Our preschooler's teacher has been hinting that he might be "hyperactive." She says it's hard for him to sit still, he talks a lot without raising his hand, and he's distracted by any little thing. At home, I have to constantly remind him to do things; he says he just forgets. He can play Nintendo for hours, but if he is supposed to practice his letters with me, it seems like it is torture for him to sit in the chair.
Everyone is distractible, restless, or impulsive some of the time. And for a preschooler in particular, it's normal to be sometimes forgetful, lost in the clouds, wild, jumpy, disinterested in routines, super-playful, silly, or fidgety. The question is, are these behaviors a problem for the child or for people around him or her?
Perspectives on ADHD
One way to think about this topic is to imagine kids - or adults - on a spectrum in terms of three personal attributes: distractibility, restlessness, and impulsivity. As distractibility, restlessness, and impulsivity increase, around the 80th percentile - in the upper fifth or so of the population - we'd start to think about a child being "spirited." As the intensity of these three characteristics increases further, at around the 95th percentile we'd start thinking about a child having Attention Deficit/Hyperactivity Disorder (ADHD).
The topic of ADHD is fairly controversial these days. There's no controversy about the fact that individuals range on a spectrum of distractibility, restlessness, and impulsivity. What is controversial is what that spectrum means - and what to do about it.
In our view, there are plusses and minuses to just about any kind of temperament. We think of ADHD as a normal variation in human temperament, and that humans evolved to have a variety of temperaments in represented in the hunter-gatherer groups that our ancestors lived in for millions of years. Groups whose members had only cautious, conservative temperaments would not explore and take risks as much as they should - while groups with only spirited/ADHD members would not be as prudent and planful as they should be. The groups that would have the best odds of survival - and passing on their genes - would be the ones with a mix, a synergy of temperamental types.
So, in a sense, ADHD is normal. That six-year-old boy running around the playground, getting into a million things, full of spirit and passion, bored with schoolwork, driving his parents and teachers crazy . . . .would be on the fast track to becoming a mighty hunter or explorer - and admired and successful within his tribe - a hundred thousand years ago. But today, he's sitting in the principal's office because he just can't hold it together to sit quietly at a desk for six hours a day.
In short, the "disorder" of ADHD is really a disorder of fit between perfectly normal - albeit inattentive, looking-for-action, intense, easily upset, on the move, impulsive, delightful, make-you-pull-your-hair-out - children and an environment that places historically unprecedented demands on young people (and grown-ups, too) to concentrate, sit still, and absorb streams of abstract material. These modern environments are recent, in the evolutionary time scale, and humans have not had time to adapt.
Some feel that ADHD has been long under-diagnosed. Others feel that children's inability to pay attention, focus on their work, and control their bodies and impulses is usually due to psychological issues, including lax parenting. All kinds of secondary issues can get mixed up in the question of whether a child has ADHD: school district politics, fears of stigmatizing a child, moralistic views of child development, social agendas about "good old-fashioned parental discipline," etc. We suggest focusing on the facts (what a concept), getting a good assessment (see below), and working on practical issues.
Bottom-line: ADHD is a concern, but it can be taken care of (see our next column). Unlike progressively worsening conditions like multiple sclerosis, ADHD usually gets better over the course of an individual's development and often disappears entirely by adulthood.
Some Facts about ADHD
Fundamentally, ADHD involves weaknesses in regulation (of attention, activity, and desires). In a sense, someone with ADHD is like a big car with bicycle brakes. If the car is moving slowly or uphill, things work OK. If the car is moving quickly and/or the road is downhill, there's a problem.
There are three types of ADHD
(A)Inattentive, distractible, hyperfocused, daydreamy: inconsistency in attention.
(B)Impulsive, restless, hyperactive
Combined (A and B)
ADHD can vary in intensity from mild to moderate to severe. It can appear inconsistently, and in some settings more than others. It can change during a child's development.
Common estimates are that approximately 5 to 10 percent of children have ADHD. This means that a typical class will have one to four children with ADHD. Boys are diagnosed with ADHD more than girls, although girls are probably underdiagnosed because their type of ADHD is often more daydreamy and less problematic for parents and teachers. ADHD often persists into adulthood, particularly inattention and impulsiveness.
ADHD is biologically based and studies have revealed a genetic link. It is not a character defect or personality flaw or motivated effort to drive parents and teachers crazy! A child's environment can help or aggravate ADHD, but not create it.
There are many positive aspects typically associated with ADHD. These include high energy and enthusiasm, and above average intelligence, intuition, and creativity. People with ADHD are often lively and likable individuals. They are typically results-oriented, with a bottom-line focus.
Unfortunately, there are often aspects of ADHD that are problematic for children, parents, and teachers:
Inaccurate (often negative) opinions of self, others, and situations. Fix on one aspect of something, losing the big picture. Often misread social cues.
Forgetfulness. Poor organization. Rush through tasks. Procrastination and poor follow-through.
Want immediate rewards. Low tolerance of frustration or boredom. Impatient.
Intense kids who like high intensity situations. Get aroused ("hyped") real easily; "hair-trigger gas pedals."
Emotions on the surface. Easily hurt. Unstable moods. Background sense of unease, insecurity, or worry.
Other concerns are frequently associated with ADHD and are often the focus of parents and teachers. They include behavior problems, low self-esteem, underachievement at school, problems with peers, and risky behavior. These issues can mask underlying ADHD. Painfully, children with ADHD are often the target of physical and emotional abuse by parents and caregivers.
Children with ADHD can be termed "stupid," "retarded," "lazy," or "flaky." They can become the target and presumed culprit for family discord or classroom problems. A stressful and upsetting BIG STRUGGLE often revolves around a child with ADHD. It is important to allow the person with ADHD to step out of the "problem role." The reactions of others can unwittingly maintain ADHD behaviors.
In a recent popular book about ADHD, Driven to Distraction, the author commented: "The picture of a young child who starts out well and then gradually sees his school performance tail off while teachers grow increasingly moralistic in their explanations should always suggest the possibility of ADHD."
Assessment
The first step when ADHD is suspected should be assessment by a licensed psychotherapist and/or physician. School districts can sometimes help. A good assessment involves consultations with teachers and parents, review of school records, and observation of the child in natural settings. The most reliable diagnostic tool is the individual's history. There is no single "test" for ADHD. ADHD should never be ruled out on the basis of testing or doctor's office visits alone!
Sometimes other issues are primary and produce ADHD-like symptoms. Psychological issues include anxiety, depression, significant separation from parents, and family discord. Biological issues include intense allergies, chronic infections, seizure disorders, and hyperthyroidism. These other possibilities should always be ruled out through investigation by the applicable licensed professional.
ADHD and learning difficulties are statistically associated and can mask and exacerbate each other. If diagnosis is still unclear after assessment, address the ADHD and then see what learning disabilities remain; ADHD is the more general factor.
Care of ADHD
In our next column I will describe the care of ADHD. We use the word "care" instead of "treatment" because it is important to remember that there is a whole person suffering a condition not of his or her choosing.
In sum, we recommend four key elements in the care of ADHD
Education and understanding
Community and support
Holistic physical interventions
Psychological interventions within the child and at home and school
Please note that we have not mentioned Ritalin, which many people consider equivalent to a diagnosis of ADHD. Sometimes a fifth element -- medication -- may sometimes be called for in the care of a child, but only after the first four elements above have been thoroughly explored.
We will discuss all this issues in detail next month!