A Beautiful Mind

[zac's mum]

Looking forward :boogie:

[TwinkleIC]

Dear KPs, here's our first post on ADHD. Enjoy!


There’s More to ADHD
By the professional team from Twinkle Intervention Centre

Introduction
Attention-deficit/hyperactivity disorder (or ADHD for short), which is used to be known as hyperkinetic disorder, is one of the most common neuro-behavioral disorders in the world today. It affects people across all ages and its prevalence rates vary among children, adolescents and adults. In other words, it means ADHD is universal in humankind and it occurs in all races across the world. Howard and Landau (2000) reported that ADHD is one of the most common reasons for a child to be referred for support services in school [in USA].

According to the ADHD Institute (2017) based in Switzerland, “[A]lthough there is no global consensus, meta-regression analyses have estimated the worldwide ADHD prevalence at between 5.29% and 7.1% in children and adolescents (Willcutt, 2012), and at 3.4% (range 1.2-7.3%) in adults (Fayyad et al., 2007). ADHD symptoms can appear in young children or preschoolers as early as between the ages of 3 and 6 and can continue through adolescence and adulthood however the prevalence of ADHD in very young children (aged below 6 years) or later in adult life (aged above 44 years) is less well studied (Fayyad et al., 2007)” (para. 2).

Classical Symptoms of ADHD
ADHD (Diagnostic & Statistical Manual-5th Edition; DSM-5 Diagnostic Code: 134.00 and 134.01; International Classification of Diseases-10th Edition-Clinical Modification; ICD-10-CM Diagnostic Code: F90.0, F90.1 and F90.2) is marked by a triad of classical symptoms: inattention, hyperactivity and impulsivity. These symptoms interfere with an individual’s daily functioning and/or lifespan development. Each of these symptoms will be briefly described below:

•\tInattention: This first symptom refers to an individual’s tendency to go off-task with a lack of persistence, and often displays difficulty in sustaining his/her focus. The person can be rather disorganized and it is important to take note that it is not to be mistakenly diagnosed as ADD or ADHD when it could be Executive Function Disorder (EFD) whose hallmark symptom is disorganization. Both parents and teachers should not be mistaken by these challenging behavioral problems as defiance or lack of comprehension. The symptom of inattention is also shared by another disorder known as Deficits in Attention, Motor Control and Perception (DAMP), which is sometimes used to describe individuals who have signs of both Developmental Coordination Disorder (DCD) and ADHD (Dyspraxia Foundation, 2013). It is most commonly used in Scandinavia. “DAMP is diagnosed on the basis of concomitant attention deficit/hyperactivity disorder and developmental coordination disorder in children” (Gillberg, 2003, p. 904). According to Gillberg (2003), a clinically severe form of DAMP “affects about 1.5% of the general population of school age children; another few per cent are affected by more moderate variants … There are many comorbid problems/overlapping conditions, including conduct disorder, depression/anxiety, and academic failure. There is a strong link with autism spectrum disorders in severe DAMP” (p. 904).

•\tHyperactivity: This second symptom refers to the individual’s explicit habit of moving about constantly. This behavioral trait includes in situations where frequent movements are considered disruptive and/or inappropriate, especially during a lesson in class. It also includes excessive fidgetiness such as tapping and/or talking. It may become an extreme form of restlessness or can result in wearing others out with constant activity. It is, therefore, important to rule out the Inappropriate Behavior and/or Feelings Disorders (IBFD) (Educator’s Diagnostic Manual; EDM Diagnostic Code: ED3.00 with specific types ranging from ED3.01 to ED3.06) (Pierangelo & Giuliani, 2007).

•\tImpulsivity: This third symptom refers to the individual’s making hasty decisions and/or actions that often happen in the spur of moment without first thinking about them. As a result, such a decision made or action taken often may lead to high potential for harm. It can take place quite suddenly because of the individual’s desire for an immediate reward or, more likely, because he or she is unable to delay gratification. Often such an impulsive person is seen by others as socially intrusive and irritating because he or she tends to excessively interrupt others during a conversation or during an occasion when an important decision has to be made with no due consideration of the long-term negative consequences. It is also important not to confuse between impulsivity in ADHD and that in Impulsive Control Disorder (ICD) (ICD-10 Diagnostic Code: F63), which includes intermittent explosive disorder, kleptomania, pyromania, compulsive gambling and trichotillomania.

Subtypes of ADHD
Not all children present all three symptoms and may be diagnosed with one of three subtypes of ADHD where only one or two of the primary symptoms are problematic or observed. It is important to identify the particular subtype as treatment may differ for the various subtypes. The subtypes are:
1) ADHD predominantly inattentive subtype
2) ADHD predominantly hyperactive/impulsive subtype
3) ADHD combined subtype.

Girls are more likely than boys to be diagnosed as predominantly inattentive and often go undiagnosed due to their otherwise cooperative nature. In contract, boys are more likely to be diagnosed with either predominantly hyperactive/impulsive subtype or combined subtype. Children with ADHD combined subtype are more likely to experience academic difficulties as soon as they enter school (Howard & Landau, 2000).

Assessment and Comorbidity
No single test, questionnaire or observation alone is sufficient to diagnose ADHD, nor should a single source of information (i.e., teacher or parent) be considered adequate for a reliable and accurate diagnosis. A comprehensive evaluation uses multiple methods and sources of information including diagnostic interviews with parents and teachers, ratings of the child’s behaviour, and direct observations in all settings where problems may occur.

ADHD commonly occurs alongside other diagnoses that may mask or amplify the symptoms of ADHD. If ADHD is suspected, a comprehensive assessment by a qualified professional should be considered to rule out or identify the possibility of comorbid disorders that may share symptoms of ADHD and therefore ADHD may not be present at all. In many instances, symptoms of ADHD may be mistaken for emotional disturbance and/or disruptive behavior (also known as emotional behavioral disorder) as well as disciplinary problems, or even totally missed out, especially in a well-behaved child with a quiet disposition, leading to a delay in the proper diagnosis.


Treatments for ADHD
Depending on where you live, treatment for ADHD is done differently in different countries. For instance, in the USA, medication (i.e., prescription of stimulant drugs) is the main treatment of choice. Unlike the United States, Australia adopts a holistic approach which includes special adjustments in schools, diet, parent education and appropriate therapies, but stimulant drugs are used only as a last resort in severe cases only. In another example, in the mainland China, nutrition constitutes an important treatment and medication does not feature. The popularity of such an alternative to medication is much to do with the negative experiences with stimulant drugs, and either more positive experiences with alternatives (e.g., some complementary or alternative therapies, or even supplements), which can come in either of the two forms: placebo effect or nocebo effect. Hence, it is advisable for parents to do more research on their own or consult some professionals whom they know personally, before they decide on their course of action.

Stay tuned for an article to help parents with ADHD behaviour interventions in the home.

If you suspect your child may have ADHD or ADHD-like symptoms, seek a comprehensive evaluation from a qualified professional. Early identification and early intervention to mitigate the effects of the symptoms will yield the most successful results for your child.


References
Fayyad, J., De Graaf, R., Kessler, R., et al. (2007). Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. British Journal of Psychiatry, 190, 402-409.
Gillberg, C. (2003). Deficits in attention, motor control, and perception: A brief review. Archives of Disabled Child, 88, 904–910.
Howard, A.M. & Landau, S. (2010). Helping Children at Home and School III: Handouts for Families and Educators, Bethesda, MD: National Association of School Psychologists.
Pierangelo, R., & Giuliani, G. (2007). The Educator’s Diagnostic Manual of disabilities and disorders. San Francisco, CA: Jossey-Bass/John Wiley & Sons.
Willcutt, E.G. (2012). The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics, 9, 490-499.

[TwinkleIC]

Dear KPs, as promised! here is the add on to the earlier main article on ADHD. We hope you find them useful! Please see free to post any questions or experiences for sharing and learning! Happy reading!


Practical Strategies for Supporting a Child with ADHD
By the professional team from Twinkle Intervention Centre

Due to differences in neuro-chemical make-up, children with ADHD may struggle with daily tasks that parents take for granted because other children find them easy to do. This can lead to frustration for the child with ADHD and for the parent. The child tries to do what the parent expects but doesn’t know why he/she is unsuccessful. The parent gives instructions that seem clear and obvious yet the child does not manage to follow through. It can sometimes end up in a battle that results in confusion, misunderstanding, and anger. But all hope is not lost. Children with ADHD can achieve these tasks too, with the right amount support and understanding to help them on a daily basis.
The triad of classical symptoms are the culprits for the disconnect that seems to occur with kids who have ADHD. Depending on the most problematic symptoms, you may consider the following strategies to support your child:

Coping with Inattentiveness
1.\tObtain the child’s attention and say the child’s name before you give the instruction.
2.\tKeep instructions simple and give one step at a time
3.\tBreak down activities to bite-size tasks so they are easy to do and your child gains a sense of accomplishment along the way that serves as motivation to keep going
4.\tUse visuals (e.g., colorful pictures, charts and diagrams) to help with multi-step instructions or routines
5.\tMake daily tasks fun by using songs or games to help the process and capture their attention
6.\tMonitor the child and offer frequent short breaks.
7.\tKeep track of the time your child can remain on task on a visual chart and praise your child for increases in on-task behaviour.

Coping with impulsiveness
1.\tAlways prepare your child with ADHD for any transitions. Talk to your child beforehand so your child knows what is expected and can regulate his/her response when it is time to transition
2.\tImpulsive children need to be taught how to check their work for errors or omissions. Take the time to teach your child how to do this. It may require you to do it with your child many times before he/she does it on his/her own.
3.\tA child should know in advance what the consequences will be for not following through with an instruction. Once an agreement is violated, the stated consequence must be applied.
4.\tBe brief. Don’t engage in lengthy explanations. Be direct. Be specific.
5.\tKeep track of progress your child makes with regulating impulsive behaviour on a visual chart and praise your child for the progress made.

Coping with hyperactivity
1.\tManage the child with ADHD with high level of authority without engaging in a battle of the wills. Consequences should be immediate, relevant, and consistent. Lengthy discussions are counterproductive.
2.\tUse command language that is authoritative yet respectful (Sally, put the toys away before dinner) not question language (Sally, would you mind putting the toys away before dinner?).
3.\tUse your child’s excess energy by getting him/her to help out or to run errands
4.\tConsider interactive elements in his work. Don’t insist that your child remain seated to do homework. If standing helps mitigate some of the excess energy, allow it so long as the work is being done.
5.\tBuild in energy-using tasks around activities that require attention (e.g., do five questions of homework then 10 jumping jacks) and gradually increase the number of tasks that require attention before another energy-using task is introduced.

Generally, consider the following:
1.\tManage by exception: occasionally unforeseen circumstances or other minor behaviours disrupt the routine. Look out for the good things the child does and let go the rest of the not so good things. Choose your battles.
2.\tDiscipline with dignity: deal with the behavior and not the person. Children with ADHD do not choose to be inattentive, impulsive or hyperactive. They need support and understanding to manage these symptoms.
3.\tFocus on substance over form. Even an effort to comply with expectations and routines is progress in the right direction and should be praised.
4.\tConsistency is key. If you cannot maintain the routine it sends a message to your child that the routine is not really important.
5.\tProgress for desired behavior is built slowly like how the Romans built Rome
6.\tConsequences serve a purpose however inconsistency will undermine your efforts. If you stated a particular consequence will result from not following directives, you must follow through with it.
7.\tKeep daily charts that are visual so you and your child can see what is expected on each day as well as the progress they are making.

[zac's mum]

Thank you for sharing! You sound like you have a lot of experience, knowing what works and does not work.


My son is very “high energy” (probably considered hyperactive but not inattentive and definitely not impulsive). The strategies which you mentioned for the hyperactive category kids are exactly what has worked with him so far. Since 2 years active toddler stage till now 8 years old. So yeah...just contributing my story to validate your research findings

[swortionery]

Agreed. The above two posts were well-written and well-researched. In particular, I like this part:

[quote]1. Obtain the child’s attention and say the child’s name before you give the instruction.[/quote]This is something that's really important, but is often missed out. Kids with ADHD sometimes don't even realise when they're being called out until the disciplinary action escalates. This can lead to emotional dysregulation, a co-morbidity of ADHD that's frequently overlooked.

[zac's mum]

I have helped out as a volunteer in a P1/P2 school classroom before, and in one case I noticed that the teacher managed the ADHD child’s inattentiveness by putting the child’s desk right up in front, touching the same wall which the whiteboard was hung on. So he was literally seeing nothing but the whiteboard. The rest of the classmates’ desks were in the usual position, grouped into 5 teams of 5-6.


Is this a common management tool, do you know?

I have also witnessed the same child displaying the impulsive side of his ADHD during PE lesson. The teacher asked the kids to queue up for their turn to try an obstacle course. The child was at the end of the long line but probably did not have the patience to wait…he kept breaking line to come to the front, actually to peek at how the current student was doing the activity. Maybe he wasn’t sure of how to do it, or he wanted to see the action as it was ongoing. His classmates thought he was cutting Q, so they addressed him by name and asked him to queue up properly. He would obey but then keep coming back to watch again. And eventually lost his place in the queue because he couldn’t keep track where his place was. Which led to real queue-cutting this time, and some angry outbursts from the persons behind who had been intercepted.

My question is: could the adults have managed this better? The PE teacher was understandably preoccupied with supervising the obstacle course itself. And me as an external volunteer, had been briefed not to intervene. But I am just curious, how could the student have been helped to understand/self-regulate during situations requiring him to queue up? Queuing up behavior and patience (delayed gratification) is usually non-understood by preschoolers because their prefrontal cortex is not yet developed (based on what I read). But ADHD kids may not ever reach this developmental step till even adulthood. So how to help them deal with such situations (and the wrath of their irritated peers)?

[TwinkleIC]

Hi, apologies for the late reply.

Please note that the reply does not represent the community's view and is for the purpose of sharing and learning.

Question 1: Is this a common management tool, do you know?
Getting a child to face the wall and hopefully the child reflects is a common tool but there are actually other better behavior management tools in which parents and educators can use.

Question 2: Could the adults have managed this better?
The emphasis will be having a trained adult in order to help out positively in a situation where assistance is needed to control a group of students (as in this case is a Physical Education lesson

Question 3: How could students be regulated during situations like queuing up etc?
There are 2 perspectives to the above question. If it is a situation where either queuing or staying composed and wait patiently are required (as in going in for movies, line up for taking food etc), then having a buddy, an Allied Educator or a trained volunteer to remind the child to stay calm will help. Alternatively, the trained person can show the act of queuing properly and exercise patience. But, if it is a situation where there is novelty and excitement is really hard to control (especially so when there are preschoolers), then there should be some flexibility to be exercised by the teacher in charge by letting “loose” the students in order to fully enjoy the ah-ha moment of discovery.

[zac's mum]

Hi thank u for your reply! I appreciate it and understand it is an opinion rather than professional advice


I just wish to clarify that in my Question 1, the boy was not being punished. Rather, the teacher who placed his desk against the wall was using it as a permanent solution to help him focus on the whiteboard, rather than being distracted by other things going on around him.

As you may know, it is a common classroom tool to seat the compliant well-behaved students at the back row, and conversely to seat the more disruptive ones in the first row, right under the teacher’s nose. But that was the first time I had seen a child being placed in such an extremely front position and away from his peers.

But anyway, since this is a forum mainly for parents (rather than MOE teachers), please do continue to share how we as parents can help our kids. :celebrate:

[TwinkleIC]

Dear KP mummy,

Thank you so much for your sharing. We learn and grow together as a community to support one another in this journey to help our child.
The next sharing will be on Dyslexia! Stay tuned