In This Article:
Attention Deficit / Hyperactivity Disorder, for short ADHD, is an evolving condition that affects the ability to exercise self-control, accompanied by attention and concentration difficulties, impulse control, and level of activity. These problems are essentially due to the child’s difficulty to adjust his / her behavior according to the time spent, the goals to reach, and the requirements of the environment. It is good to point out that ADHD cannot be referred to as a normal stage of growth that every child has to overcome, nor is it the result of ineffective educational discipline, and much less an issue due to the child’s “malice”.
Principal ADHD symptoms
ADHD poses multiple challenges for those who suffer from it, for the family and for the school, and often represents an obstacle in achieving personal goals. It is a problem that generates unease and stress in parents and teachers who are unprepared in managing the child’s behavior.
The parents often witness other people’s reactions towards behavioral profile of their hyperactive child’s behavior: at first, strangers tend to ignore unrestricted behavior, frequent interruptions in adult speech, and violation of common social rules. Against the background of repeated manifestations of the absence of control of the child’s demeanour, such persons try to stop on excessive “exuberance”, failing to arrive at the conclusion that destructive or rude behavior is intentional. It can be that the parents arrive to the same conclusions as the strangers come to, commonly coming to: “The child’s problems are due to the way he or she was educated; more discipline, greater limitations and some nice punishment would be needed. The parents are incapable, incompetent, overly indulgent and permissive, and consequently, that the child’s behavior is the result of their upbringing.”
What is said above will certainly stir many parents into action, making them realize that one needs to take measures in order to socially adapt such children, it is equally true that it is urgent to make other adults understand what the real nature of the hyperactivity problem is. It is necessary that all people having to interact with ADHD children know and understand the motivations of the behaviors of such children, by setting aside the absurd and unjustified explanations of accusing and hurting their already overwhelmed and stressed parents for this situation.
First, you need to establish whether child you are thinking of really has Attention Deficit / Hyperactivity Disorder (ADHD) or if it is simply restless and with the head in the clouds. No person other than a specialist (for example, a psychologist or neuropsychiatrist), should be allowed to determine that child presents an ADHD case – or contrarily, that he or she doesn’t.
Below you can find disturbance descriptions to provide parents and teachers with a clearer definition of the problem, to understand what behaviors are to be reduced and what can be considered a simple variability of child’s temperament.
Attention in ADHD children
The symptoms of inattention are mainly found in children who, compared with their peers, have an evident difficulty in being alert or working on the same task for a sufficiently long period of time.
Several authors argue that the main deficit of the syndrome is due to the difficulties of attention, which occur both in school / work / social situations. Since the focus of attention is multidimensional (selective, maintained, focused, divided), the latest research seems to agree that the most obvious problem in ADHD is to keep the focus, especially during repetitive or boring activities.
These difficulties also occur in playing situations where the child manifests frequent passages between several games, seeming to unable logically conclude any of them.
There are obvious difficulties at school whenever attention to details is required, when trivial “distraction errors” occur, and work is incomplete and messy. Teachers and parents report that children affected with this disorder seem to not hear or let their head wander when they talk to them directly. Learning abilities of an overactive child may be affected by the disorder with which it manages the school material and the ease with which they are distracted by sounds or other irrelevant stimuli. Despite these observations, research is consistent with the assertion that ADHD children are not easily distracted by other persons. It seems, therefore, that attentive issues become evident in particular when the task to be performed is not attractive and motivating for the child.
Hyperactivity in ADHD children
The second feature of ADHD is hyperactivity, that is, an excessive level of motor or vocal activity. A hyperactive child manifests continued agitation, difficulty sitting and holding in place. According to the stories of parents and teachers, children with ADHD seem “driven by a engine”: they are continuously on the go, both during work and play, with parents and with teachers. Very often the movements of all parts of the body (legs, arms, and trunk) are not harmoniously directed towards achieving a purpose.
Hyperactivity is considered a behavioral dimension in which children (as well as adults) can be placed between the calmly organized pole and the restless-inattentive pole: this is a continuum along which all people find their place and where, of course, children with ADHD occupy an extreme position.
Impulsive behavior in ADHD patients
Impulse is manifested in the difficulty of delaying an answer, inhibiting inappropriate behavior, awaiting gratification. Impulsive children respond too fast (often compromising on the accuracy of their answers), frequently interrupt the others when they are talking, they can not stand in line and wait for their turn. In addition to persistent impatience, impulsiveness also manifests itself in taking dangerous actions without considering the possible negative consequences. Impulsivity is a feature that remains quite stable during development (although it knows different shapes according to age) and is also present in adults with ADHD.
Causes of ADHD
What the reasons for ADHD onset are continues to be one of the most intricate and still unresolved issues of childhood psychiatry, psychology and clinical genetics.
Since 1902, with the first description by George Still, it was hypothesized the presence of an unspecified CNS malfunction as a cause of the disturbance. Throughout the twentieth century, many researchers found interesting similarities between the demeanor of ADHD children and that of patients with lesions in the frontal regions (in particular the prefrontal area) of the cerebral cortex: disinhibition, issues of attention, planning difficulties, and cognitive strategies.
Researchers of various disciplines have made available their knowledge and tools to find significant differences between healthy children and those affected by ADHD: in individual cases, patients are able to display the plausibility of their hypotheses, others less. In particular, some studies using electrophysiological measurements have failed to replicate the existence of a specific pattern of typical functionality of ADHD affected children, despite the fact that it has not been established that the latter have lower levels of arousal. Other researches based on brain imaging techniques have proven that such children consistently display inferior levels of brain activity (measured by glucose or oxygen consumption): in particular, in the circuit linking prefrontal regions with the limbic system through The striated body. In line with what has just been said, other brain imaging researches have shown that some brain areas of children with ADHDs are smaller than those of controls: the right frontal area, the caudate nucleus, the pale globule and the cerebellum. There are numerous regions in these regions with dopamine and noradrenaline circuits: in fact, ADHD children exhibit inferior levels of such neurotransmitters than control children.
Another strand of research on the causes of ADHD investigated the presence of complications during pregnancy or delivery. Overall, children with ADHD have had more pre- or perennial problems than controls. This, however, cannot be considered as sufficient grounds for the development of ADHD.
Most of the scientific research investigating the causes of ADHD concerns genetics. The reasons for this stem from a series of relevant results obtained on relations of ADHD patients and molecular genetics. In fact, 57% of the parents of ADHD affected child suffer from the same condition, the percentage falls to 32% if they are non-twin brothers; Percentages that are 6 to 12 times higher than the incidence of the condition in the normal population. According to a large study by Goodman and Stevenson, the percentage of causality of ADHD attributable to genetic factors ranges between 70% and 91%, while the remaining 10% -30% is attributable to environmental factors. It therefore seems plausible to hypothesize about the onset of the disorder being attributable, for the most part, to hereditary factors. At the same time, the severity, evolution and prognosis of symptoms depend on factors related to education and the social background in which the child is placed.
Diagnostic criteria for ADHD
The most recent description of Attention Deficit Disorder / Hyperactivity Disorder maintains that a child is required to present the minimum of 6 symptoms for ADHD diagnosis, manifested over six months and at least two contexts. In addition, these events should be observed in pre-school years, up to age 7, above all that, undermine school and / or social performance.
If a subject who presents only 6 out of the 9 symptoms of inattention, ADHD diagnoses is termed as inattentive subtype. If a subject presents only 6 of the 9 symptoms of hyperactivity-impulsivity, then ADHD is diagnosed – hyperactive-impulsive subtype; Finally, if the subject presents both issues, then ADHD is diagnosed as subtype combined.
- Both (1) or (2):
(1) At least 6 of inattantion symptoms listed below that have been manifested during at least 6 months with an intensity that causes mismatch and is in conflict with the development level:
(A) often fails to consider details or makes mistakes of ignorance at school, work or other study or work-related situations;
(B) often has difficulty in paying attention to tasks or gaming activities;
(C) appears as not attending to what is explicitly and audibly narrated;
(D) often fails to completely follow the instructions and finds difficulty in ending school tasks, housework or job duties (not due to opposing behavior or difficulties in understanding);
(E) often finds it challenging to organize various tasks or activities;
(F) often avoids, opposes or is unwilling to participate in activities that require reluctant to participate in tasks that require consistent mental effort (e.g., homework or school);
(G) often loses material needed for tasks or other activities (e.g., toys, materials assigned for the activity, pencils, books, etc.);
(H) is susceptible to distractive sounds, images, occurrences, etc.;
(I) often fails in daily activities.
(2) At least 6 of hyperactivity-Impulsivity symptoms listed below that have been present for at least 6 months in the intensity that can be described as disadvantageous and inappropriate according to the level of development:
(A) often moves hands or feet or fidgets in the chair;
(B) often gets up in class or in other situations where he or she is expected to sit;
(C) often is excessively physically active in situations where it is inappropriate (in adolescents and adults this symptom is often limited to a subjective feeling of restlessness);
(D) often finds it difficult to play or engage quietly and in other quiet activities;
(E) is continually “running” or acts as if he or she is “driven by an engine”;
(F) often speaks excessively;
(G) often “blurts” responses without waiting to hear the end of the question;
(H) often finds it difficult to wait for their turn to speak;
(I) often interrupts or behaves intimately towards others (e.g., breaks into games or conversations of others).
- Hyperactivity-impulsive symptoms that are presented as problematic must be manifested before the age of 7.
- Problems caused by the above listed symptoms must occur in at least two contexts (e.g., at school [or at work] and at home).
- Substantial evidence of impairing nature of such symptoms, detrimental to social functioning, should be presented before the diagnosis is concluded.
- Symptoms are not manifested solely during a Generalized Developmental Disorder, schizophrenia or other psychotic disorders or that are not best justified by other mental disorders (e.g., Mood Disorders, Anxiety Disorders, Disorders Disorders or Personality Disorders).
Symptoms and diagnostic criteria according to DSM-IV
Although considerable progress is observed in the nosocomial descriptions of the disorder, there remain numerous doubts and doubts as to the validity of this diagnosis. In particular, it is still unclear whether the underdog subtype is indeed a ADHD manifestation, or if it is a different disorder, or is the consequence of a psychological discomfort arising from heterogeneous causes. Secondly, research has not yet shown whether the hyperactive-subtype subtype can be separated from the combined subtype or represents an early stage of development of the same disorder which, in conjunction with elementary education, assumes the garment of the combined subtype.
As repeatedly repeated, Attention Deficit / Hyperactivity Disorder label is derived from the DSM-IV diagnostic description published by the American Psychiatric Association, while that of hypercinetic syndrome is described in ICD-10, published From the World Health Organization. ICD-10 distinguishes, within the category Hypercinetic Syndrome, Attention Activity and Attention Disorder and Hypercinetic Conduct Syndrome.
Concerning Activity and Attention Disorder, the symptoms are the same as those of DSM-IV. Despite this partial overlap, the discrepancies between the two manuals are significant. In particular, the diagnosis of Activity and Attention Disorder – DAA is only given if a child presents at least 6 symptoms of inattention, three of hyperactivity and one of impulsivity: in this way this diagnosis is Almost overlapping with that of ADHD – a combined subtype described in DSM-IV. From this difference it follows that the incidence of DAA and ADHD is radically different: between 1% and 2% the first and between 3% and 5% the second.
Also according to DSM-IV symptoms must manifest themselves before the subject reaches 7 years, while according to ICD-10 before 6. Both manuals require that the disorder is pervasive, that is, it manifests in at least two contexts (e.g., at home or at schoo / work), and which significantly impedes social and educational (or work) functioning.
The ICS-10 hypercinetic syndrome diagnosis describes those cases that, in addition to showing symptoms of Activity and Attention Disorder, also show aggressive and / or opposing / provocative behaviors.
These differences in the diagnostic parameters of the two manuals explain the diversity in the frequency of diagnosis of inattention / hyperactivity disorders between North America and Europe: the first ones prefer the APA system and the second WHO system.
The most homogeneous diagnostic description, which probably describes a real disorder, is that of the ICD-10, although it should be observed that about 3% of children with attentive issues, whether or not associated with learning disabilities, anxiety or Of the mood that find no place within the ICD-10 manual. This results in the fact that they do not activate the necessary cognitive rehabilitation procedures. It seems appropriate to emphasize the need to consider the presence of these children who need help, as well as those with hyperactivity / impulsiveness.
ADHD subtypes according to DSM-IV
As described repeatedly, DSM-IV allows the possibility of diagnosing ADHDs in heterogeneous cases among them, for example, an extremely hyperactive child will receive the same ADHD diagnosis as a person unable to concentrate, but absolutely calm and calm .
Several researches have been made to demonstrate the presence of subtypes within ADHD, in part to justify the DSM-IV proposal in part to isolate other subtypes, different from both cognitive-behavioral and etiologic point of view.
Indeed, the three subtypes of DSM-IV describe very heterogeneous children’s samples, especially with regard to comorbidity, familial background, time course, and response to drug therapy.
Lahey and Carlson have demonstrated that children affected by ADHD – underutilized subtype have more emotional problems (anxiety or mood disorder), are more timid and socially withdrawn. Those with ADHD – combined subtype and hyperactive-subtype are more predisposed to opposing adult demands, are more aggressive, and in 30% of cases receive a second diagnosis of Condom Disorder or Opposing-Provocative Disorder.
Standford and Hynd also found significant differences in teachers’ evaluations: the inattentive subtype is more isolated, more “daydreamer”, more shy, more “inactivated”, and partly similar to the group with learning disabilities. Children with hyperactivity show more symptoms such as “acting before thinking”, “frequently changing activities,” “not waiting for their turn,” and “shouting in class.” The three ADHD subtypes also differ for the age of receiving an ADHD diagnosis: the hyperactive subtype is diagnosed before the combined subtype and in turn before the inattentive subtype: according to some authors It is unclear whether this phenomenon can be accounted for by the fact that hyperactive behaviors are more evident at an early age, or whether it is the outcome of the evolution of the disorder.
Based on the results of a study conducted by Faraone in 1998, there are no substantive differences in the cognitive and psycho-social profile of the three subtypes, except in the most prevalent school-related problems of the group. The three subtypes are comparable with regard to the risk of other pathologies, the performance of cognitive learning tests.
Even more interesting, a study by Dane, Schachar and Tannock compared the activity level, through the recordings of an actigraph, of three groups of children: one with ADHD-inattentive, one with ADHD-combined and one control. In the morning, the surveyed subjects in all the groups failed to show different activity levels, but in the afternoon ADHD affected children were more active than those in the control group. It should be noted above all no essential difference was observed between the subtypes with ADHD (inattentive and combined). Therefore, if we assume that ADHD affected children can be characterized more active than others, it does not appear that there is a dramatic difference between hyperactive and inactive; Moreover, it seems confirmed that hyperactivity is a manifestation that depends on temporal and situational factors.
These apparently unusual results find partial support in another research by Marks who applied an actigraph and administered a Continuous Performance Test in ADHD affected children with the purpose of identifying subtypes that show differences in cognitive and behavioral performance. Marks and his co-researchers concluded that there are four ADHD subtypes: one with inattention, hyperactivity, inattention-hyperactivity and a lack of impulse.
The surprising result is the subjects of the subtype with impotence impulsivity were evaluated by their parents as hyperactive, though according to the measurements of the actigraph, this was not true. Our way of seeing the contrast between these results can be partly explained by the heterogeneity of the samples being studied: the age of the groups was different (we have already discussed the evolution of ADHD symptoms), the groups were diagnosed with different methods, So subtypes in subtypes were not completely overlapping.
From a strangely cognitive point of view, other research suggests that children with predominantly inattentiveness mostly experience difficulties in selecting and focusing attention and are less accurate in compiling information; Those of the combined subtype commit numerous errors of perseverance and have difficulty in ignoring the irrelevant information for carrying out a task.
Based on results from clinical evaluations of a sample of 140 children with ADHD at the Maudsley Hospital Clinic in London, professor Taylor proposed subdivision of ADHD into six subtypes. The first subgroup (consisting of 40 cases) has both hyperactivity and opposing behaviors (sometimes turning into a real disorder of conduct), most likely consisting of ADHD children who hadn’t found understanding and acceptance in adults because of their excessive agility, were treated in hostile and aggressive ways, and the latter, in turn, learned a certain pattern of behavior. The second subtype is composed of 26 cases that exhibit pervasive hyperactivity (present in all environmental contexts) and are defined as hyperkinetics; These children have linguistic and motor maturation delays (obviously, the etiology of this syndrome can be distinguished from the other subtypes). The third subgroup collects 26 children with both hyperactivity and oppositiveness, but only in the school context: they are pupils who usually also have delays in learning. The fourth group is made up of 13 children with a specific problem, with no hyperactivity or impulsivity. The fifth subtype consists of 24 cases that show, in addition to ADHD, emotional problems, especially anxiety, but also mood disorders.
It is a rarely recognized subtype, which has slight cognitive deficits and does not respond to psychostimulants. The last subgroup is composed of 11 cases with ADHD symptoms in association with artistic stretches: stereotyped behaviors, communication disturbances or difficulties in social interaction.
Secondary symptoms and associated disorders
Unfortunately, subjects with ADHD, on top of the primary symptoms described above, also exhibit other perceived behaviors considered secondary because they are supposed to stem from the interaction between the pathognomonic characteristics of the disorder and their environment. In fact, the growing clinical interest around this syndrome is to be investigated in three factors: the high incidence of the disorder, the presence of many other disorders (comorbidity), and the probability of poor prognosis.
It appears crucial to evaluate the symptoms and their precise nature as well as the presence of any related diagnoses, especially for the purpose of better therapeutic planning.
ADHD affected children are more exposed to the risks of other psychological issues. About 44% of them present one other disorder in their absolute majority, 32% present two more and 11% three more. The presence of other mental conditions is required, specifically: 20% – 56% also have a Disorder of Conduct, about 35% also exhibit Opposition / Provocative Disorder, and 25% are affected by Uterus Disorders And another 25% have Anxiety Disorders.
The development of opposing and provocative traits is a very problematic aspect of ADHD as it may be co-responsible for a series of school and social failures; And can provide considerable and justified concerns to parents. In most cases, aggressive behaviors do not reach a degree of gravity requiring a diagnosis of Condom Disorder or Opposition / Provocative Disorder, although these traits are the most accurate predictors of inflamed prognosis. Children who also demonstrate aggressive behavior are more at risk of others developing deviant behaviors, having problems with justice or drug abuse.
concludes that the two disorders differ in relation to several variables. In particular, children with behavioral disorders are more familiar with anxiety disorder, depressive disorders (especially the mother), higher familial hostility and low socio-economic level, with ADHD affected individuals displaying higher cognitive deficits and non-target behaviors (off-tasks). Both groups receive negative ratings from their comrades, but only aggressive children are both popular and rejected, suggesting that they have the social skills necessary to establish interpersonal relationships, but they do not want to use them.
Numerous studies have sought to frame the cognitive and behavioral differences of subjects with ADHD associated or not with Disorder of Conduct. For example, Taylor argues that mixed disorder (ADHD + DC) is something other than pure ADHD, a bit like the ICD-10 that supports the existence of hypercinetic syndrome of the Conduct, Where symptoms of ADHD and DC are present. Schachar and colleagues simultaneously maintained that individuals affected by a number of specific ADHDs display a poor control of the action, while children with ADHD + DC do not have this cognitive framework. The same Leung and Connolly found greater attention difficulties in the group with only ADHD than that with ADHD + DC.
If from the cognitive point of view the performance of ADHD group is characterized as inferior to that of ADHD + DC group, the behavioral pattern of the mixed-disturbance group is definitely more compromised, especially in relation to peers, adults and Prognosis in adolescent age.
Even in the processing of social information, there are differences between hyperactive / aggressive and only hyperactive children; The first ones attribute more hostile intentions to peer behavior in ambiguous situations and respond more aggressively to ambiguous and provocative behaviors.
Several longitudinal studies on hyperactive children have shown that adolescent hostile behavior is predicted by the degree of aggression during childhood. In the family context, ADHD + DC group is characterized by greater dysfunctions and conflicts, poorer communications and anger, more hostility and false belief than ADHD group.
These data suggest the possibility that socio-cultural factors are formative in DC development, while ADHD appears more linked to innate predisposing factors.
Cognitive deficits and school difficulties
ADHD affected individuals display poorer school performance than their peers, even though they have the same intellectual skills. The explanation of this phenomenon is to be looked at in the attentive difficulties and cognitive self-regulation, in the vast majority of impulsive responses and in hyperactive behavior within the class. The number of children affected with ADHD who have repeated at least one class is three times that of their peers at school.
Extensive research has been carried out to analyze the overlap between ADHD and other learning disabilities (reading, writing and math). Barkley, using the cut-off criterion of -1.5 standard deviations (ie, calculated the percentage of subjects with ADHDs who had performances below that cut-off relative to the normal population) established that individuals affected by ADHD present An instrumental reading disorder (speed and correctness) in 21% of cases, 26% have a spelling deficit and 28% Problems in the logical-mathematical area.
If we take into account that overall learning disturbances occur in about 3% of the school population, it is easy to calculate that children with ADHDs are 7 to 9 times more likely to even experience a learning disorder.
Although the nature of this correlation has not yet been clearly defined, it is equally possible that high comorbidity can prove to stem from different mechanisms:
- Typical ADHD behaviors cause a secondary learning disorder: in this case, the difficulties of attention and impulsivity interfere with the acquisition of scholastic skills. In this, School Awareness Disorder (DAS) is an artifact found in the last years of elementary school when a person with ADHD performs inferior to companions but possesses the neurocognitive prerequisites for reading and writing. In this case the clinician should be cautious not to exchange a learning delay with a DAS, it is advisable to check the child’s performance during the first steps of mastering the written language: if there were no problems, poor school performance is not Are due to a learning disorder.
- The DAS determines the appearance of typical ADHD traits (inattention, hesitation and restlessness). This could happen because a child with DAS collects a series of school failures that lead him to lose any interest in school. From this, hesitant behaviors can develop that take forms similar to ADHD markers. In this case, the practitioner should be very cautious not to exchange a DAS with a ADHD, especially by informing the child of the child before entering elementary school.
- The third possibility may occur when both disorders are present at age 6, the moment the child is placed in elementary school. In this case, the two disorders are contagious because there are neurocognitive impairments that determine the onset of both ADHD and DAS.
The group with mixed disorder is what divides the researchers into the interpretation of the problem: according to some the cognitive performance of the group with ADHD + DAS is more reminiscent to that of children with DAS. The associated ADHD would be a secondary phenomenon of a learning disorder. Other authors, for example, Taylor, believe that the mixed-disturbance group is a ADHD subtype, with distinct features compared to the “pure” ADHD.
In addition to the problem of overlapping with learning disabilities, experts believe that ADHD affected children are presented with a number of school difficulties because of an inability to use their cognitive resources. In particular, work memory, learning strategies and inhibition of irrelevant information. This cognitive profile results in negative consequences for the understanding of written texts, for the study and for the solution of arithmetic problems.
Anxiety issues make ADHD affected children face a number of problems with concentration, impulsiveness and restlessness, just like those with ADHD, but the first, unlike the latter, are unduly concerned about their future. Even in the distribution of the two sexes, the two disorders can be differentiated; in fact, anxiety problems are present in the females compared to males (the picture is completely overturned in ADHD).
In adulthood some cases with ADHD may develop anxious traits that stem from series of social and educational failures that have accumulated during growth, and make them insecure with respect to their abilities and uncertain about the results of their behavior.
Another 25% of persons suffering from ADHD receive a second diagnosis of Love Disorder. From a clinical standpoint, it is rather challenging to discriminate against a mood of ADHD, as parents report for both issues: concentration difficulties and hyperactivity. In fact, often children who experience an emotional discomfort manifest their illness through a series of behaviors including shaking and inattention. Therefore, it is required for the clinician to conduct a structured clinical interview with parents to investigate the presence of other symptoms that are outside the scope of ADHD, for example, manifested interest in activities considered first to be pleasant, feeding or sleep irregularities, and the presence of neg,ative allegations about himself and situations in general.
As it is observed for anxiety disorder, some ADHD children may develop the symptoms of Mood Disorder as they may experience the subjective feeling of failure and frustration because of the many academic and social failures. This mode of thinking arises mainly from their idea that failures are due to a skill deficit. Millich and Okazaki, using the “learned helplessness” paradigm, verified that children affected by ADHD more frequently interrupt activity before others when experiencing failure or frustration, thus confirming their major Willing to develop a Disorder of Love.
Behavioral self-control problems naturally also affect interpersonal relationships.
It is but natural than that persons affected byADHD are often rejected and are the least popular among their companions. Teachers evaluate them negatively not only from the profit’s standpoint, but above all in terms of behavior and respect for social rules. The quality of their interactions is certainly not adequate, both in structured contexts and in play, as there is a high frequency of negative both verbal and non-verbal behaviors, less interaction with companions, low levels of affective expression and greater social retreat Followed by aggression.
It should be pointed out that very often children with ADHD, without aggression, do not intentionally exhibit these disturbing behaviors, and are genuinely surprised by the negative outcomes of their maladaptive actions. Surely the presence of aggression, frequently related to the disorder, is partly responsible for greater severity of behavioral disorders.
Overactive children are described by their comrades as non-cooperative in group situations, intrusive and in some cases aggressive and provocative, and risk not to benefit from socialization opportunities with their comrades.
Barkley, DuPaul and McMurray through sociometric research have established that children affected by various ADHDs (combined and hyperactive subtypes) receive more frequent negative assessments from comrades, while those with predominant inattention receive fewer evaluations in general. More cooperative behaviors have been observed in structured contexts among companions, where ADHD affected individuals can assume a more active and collaborative role than when they are in other contexts.
When their role is more passive and unclear, hyperactive children become more controversial and incapable of communicating with their peers profitablely.
How to deal with ADHD
Based on the data of scientific literature, the ideal treatment for ADHD is multimodal type, that is, a treatment that implies the involvement of school, family and child itself, beyond in a pharmacological intervention.
Apart from the pharmacological discourse, interventions that could be applied relate to the psycho-social sides of the matter. The cognitive and behavioral tradition has allowed the development of some educational and therapeutic programs that have also been published in our country, and others are under preparation (see editions of the Publishing House Erickson).
The behavioral approach is characterized by a detailed assessment of the elicited and maintained reactions towards specific external stimuli, strategies to produce a change in the surrounding environment and thus in the responses and attitude of the parents. To conclude the intervention, a review is made to evaluate the successes of the treatment.
During behavioral treatment, both productive and counterproductive events that either increase or decrease the frequency of certain behaviors are identified and therefore adjusted in order to reduce problematic patterns in the behaviour and amplify adaptive forms of behavior. It is suggested to use coins or other tokens that can be earned by the patient as encouragement for adaptive behaviors. Such tokens can later be exchanged for incentives that build up the child’s reinforcements, such as pocket money, treats, perks, toys or time allowed for the child’s favorite activity. The point system can be used successfully by parents, teachers, and clinicians, either by working with groups or individually.
The most important weakness in behavioral therapy is the difficulty in maintaining, over time, the improvement achieved, and in generalizing changes in situations that are different from the one created within the treatment. The outcomes can be reinforced by intervention in contexts where change of behavior is required, based on time and place, facilitating the transfer to naturally use the reinforcements, gradually decreasing the reinforcements, based on training parents and educators to highlight the behaviors desired and to change and control contingencies.
The problem is that it is rather challenging for adult supervisors to consistently support such a behavioral program. The maximum benefit of a behavioral program is achieved through cooperation between family and school, focusing on a range of behaviors, providing the context.
Parental behavioral modification is rooted at the theory social learning, and was specifically designed for parents of non-cooperative, opposing and aggressive children. The results achieved in the course of training programs for parents proved to improve and strengthen desirable behavior patterns in ADHD children. Such training teaches responsible adults to improve social abilities of their ADHD affected children, reinforcing the importance of an active role in the organization of the child’s social image and teach the child to get on with the adults in the environment where the child is living (teachers and other educators).
The focal point of such training is to teach parents express their will in a clear instructive way, to encourage acceptable behaviors, to ignore some problematic behaviors, and to effectively use punishments.
This type of intervention is included in multimodal treatment. The assessment of the effectiveness in the training of social skills encounters the problem of the absence of homogeneity among ADHD children and the variety in the aetiology of social skills deficits within the group. Practical problems in this regard include the need to provide specific intervention for the particular deficiency of each patient and the inability of children to proceed from theoretical knowledge about skill to their practical implementation.
It can be concluded based on the clinical experience that treating patients individually does not always yield optimal outcomes and benefits, partly because ADHD affected children have poor self-observation abilities. Contrarily, during group therapy, the set of problem behaviors emerges naturally and can be modified through behavioral modeling, drills, validation, and reinforcements. The use of environments such as school, rather than a private clinic or private study, can increase generalizability.
Cognitive-Behavioral Intervention (ICC)
ICC or problem-solving therapy can be conducted both individually and in group. This type of intervention embraces cognitive strategies training that include problem-solving stages and self-observing, with behaviour all of the modelling tools implemented (reinforcements, self-reinforcements, and modelling).
The ICC has developed in an effort to maximize the generalization and duration of behavior modification techniques. ICC studies among ADHD patients with such behavioral complications as aggressiveness and impulsiveness have shown improvements in cognitive impulse, social demeanor, and the implementation of difficult management strategies.
The biggest problems are the difficulty of generalizing situations where there is no specific treatment and the fact that children find it challenging to apply specific techniques they have been presented with, unless they are motivated to do so. A treatment that also includes self-monitoring and self-evaluation is extremely useful for improving self-control.
An intensive treatment model on problem solving skills seems to be additional and superior to individual-focused relationship therapy, improving behavior of hospitalized children, and behavioral problems, many of which have ADHD associated with other disruptive disorder.
Development of ADHD
The mean age at which hyperactivity disorder reveals itself falls between 3 and 4 years. There are, however, numerous cases involving ADHD symptoms ranging from 6-7 years old, age limits established by ICD-10 and DSM-IV, for diagnosing ADHD.
Regarding the disorder evolution, it is necessary to anticipate that it is manifested in different times and modes depending on a series of variables that mediate symptomatic manifestations. These include: the quality of relationships with and among family members, the acceptance of the child in the educational environment, the general cognitive profile (and intellect in particular), and other disorders in the history that may possibly complicate the pathological picture. The evolutionary changes of the disorder are more understandable if we note that the difficulties are most evident when the child fails to meet the requirements of the environment. Therefore, in conjunction with “shots” of environmental issues related to development, issues become more apparent: for example, in conjunction with elementary school entrance, increased complexity of tasks, new social demands during pre-adolescence And adolescence.
We can subdivide the evolution of ADHD into five phases: before birth (we estimate the risk factors for the onset of the disorder), the first three years of life, the age of kindergarten, elementary school, pre – adolescence, adolescence.
Numerous genetic studies have shown that some characteristics of the parents are predictive of the presence or not of ADHD in the child. For example, some studies have found that parental groups with antisocial behavior or alcoholism problems tend to have children with ADHD more often than others. Other research has found that complications during pregnancy or childbirth are risk factors for the onset of a ADHD. However, these do not cause the condition per se, being but contributing factors that put persons in a risk group of having a child with ADHD. The very presence of attentive and / or behavioral problems in parents is a major risk factor for the child to manifest ADHD in the early years of development. In this case, the probabilities of a child inheriting the disorder from a parent with ADHD reach up to 57%.
Barkley proposed a list of risk factors, sorted by importance, associated with the genesis of ADHD:
- Psychological disorders history in the family, in particular ADHD;
- Cigarette and alcohol abuse of the mother during pregnancy, whether or not associated with the mother’s other health problems;
- Absence of an adequate parent or education;
- Child health problems or developmental delays;
- Early onset of high levels of motor activity;
- Critical and / or direct attitude of the mother during the early years of the child.
Contrary to the risk factors, a list of factors that we could define as protective to help the child to limit the negative outcomes of ADHD, including:
- The mother’s high educational level;
- Good baby’s health shortly after birth;
- Good cognitive ability of the child (in particular linguistic);
- Family stability.
Often parents report their ADHD affected children to be difficult from birth: very irritable, prone to inconsolable crying, easily frustrated, with difficulty sleeping and feeding. Moreover, these children are less sensitive to rewards and are even more difficult to educate, as they give unpredictable responses to educational techniques commonly used for behavioral control. Consequently, the child’s frustration impulsiveness and low frustration can have negative effects on interaction with the mother, triggering a vicious circle that leads to anxiety in the symptoms.
In his or her early school years, such child tends to be very active and, although having an intelligence similar to that of his peers, shows a little mature behavior over the chronological age. Depending on the situation, the child with ADHD behaves in a more or less problematic way: in free play situations where there is ample freedom of movement, he or she does not show any particular difficulty, but in contexts where compliance with certain Rules the child is labeled as “problematic and difficult to handle”. The child’s play with ADHD is simpler, stereotyped, poor in meaning, characterized by simple motions and continuous changes of interests. With entry to elementary school, the difficulties increase because of the presence of a set of rules that must be respected and the tasks to be performed. Teachers continue to describe these pupils as immature to their peers, especially from a behavioral point of view. Both parents and teachers are somewhat baffled by the tremendous variability of their attentive performance: in class they can not attend the lesson for just five minutes, successfully completing a video game that lasts for half an hour. Interpersonal problems, often present during pre-school age, persist and tend to increase in severity; This is probably because positive interactions with comrades require increasingly social skills, communication and self-control with the advancement of age.
With growth, hyperactivity tends to decrease in terms of frequency and intensity, and may be partially replaced by “internalized agitation” which is manifested mainly by intolerance, impatience, and continual change in activity or body movements. In addition, development can lead to behavioral traits that further impede the child’s well-being in his social environment, such as obstinacy, poor obedience to rules, bullying, the most lazy mood, poor Tolerance to frustration, anger and low self-esteem.
During pre-adolescence, uncontrolled behavior and inattention do not allow easy acquisition of social skills, indispensable for a fair fair play: the boys with ADHD show little capacity to maintain friendships and resolve interpersonal conflicts.
During adolescence, moderate attenuation of symptomatology is observed on average, however, not offering a full recovery, as there are often other mental disorders such as depression, antisocial behavior or anxiety. In a follow-up study conducted by Lambert, it has been pointed out that among children diagnosed with ADHD during elementary school years, 70% and 80% of them still experience symptoms of the disorder.
At this age, problems of identity, group acceptance, and physical development are issues that do not always manage to be effectively addressed by a boy with ADHD. Inevitable failures can result in self-esteem, poor self-confidence, or even clinically significant anxiety or depression.
Therefore, in addition to ADHD being predominantly chronic, a note should be made that concomitant presence of an Opposition / Provocative Disorder or Conduct Disorder results in a more infrequent prognosis, since the boy may manifest serious antisocial behavior and problems with the law. These data are backed up by those of a recent follow-up research during which, for 10 years, the behavior of a 6-7-year-old group of 6-year-olds with hyperactivity was analyzed: this symptomatology is an essential criteria in the risk of subsequent antisocial behavior, interpersonal problems and the presence of other psychiatric disorders.
Choosing the right treatment for ADHD individuals
In international literature, from the seventies to the present, it is possible to identify at least 5 models aimed reconstructing and explaining the complex pattern of cognitive and behavioral deficits of ADHD affected children. In this short section we will not consider rather overcome theories, which have already been addressed in the section on the history of ADHD, including that of Still on the lack of moral control and lack of will, and that of Wender on the minimum cerebral dysfunction.
In the 1970s and 1980s, Virginia Douglas gave a radical impetus to studies on children’s cognitive processes with DDA, so that ADHD nosocomial description introduced by DSM-III began to emphasize above all the cognitive deficits Compared to behavioral ones.
The Douglas model outlines the presence of 4 primary deficits:
- weak investment in terms of maintaining the effort;
- modulation deficiency of the psycho-physiological arusal that makes the subject incapable of meeting the demands of the tasks;
- strong search for intense and immediate stimulation and gratification;
- difficulty in controlling the pulses.
The consequence of these primary deficits is then manifested in a general self-regulation deficit that includes planning, organizational, executive, metacognition, cognitive flexibility, self-monitoring, and self-correction deficiencies. Concerning executive functions, it is sufficient to remember that this term is a series of mental processes including cognitive flexibility, planning, work memory, verbal fluency, mental representation of a goal, voluntary effort to maintain, voluntary use of strategies and Inhibition of inappropriate responses.
In the 1990s Sergeant’s group proposed the so-called cognitive-energy model that envisages three levels of information processing:
- The superordinate one coordinates the actions and is the headquarters of the executive functions (according to Sergeant: task mental representation, planning, monitoring, inhibiting, responding to a response, finding and correcting errors in order to maintain an adequate problem-solving condition).
- The second level is the purely energetic one in which the existence of three pools is proposed: the first, more sophisticated, is the effort (effort required to provide the person with the energy needed to carry out a task) ; The effort controls the arousal and activation. Arousal is defined as the energy needed to provide rapid responses (usually for stimulation analysis); Activation is the energy needed to keep watch.
- The third level of information processing consists of three systems: decoding, processing and motor response. Sergeant’s model predicts that children with ADHD have a deficit on the activation component that results in engine performance impairment; While the arousal-decoding circuit is intact. According to Sergeant, children with ADHD have a deficit over the top control component (executive functions) but it is still unclear which of these processes are compromised and what seems intact.
In 1997, Barkley proposed the so-called hybrid model, specific for Attention Deficit / Hyperactivity Disorder, according to which the central problem of these children is an inhibitory deficit and executive functions. Barkley suggests a close resemblance to the performance of children with ADHD with those of adult patients with pre-frontal lesions and argues that the inhibitory deficit causes difficulty at work memory level, self-regulation of emotions, motivation and arousal, language interiorization, and analysis / Synthesis of events (reconstitution).
A little more articulated from the neuropsychological point of view is Swanson’s proposal which resumes a formulation of attentive networks proposed by Posner and Peters.
The Posner model expects three networks to monitor the attentive processes:
- execution / control,
- keeping the alert,
The executive-based circuit monitors target-driven behaviors, target detection, error detection, conflict resolution, and inhibition of automated responses. From the neurological point of view, the executive network finds correspondence in the medial frontal lobe, including the track’s lap.