Understanding ADHD

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What is ADHD?
How common is ADHD?
What causes ADHD?
Do children grow out of it?
How is a diagnosis made?
What are the treatments?
What should I do if I'm worried?
Useful organisations
Websites
Further reading

"I always worry when I go to pick John up from school. It seems every day some problem has arisen. I feel people think I'm just a bad parent."

"To try and get Manjeet to do her homework and hand it in, in a presentable form, can take all night. We often get comments from the school on how messy her work is, but she does try so hard."

"Ben is so unpredictable; one minute he will be in a good mood, and the next he will be shouting at his sister. When we have other children around, he will act very silly, and then boss them about."

"I don't care what you call the problem, my child needs help."

These children can have severe behavioural problems with difficulties paying attention and controlling activity levels, and they may or may not have learning difficulties. This booklet describes the behaviour and gives an overview of the various theories about ADHD. It suggests what can be done to help, and the practical steps that parents, teachers and other carers can take.

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What is ADHD?

Many parents worry about how their child is behaving, from time to time, but untamed behaviour is a normal part of growing up. The difference between this and ADHD is how extreme it is. Children with ADHD usually behave in the same challenging way, wherever they are and whoever they're with. Unless they get the special help they need, ADHD can be damaging to them, to their family, and to their future. Children can be very young when problems start. Parents often describe their children as being 'motor driven'. They will be restless, on the go the whole time, often very clumsy and always asking for attention.

In the first two years of school, teachers will find them untidy, disorganised and forgetful. As time goes on, they may also find that the child finds it hard to sit still or stick to one task, and that learning and writing is very challenging for them, because they are so easily distracted.

Children with ADHD are highly impulsive, and may speak or act without thinking about what they are saying or doing. They are also very talkative and can find it difficult to listen, and take turns in conversation. As a result, they may come across as bossy to other children, which may make it harder for them to maintain friendships.

As they grow older, their own restlessness can make them feel frustrated and dismayed, making their problems worse. Most children misbehave occasionally. It doesn't mean that there's anything wrong. But if the behaviour has been going on for a long time, it could mean there is a problem, although not necessarily ADHD. If you are worried about your child, you are entitled to help, whether or not your child has ADHD.

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How common is ADHD?

It's hard to judge how many children have ADHD, because different experts use different terms and definitions. This is very confusing for parents and everyone else involved. Statistics vary (in both the UK and the USA), but the latest figures seem to suggest that around five percent of school children in the UK show ADHD behaviour.

It seems that more boys than girls receive this diagnosis, but the reasons why aren't clear. It may have something to do with society's expectations about the way we should behave. In the USA, for instance, groups such as the National Association for the Advancement of Colored People have argued that more Black boys are included in the category than should be.

In the UK, a small study of hyperactivity found that Asian children, rated by their teachers as being as hyperactive as their white classmates, were actually less hyperactive in the classroom. Clearly, it's difficult to arrive at a true picture, so ADHD should be seen as way of defining a set of behaviours that is still open to change, not as a cut-and-dried 'illness'.

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What causes ADHD?

Nobody knows exactly why, and there may be a number of different factors at work. Inheritance can play a part, because a child with ADHD is four times as likely to have a relative who had the same childhood difficulties. Many doctors, particularly in the USA, believe that ADHD is caused by a shortage of the brain chemicals that help a child to concentrate, plan and carry out their activities, and control their emotions. But some experts think that it's unlikely to be just down to these chemicals, and that other influences are at work on a child, from birth onwards.

It's been suggested that stress may act as a trigger to the problem. There's no doubt that stress in the family upsets parents' relationships with their children, making children more disruptive. Families with children diagnosed with ADHD very often show signs of being under stress, but this is hardly surprising. If you have a child with ADHD, your home may feel like a battleground, and your confidence as a parent is likely to be very low. In other words, it could be hard to tell what comes first, the stress or the ADHD.

Another theory is that certain foods and food additives may make your child more irritable and frenetic. Getting hold of a qualified dietician to help may be difficult, but cutting out caffeine and sugary drinks and snacks can be a good start. These measures do not need dietetic advice since sugary foods containing sugar and caffeine usually have minimal nutritional value, anyway. The problem with excess sugar in the diet is often overlooked – the child gets a sugar rush and then needs another one quite soon, as they start to feel 'low' or moody.

Whatever the cause of the problems, parents should never feel to blame. What you need is an understanding of the problems you're facing and help in dealing with them.

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Do children grow out of it?

The more help a child gets, right from the start, the more likely they are to go on to lead positive and successful lives. The longer hyperactivity or behavioural problems go on, the greater the chance of both school and family reacting against the child, and the child reacting against them. School and family environment have an enormous influence on the way a child grows up. People who were hyperactive as children do sometimes go on to have problems in adult life. These tend to be around self-organisation, organising their thoughts and sustaining focus.

Although it's hard to generalise, because of all the different kinds of behaviours included under ADHD, it's clear that many children do grow out of their problems. There's no reason to assume that your child won't.

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How is a diagnosis made?

There aren't any special DNA tests, blood tests or other laboratory tests for ADHD. Only a child mental health expert (a child psychiatrist, an educational psychologist or a paediatrician) can make the diagnosis, based on the DSM-IV (the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders), or the ICD-10 (its European counterpart). One aim is to rule out any other possible causes for your child's behaviour, such as language or hearing difficulties, dyslexia, autism, Asperger's syndrome, epilepsy or depression.

ADHD is the usual term (though it's sometimes called Attention Deficit Disorder [ADD]), and describes the two different groups of symptoms: hyperactivity (behaviour problems) and attention deficit (learning problems). Most children have a mixture of both types of symptoms, but others have only one type or the other. The term is sometimes written AD/HD to reflect this (as in 'and/or'). If your child isn't particularly hyperactive, they may still be diagnosed as having ADHD, but it will be called 'ADHD without hyperactivity'. Girls often have this diagnosis, while boys tend to have both aspects of the problem.

Whoever does the diagnosis will observe your son or daughter carefully and may give them tests to do (for example, psychometric tests and Continuous Performance Tests), which help build a picture of their mental processes. They will also collect as much information as possible from parents, teachers, playgroup leaders, social workers, health visitors and anyone else involved in looking after your child. They will take into account whether there are any other medical reasons for the behaviour, and what else might be going on in your child's life.

Once they think they know what's wrong, they will suggest the best available treatment for that particular child. Not all children will be offered the same treatment for ADHD.

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What are the treatments?

Ideally, you should get a package of treatments involving behaviour management, counselling or psychotherapy, special help at school, and, possibly, medication. Unfortunately, access to all these forms of help may be limited by lack of funding. On top of any treatment your child is offered, it's vital that you, as parents, get the help and support you need to learn the extra skills that can help your child. This will make you feel more confident about coping, and will help reduce stress and conflict within the family.

Behaviour management
Children want to get their parents' attention; it's a powerful reward for them. Unfortunately, scolding, arguing or shouting are powerful forms of parental attention, even though they are negative. Because children with ADHD are very difficult to manage, they tend to get more negative attention, and so will continue to behave badly. This cycle, which is called negative behaviour reinforcement, needs to be broken.

To do this, behaviour management encourages parents to notice when a child is being good, and to reward them. Children benefit from being praised often, enthusiastically and clearly. They need to know why they are being praised. This is known as positive behaviour reinforcement.

Parents may need to learn how best to handle bad behaviour – ignoring a child is not always the right thing to do, but for some behaviour it may be best. The vital thing for parents is to have a good behaviour strategy to start with, so that they know which forms of behaviour can be ignored and which are unacceptable and need to be tackled first.

It is important to maintain boundaries and discuss why some behaviour is unacceptable, as a child may not immediately understand why something is wrong. Then keep to the rules, so that your child doesn't get confused. It is also very important to let them know when they are getting it right. You should try to avoid using 'stop' instructions, such as, 'stop shouting', and say something like, 'please speak more quietly', instead. You should also try taking time out if your child keeps refusing your request, which gives you all a chance to cool off.

Behaviour management techniques take time and great patience on everybody's part. Parents often find they have just as much to learn as their children, and need plenty of support. But the techniques have been shown to be very effective, and a positive reinforcement cycle can soon gain momentum, once it's established.

It's just as vital to help your child gain more self-control, both at home and at school. Putting more structure into their daily life,to help them get better organised, is an important first step. It's a great help to children to use things like alarm clocks to break homework into chunks, and lists of tasks they can tick off each day. Getting a good routine going is essential. At school, it's important that they're encouraged to take an active part in learning, helped to set their own pace, and provided with lessons that have the right content level, variety and interest. Educational psychologists are often the best people to advise parents and teachers on effective programmes for their children.

Social skills training
Social skills training teaches children how to manage their relationships better, by reading the hidden signals of communication. It teaches them to understand what impact their behaviour has on other people, so they can change it.

Counselling
Counsellors are trained to help children to talk through the reasons for their behaviour and its consequences. Children diagnosed with ADHD almost always feel bad about themselves. Counselling can help them to tackle this, gain more self-control, focus their attention, and find better ways of learning and organising themselves.

As a parent, you also need to look honestly at the way your family works as a whole. You may well find family therapy can give you all a chance to talk through the worries or problems that may be contributing to your child's behaviour. It's also a good chance to discuss how your child's behaviour is affecting the rest of the family. GPs, family therapy centres or child and family consultation services can all be useful starting points for helping parents, as well as children.

Psychotherapy
Child psychotherapists are skilled at helping children to recognise and tackle their own distress. Some ADHD-diagnosed children can become very severely demoralised, anxious or depressed. A child psychotherapist can provide intensive and longer-term help for them. Note that, overactive and disruptive behaviour can in itself be a sign of unhappiness in a child, rather than being a sign of ADHD.

Medication
There is some controversy about using drugs to treat ADHD. Some experts have said that it gives both the children and their families a breathing space from the troubled behaviour, and helps them to maintain a more loving relationship with their child. Others believe that children are being prescribed these drugs unnecessarily and fear that using them may mask emotional or other causes behind the behaviour, especially in very young children. The long-term effects on the child's brain, which is still developing are not known.

Although stimulant drugs have been used to treat ADHD since 1937, one of the most popular drugs, Ritalin, was virtually unknown in Britain at the beginning of the 1990s, but between 2001-2002, prescription rates rose by 22 per cent. Over a five year period, the number of prescriptions for children rocketed by 102 per cent to 254,000 items. There have been cases of these drugs being misused, with youngsters selling them to other people. The drugs used are methylphenidate (trade names, Ritalin, Concerta and Equasym) and dexamphetamine (trade name, Dexedrine), which are stimulants that act on the central nervous system. They are Schedule II controlled drugs, falling into the same category as barbiturates and methadone, and are related to amphetamines ('speed'). It's not known exactly how they work, but it's possible that they top up the chemicals in the brain that help communication between brain cells.

These drugs can sometimes have unwelcome side effects, particularly at the beginning of treatment. Children may have less appetite, lose weight and have problems falling asleep. These drugs may retard growth (which should be monitored). The medicine usually lasts for about three to five hours at a time, and when it wears off, there can be a rebound effect, with the problem behaviour returning in an extreme form. In about ten per cent of children, the drug can make them tearful and withdrawn. Reducing the dose often helps. Doctors need to carefully calculate the right dose of the drug, and monitor the effect on each child. If one kind doesn't work, they may suggest a different one. Some children take these stimulants for six months, others for much longer, depending on how helpful they prove.

The National Institute for Health and Clinical Excellence states that these stimulants shouldn't be used as the first or only treatment, and most doctors agree that they should only be used when absolutely necessary. The British National Formulary advises that the use of amphetamines should be discouraged as they may cause dependence and psychotic states.

The drug safety and risk committee of the Food and Drug Administration (FDA) in America recommended in February 2006 that ADHD stimulant treatments should carry a black box warning of the risk of sudden death, following a report listing 25 sudden deaths in both adults and children, between 1999 and 2003. Some of these were patients with known heart disease, and the cautions for these drugs do include heart disease.

The alternative to amphetamines is atomoxetine (trade name Strattera) which is not a stimulant, but acts in a similar way to antidepressants and is much less likely to be abused as a street drug. Its effects last longer than those of the stimulants, so that it may need to be taken only once a day. Possible side effects include liver problems which are rare but serious, as well as loss of appetite and digestive problems and raised blood pressure. (For more information see Mind's factsheet, Drugs for attention deficit hyperactivity disorder) Methylphenidate and atomoxetine are not licensed for use in children under the age of six years; dexamfetamine is not licensed for children under the age of three years. Drug treatment should always be initiated by a specialist with expertise in ADHD.

When these drugs aren't suitable, don't work or have unpleasant side effects, doctors may prescribe antidepressants. Sometimes, these may be useful when a doctor feels a child's depression is more disabling than their ADHD-diagnosed problems, but they may also have side effects. There are, however, very few types of antidepressant that a doctor might prescribe to a child. For more detailed information see Mind's booklet Making sense of antidepressants.

The medication can't cure the problem, but it can help the child to think more clearly, understand better and feel calmer and more in control of themselves. This means they can take proper advantage of the other help they are getting at home and at school. Drug holidays are often built into the treatment plan so that the doctor has a chance to judge the continuing benefits of the medicine, and to allow growth to catch up if it is thought to have been retarded by the drug.

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What should I do if I'm worried?

If you're worried about your child's behaviour, talk to their teacher or your GP. They should be able to suggest ways of addressing the problem. If you feel that you're not getting the help you need, then you should discuss with your GP whether a referral to the local educational psychology service or a child mental health specialist would be a good idea. The school or, failing that, your local education authority, should be able to help you get an appointment with an educational psychologist.

Make sure the school knows about any diagnosis, so that teachers understand the problems your child is having and what is being done about them. An educational psychologist should be able to draw up suitable programmes to help your child cope with school, and to ensure that everybody involved with your child's care is aware of what is needed. The more you can learn about the problem and the way to deal with it, the more you will feel in control of the situation.

You may want to get help, advice or more information from other sources, such as parents' support groups or organisations specialising in child mental health. (See Useful organisations.) Parenting classes are sometimes available through these groups, and may offer some helpful tips. There may be local groups for families with a child who has ADHD. Sharing your difficulties with other parents who know what you're talking about can be a great relief and very supportive. (See Useful organisations.)

Behavioural problems in children are very difficult for everyone; for parents, brothers, sisters, teachers and carers, as well as the children themselves. It's important to ask for help, and to stay optimistic and positive. With appropriate help, a child's behaviour usually improves. If you help your children, while they are young, to learn the skills and strategies they need in order to help themselves, they can overcome their problems very effectively.

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Useful organisations

ADDISS
10 Station Road, Mill Hill, London NW7 2JU
tel. 020 8906 9068, fax: 020 8959 0727
email: info@addiss.co.uk
web: www.addiss.co.uk
The national attention deficit hyperactivity disorder information and support service

The Association of Child Psychotherapists
120 West Heath Road, London NW3 7TU
tel. 020 8458 1609, fax: 020 8458 1482
email: inquiries@acp.uk.net
web: www.acp.uk.net
For information on child psychotherapists working in your area

British Association for Counselling and Psychotherapy (BACP)
BACP House, 35–37 Albert Street, Rugby CV21 2SG
tel. 0870 443 5252, fax: 0870 443 5161
minicom: 0870 443 5162,
email: bacp@bacp.co.uk
web: www.bacp.co.uk
See website or send A5 SAE for details of local practitioners

The British Psychological Society
St Andrews House, 48 Princess Road East, Leicester LE1 7DR
tel. 0116 254 9568, fax: 0116 247 0787
email: enquiry@bps.org.uk
web: www.bps.org.uk
Publishes a directory of chartered psychologists

Hyperactive Children's Support Group
71 Whyke Lane, Chichester, West Sussex PO19 2LD
tel. 01243 539966, fax: 01243 552019
email: hyperactive@hacsg.org.uk
web: www.hacsg.org.uk
The HCSG offers access to local groups throughout the UK

Psychiatric drug helpline
tel. 020 7919 2999
Helpline run by pharmacists

YoungMinds
48-50 St John Street, London EC1M 4DG
tel. 020 7336 8445, parents info service: 0800 018 2138 fax: 020 7336 8446
web: www.youngminds.org.uk
A national charity committed to improving the mental health of all babies, children and young people

Youth Access
1–2 Taylors Yard, 67 Alderbrook Road, London SW12 8AD
tel. 020 8772 9900, fax: 020 8772 9746
email: admin@youthaccess.org.uk
web: www.youthaccess.org.uk
Information on youth counselling

Websites

www.adders.org
Provides information and practical help

www.chadd.org
Information for children and adults with ADHD

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Further reading

The BMA new guide to medicines and drugs (sixth edition) The British Medical Association (Dorling Kindersley 2004)
Drugs used in the treatment of mental health disorders: FAQs (forth edition) S. Bazire (Academic Publishing Service 2004)
How to assert yourself (Mind 2006)
How to cope as a carer (Mind 2003)
How to cope with exam stress (Mind 2004)
How to cope with loneliness (Mind 2004)
How to cope with sleep problems (Mind 2005)
How to cope with the stress of student life (Mind 2003)
How to parent in a crisis (Mind 2004)
How to stop worrying (Mind 2004)
How to survive family life (Mind 2004)
Living with mental illness: a book for relatives and friends E. Kuipers, P. Bebbington (Souvenir Press 1997)
Making sense of antidepressants (Mind 2006)
Making sense of herbal remedies (Mind 2004)
Making sense of homeopathy (Mind 2004)
Mental health, race and culture S. Fernando (Palgrave 2002)
The Mind guide to food and mood (Mind 2004)
The Mind guide to managing stress (Mind 2005)
The Mind guide to physical activity (Mind 2004)
The Mind guide to relaxation (Mind 2004)
Parenting well when you're depressed: a complete resource for maintaining a healthy family J. Nicholson, A. D. Henry, J. C. Clayfield (New Harbinger 2001)
Understanding anxiety (Mind 2005)
Understanding autistic spectrum disorder (Mind 2004)
Understanding borderline personality disorder (Mind 2004)
Understanding childhood distress (Mind 2004)
Understanding depression (Mind 2006)
Understanding learning disabilities (Mind 2004)

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This booklet was written by Sara Dunn and revised by Sabrina Hibbert and Saffia Ahmad
First published by Mind 1997. Revised edition © Mind 2006 ISBN 1-874690-66-9

No reproduction without permission