Usually a medication should be tried for a week to see if it helps. If necessary, however, the doctor will also try adjusting the dosage before switching to a different drug.
Other types of medication may be used if stimulants don’t work or if the ADHD occurs with another disorder. Antidepressants and other medications may be used to help control accompanying depression or anxiety. In some cases, antihistamines may be tried. Clonidine, a drug normally used to treat hypertension, may be helpful in people with both ADHD and Tourette’s syndrome. Although stimulants tend to be more effective, clonidine may be tried when stimulants don’t work or can’t be used. Clonidine can be administered either by pill or by skin patch and has different side effects than stimulants. The doctor works closely with each patient to find the most appropriate medication.
Both parents and their children may need special help to develop techniques for managing the patterns of behavior. In such cases, mental health professionals can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other.
Several intervention approaches are available and different therapists tend to prefer one approach or another. The following interventions have proven successful in helping parents and children:
Psychotherapy works to help people with ADHD to like and accept themselves despite their disorder. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change. However, people dealing with ADHD usually want to gain control of their symptomatic behaviors more directly. If so, more direct kinds of intervention are needed.
Cognitive-behavioral therapy helps people work on immediate issues. Rather than helping people understand their feelings and actions, it supports them directly in changing their behavior. The support might be practical assistance, like helping Henry learn to think through tasks and organize his work. Or the support might be to encourage new behaviors by giving praise or rewards each time the person acts in the desired way. A cognitive-behavioral therapist might use such techniques to help a belligerent child like Mark learn to control his fighting, or an impulsive teenager like Lisa to think before she speaks.
Social skills training can also help children learn new behaviors. In social skills training, the therapist discusses and models appropriate behaviors like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance to practice. For example, a child might learn to “read” other people’s facial expression and tone of voice, in order to respond more appropriately. Social skills training helped Lisa learn to join in group activities, make appropriate comments, and ask for help. A child like Mark might learn to see how his behavior affects others and develop new ways to respond when angry or pushed.
|Some Coping Strategies for Teens and Adults with ADHD
Adopted from: Weinstein, C. “Cognitive Remediation Strategies.”
Establishing The Proper Learning Environment
Seat students with ADD near the teacher’s desk, but include them as part of the regular class seating.
Place these students up front with their backs to the rest of the class to keep other students out of view.
Surround students with ADD with good role models, preferably students whom they view as significant others. Encourage peer tutoring and cooperative/collaborative learning.
Avoid distracting stimuli. Try not to place students with ADD near air conditioners, high traffic areas, heaters, or doors or windows.
Children with ADD do not handle change well, so avoid transitions, physical relocation (monitor them closely on field trips), changes in schedule, and disruptions.
Be creative! Produce a stimuli-reduced study area. Let all students have access to this area so the student with ADD will not feel different.
Encourage parents to set up appropriate study space at home, with set times and routines established for study, parental review of completed homework, and periodic notebook and/or book bag organization.
Giving Instructions To Students With ADHD
Maintain eye contact during verbal instruction.
Make directions clear and concise. Be consistent with daily instructions.
Simplify complex directions. Avoid multiple commands.
Make sure students comprehend the instructions before beginning the task.
Repeat instructions in a calm, positive manner, if needed.
Help the students feel comfortable with seeking assistance (most children with ADD will not ask for help).
Gradually reduce the amount of assistance, but keep in mind that these children will need more help for a longer period of time than the average child.
Require a daily assignment notebook if necessary:
- Make sure each student correctly writes down all assignments each day. If a student is not capable of this, the teacher should help him or her.
- Sign the notebook daily to signify completion of homework assignments.
Give out only one task at a time.
Monitor frequently. Maintain a supportive attitude.
Modify assignments as needed. Consult with special education personnel to determine specific strengths and weaknesses of each student. Develop an individualized education program.
Make sure you are testing knowledge and not attention span.
Give extra time for certain tasks. Students with ADD may work slowly. Do not penalize them for needed extra time.
Keep in mind that children with ADD are easily frustrated. Stress, pressure, and fatigue can break down their self-control and lead to poor behavior.