Early Childhood Education

Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder (ADD/ADHD)

Attention Deficit Hyperactivity Disorder is a syndrome characterized by serious and persistent difficulties in one or more of three specific areas: attention span, impulse control, and hyperactivity. ADD/ADHD is a chronic disorder that can begin in infancy and extend through adulthood, having negative effects on a child’s life at home, in school, and within the community. ADD/ADHD presents along a spectrum of severity, and can involve attention problems, primarily hyperactivity, or a combination of the two. It is conservatively estimated that 6-9 percent of the U.S. school-age population is affected by ADHD.

Diagnostic Features

The Diagnostic and Statistical Manual of Mental Disorders (4th ed., revised) identifies three subtypes of ADD/ADHD, each of which requires six or more criteria for diagnosis:

1. Inattentive type

• Pays little attention to details; makes careless mistakes.

• Has a short attention span.

• Does not listen when spoken to directly.

• Does not follow instructions; fails to finish tasks.

• Has difficulty organizing tasks.

• Avoids tasks that require sustained mental effort.

• Loses things.

• Is easily distracted

• Is forgetful in daily activities

2. Hyperactive/impulsive type

Hyperactive symptoms are the following:

• Fidgets; squirms in seat.

• Leaves seat when remaining seated is expected.

• Often runs about or climbs excessively at inappropriate times.

• Has difficulty playing quietly.

• Talks excessively.

Impulsivity symptoms are the following:

• Blurts out answers before answers are completed.

• Has difficulty waiting his/her turn.

• Often interrupts or intrudes on others.

3. Combined type

This category includes children who meet criteria for both the Inattentive and the

Hyperactive/Impulsive types.

In addition to the criteria above, to be diagnosed with ADHD a child must: manifest symptoms prior to age 7, present symptoms for at least six months, and present symptoms in more than one setting (school, home, community). Symptomatology must be excessive and functionally impairing beyond what is expected for the child’s developmental level or age.

Although it is possible to diagnose this syndrome earlier, most children are not diagnosed with ADHD until they are four- or five-years old, when they first enter a structured setting that requires sustained attention. Most diagnoses of ADHD are made by pediatricians at the request of a parent or as the result of a referral from a teacher or child-care provider. Diagnosis is generally made by parental report and history corroborated by clinical observation. More specific symptom patterns can be identified through standardized testing performed by a psychologist.

ADHD in the Classroom

In the classroom, the young child with ADHD might present in several different ways. The inattentive child is easily distractible, and has greater than typical difficulty staying focused. Such children may often appear dreamy or confused, have trouble starting and completing work, and demonstrate poor time management and organizational skills. The hyperactive/impulsive child often challenges teachers and classmates with disruptive and inappropriate behaviors. These children usually display a need for more physical movement than is tolerated in the typical classroom environment. All of these children are likely to have messy desks and backpacks, lose their papers and school materials, and forget important information or possessions. Given the coincidence of diagnosis with children’s early classroom experiences, some critics suggest that the child’s behavior is an indication of developmentally inappropriate environments and/or expectations rather than a symptom of a disorder.

There are many useful intervention strategies for optimizing the child’s experience in the classroom or child-care setting. The child’s seating can be customized to suit their individual requirements. For example, some children benefit from preferential seating close to the teacher, in the front of the classroom, to minimize visual distractions. Other children benefit from seating in the rear of the classroom to enable them to move around freely without disturbing others, and to reduce their impulse to locate the source of distracting sounds. Students can be seated close to more attentive, quieter peers who can serve as role models. The classroom can be organized to ensure a minimum of visual and auditory distractions.

Because children with ADHD have difficulty establishing and maintaining internal structure, they can benefit greatly from increased structure in the environment. Consistent classroom routines, visible indicators of schedules and tasks, clear and simple instructions, and a calm and relaxed classroom tone are generally beneficial. For inattentive children, it is crucial to maintain eye contact and use a variety of strategies to ensure that the child acknowledges and comprehends instructions. Gentle physical reminders to refocus may be useful. Many hyperactive children respond well to breaks that allow for physical movement and deep pressure (carrying heavy objects, doing jumping-jacks, running errands); these kinds of breaks should be incorporated into normal classroom routines as much as possible.

A general rule of thumb for accommodating children with ADHD in the classroom is to identify inappropriate behavior and support children in finding appropriate substitute behavior that satisfies their need for additional movement. For example, a child who repeatedly taps a pencil on a desk could be encouraged to squeeze a squishy ball instead, or a child who spins on the floor during circle time could be offered the opportunity to take a movement break by doing jumping jacks in the hallway or running an errand for the teacher.

Given the behavioral challenges these children present, it is easy to neglect the strengths that they can bring to a group. Often they are among the brightest and most energetic children in a classroom. They may compensate for their lack of organization with a capacity to get physical tasks done. Their distractibility may lead to creative options not considered by others. And their sociability, although often disruptive, may also be important in engaging other children in a project.

ADHD at Home

Young children with ADHD usually require additional patience, practice, and skill from their caregivers. Because multitasking and following sequential instructions is exceptionally difficult for these children, central family routines such as dressing, preparing for bed, and mealtimes at home and in restaurants often become battlegrounds. Sibling relationships can be negatively impacted by the negative attention directed by parents toward the child with ADHD.

Intervention strategies at home may involve behavior modification and methods for enhancing self-esteem. A calm, consistent demeanor affords the child the opportunity to attempt to self-regulate in accordance with environmental demands. Some of the strategies useful in the classroom may also be appropriate at home, for example, empowering the child by creating a list of daily tasks that the child can independently follow and check off. Adults can help children take responsibility for their possessions by setting up systems for storage and easy access to frequently used personal belongings. For hyperactive children, a degree of flexibility in structured daily activities (meals, homework, etc.) can help decrease conflict. Safe and appropriate outlets for physical movement can be tremendously helpful for these children. Parents can help reduce inappropriate behaviors by suggesting alternatives (e.g., jumping on a home trampoline rather than on the couch; running around the yard rather than the living room).

Inattentive children often benefit from taking frequent breaks, or alternating between quiet and active tasks. The environment can be modified to reduce distracting elements, for example by using a white noise machine, turning off the TV, or creating a designated area in the home that is conducive to calming down.

Associated Disorders

ADHD often coexists with other associated features and disorders. Impulse control problems, temper outbursts, behavioral rigidity, poor frustration tolerance, and intense anger are frequently seen in conjunction with ADHD. Children with ADHD are more likely to also display symptoms of other disorders such as Oppositional Defiant Disorder, Conduct Disorder, Mood Disorders, including Anxiety and Depression, Learning and Communication Disorders, and Tourettes Syndrome.

Differential Diagnosis of ADHD

Because inattention and hyperactivity may result from a variety of causes, particularly in young children, differential diagnosis of ADHD is critical. It is necessary to rule out neurological syndromes (particularly absence epilepsy); other psychiatric disorders such as autism, anxiety, and Asperger syndrome; cognitive impairments and learning disabilities, such as Nonverbal Learning Disorder; and processing difficulties, such as Sensory Integration Disorder, Central Auditory Disorder, and visual-processing disorders.

Treatment of ADHD

Treatment of ADHD is multimodal. Pharmacotherapy may incorporate different categories of medication including predominantly stimulants, but also antidepressants, anticonvulsants, or antihypertensives. Psychological interventions may incorporate behavior modification, parental management training, and family as well as individual counseling. Alternative options are also becoming more available from a variety of specialists, with variable results. Some techniques discussed frequently in the literature on ADHD include homeopathy and diet, computer-assisted training, biofeedback, hypnotherapy, mind/body techniques, sensory integration training, and applied kinesiology. Professionals in the field of early childhood special education can also help to identify the extent to which developmentally appropriate classroom routines and curriculum activities might reduce the extent of ADHD-type behaviors.

Treatment of ADHD is most likely to be successful when parents and teachers work together to monitor children’s responses to modifications to the classroom or home environment, behavioral interventions, and/or medications. Communication between home and school is particularly helpful in identifying the triggers of problem behaviors, assessing the effects of medication, and evaluating the effectiveness of intervention strategies utilized in the classroom. See also Developmental^ Appropriate Practice(s).

Further Readings: Barkley, Russell A. (2005). Attention-deficit hyperactivity disorder, A handbook for diagnosis and treatment. 3rd ed. New York: The Guilford Press; Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 4th ed. (1994). Washington, DC: American Psychiatric Association; Hallowell, Edward M., and John J. Ratey (1995). Driven to distraction: Recognizing and coping with attention deficit disorder from childhood through adulthood. NewYork: Random House; Hallowell, Edward M., and John J. Ratey (1995). Delivered from distraction: Getting the most out of life with attention deficit disorder. New York: Random House; Levine, Mel. (2002). A mind at a time. New York: Simon & Schuster; Martin, K., and A. Martin (2005). Celebrate! ADHD. Washington, DC: Cantwell-Hamilton; Reiff, M., S. Tippins, A. LeTourneau, eds. (2004). ADHD: A complete and authoritative guide. Elk Grove Village, IL: American Academy of Pediatrics.

Rika Alper and Cornelia Santschi