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The ABCs of ADHD Parent Version
This program helps parents understand
more about ADHD,
and the impact it has on school achievement.
"My parents were there, supporting me."
"It is a really hard challenge,
it's a really hard thing to climb.
And once you've overcome it, you're just... it's fine."
"Just do what you can with it,
and just work with it."
The ABCs of ADHD
In many parts of the world, it's likely that
every classroom has at least one or two students
who have been diagnosed with
Attention Deficit Hyperactivity Disorder,
better known as ADHD.
Up until recently, ADHD has been clinically diagnosed
as a behavioural disorder.
New research findings suggest that ADHD
is associated with cognitive weaknesses
that hinder learning.
To learn more about this new research on ADHD,
we looked to Dr. Rosemary Tannock,
senior scientist of the Brain and Behaviour
research program at the Hospital for Sick Children.
Attention Deficit Hyperactivity Disorder,
often called "ADHD" for short,
is a neurobiological condition
that generally first appears in preschool years,
and early childhood.
There are three main characteristics.
First is symptoms of inattention,
second, symptoms of hyperactivity,
and third, symptoms of impulsivity.
Currently, though, the medical system believes
there are really just two main dimensions of symptoms:
the inattentive symptoms,
and the hyperactive/impulsive symptoms.
And these could occur alone, or in combination.
And this gives rise to three subtypes
that are recognized formally by the medical system.
There are 3 subtypes of ADHD:
The Hyperactive-Impulsive Subtype,
which is the least common subtype,
and the Combined, and the Inattentive Subtypes,
which are more prevalent.
Classification into a particular subtype depends
upon whether meets criteria for symptoms
or symptoms of Inattention, or both.
Combined type ADHD is actually the most common
form of ADHD, it's often called "classic" ADHD.
And about 50-70% of individuals with ADHD
actually have Combined type.
These individuals and children will manifest
problems in both inattention, and hyperactivity impulsivity.
Though in adolescence the overt restlessness hyper-activity
won't necessarily be visible,
rather it will be experienced as inner restlessness,
a need to be busy all the time.
Some examples of types of symptoms would be...
These youngsters would have difficulty
keeping their minds on one thing at a time.
Ignoring irrelevant information,
and keeping hold of what's really important.
Starting and completing work,
often they're called "procrastinators",
they don't get the work done.
They could be constantly fidgeting in their seats,
these are the kind of profile that you would see
with a child with Combined type ADHD.
The main concern, however, from a teacher's perspective,
is what would would term "academic underachievement",
often failing, or at high risk for failing, the grade
despite good ability.
And in particular, teachers often are concerned
and parents are concerned,
because these youngsters have difficulty
in math, in written expression,
in key areas of the curriculum.
For example we've observed the immature strategy
such as finger counting,
even though we know they know those number facts.
They might talk aloud as they're trying
to work through the problem,
they might be fidgety, distractable,
go off task...
As a result, they complete far, far less work.
Let's turn to look at the predominantly
Inattentive type ADHD.
What's concerning is most are girls,
and they go unnoticed.
They're at risk of under-identification
in spite of cognitive and academic difficulties.
This occurs because 'acting out' behaviour in class
is much more noticeable and disruptive,
compared to the inattentive students'
inner struggle to focus and concentrate.
Children with inattention,
often referred to as the Inattentive child,
the Inattentive subtype, are,
amongst the three subtypes of ADHD,
the second most common.
So about 25-35% of those with ADHD
would meet criteria for the Inattentive subtype.
As implied by the name,
these youngsters would have major problems
in concentration, in organizing materials,
often very forgetful, losing their things,
forgetting even simple, daily routines,
such as forgetting to write down the homework
in the agenda, in their homework agenda book.
Forgetting to take the book they need for homework,
and even if they do the homework,
often having it in their backpack
but forgetting to hand it in.
There is another slightly different profile
that may also co-occur with this Inattentive subtype,
and that is the youngsters who are very daydreamy,
they're often slow-moving,
often described as in their own world,
a bit 'space cadet'-ish.
And that's a slightly different profile,
but it's still quite common.
What we know is that girls in particular
often meet the diagnostic criteria
for this inattentive sub-type.
More often than boys.
And girls in particular are overlooked,
and under-referred, and even when they are referred,
And it's not really surprising if we think
of the major difference between how girls manifest,
with their symptoms of ADHD, versus boys.
And that is girls rarely exhibit the really overt,
disruptive type of symptoms of ADHD,
so they're less likely to get out of their seat
and race around the class.
They'll be sitting at their desk fidgeting,
fiddling, not concentrating, daydreaming,
but they're not disturbing anybody,
and so don't draw attention to themselves.
If they are referred,
physicians also are less familiar with that type
of profile, so may be less likely
to confirm a diagnosis of ADHD.
And finally, even if a child, a girl with ADHD,
does receive the diagnosis,
they are less likely to receive treatment,
for example, with stimulant medication.
So they really have much more likelihood
than boys with ADHD
to have their needs un-met.
Certainly in the medical community,
and also in the educational community.
They didn't really go through
exactly what it was that I had,
and I didn't really know.
So it was just hard to understand.
So I think it's... you know, you need someone
to sit there and go through it with you
and tell you what it is.
Also, I think self-confidence, too,
was kind of hard, because they kind of told you
what you couldn't do, and what you can't do.
I don't know.
Basically, when I took courses,
I tried to take courses so that I could prove--
like I was told that I wasn't very good at math,
and I took math courses to show that I can do them,
I can take it.
What advice would you give to someone
who may have ADHD?
I think to go out and seek help whenever you can,
because I think that was my weakness,
was I didn't know what was out there.
And there are a lot of people out there
willing to help you.
Especially--I had the teacher who noticed,
and showed me the Learning Disability Center
My parents were there, supporting me.
The diagnosis of ADHD is complex,
because there is no simple test.
There is no blood test, no brain scan,
no computer task we could give a child,
But the criteria are specified.
The medical discipline has a set of guidelines,
that is called the Diagnostic
and Statistical Manual, DSM for short,
and it specifies the criteria that must be met
for a diagnosis of ADHD.
Specifically, at least 6 of 9 possible
symptoms of inattention,
and/or at least 6 of 9 possible symptoms
Moreover, there must be evidence that these symptoms
began to appear before age 7.
Also, that they are persistent for at least six months.
And also that they're pervasive,
meaning they occur in many different contexts.
For children this would be, typically, home and school.
And finally, that these symptoms must be impairing.
And all of those criteria are required for evidence
for clinical diagnosis of ADHD.
ADHD is a very common problem,
so epidemiological studies from around the world
have given estimates of 6-9%,
as high as sometimes 17%,
but this means that it doesn't matter whether
we look to countries such as Japan, Australia,
United Kingdom, any of the Scandinavian countries,
North America, the rates are the same,
It means that about 1 in 20 children,
or, more importantly for teachers,
about 1 or 2 children in every classroom,
will have ADHD.
It's more common in boys,
about 3 boys to every 1 girl.
However, in clinical practice,
there are typically many, many more boys referred,
so that the rates are 7 boys to every 1 girl.
And this is typically because boys are more overt
in their behaviour and draw attention to themselves,
and so they are referred much more commonly
and much more frequently than are girls.
[Myths or Facts about ADHD]
ADHD is so common, that it has led several people
to debate whether, in fact, ADHD is a real disorder.
Perhaps the symptoms of ADHD are just
an exaggerated response to everyday life,
sensationalized and capitalized upon
by meds, and education, the pharmaceutical industry,
and that it really isn't a real disorder.
However, what we do know is that ADHD is not new,
it's been around a long, long time.
In fact, the first description of problems
that children had, which are consistent with ADHD,
was in 1845, by a German physician, Dr. Heinrich Hoffman,
who wrote storybooks for his own children
to keep them amused at bedtime.
And he described cases from his clinic,
and the first case--it is probably very widely known--
called "Fidgety Phil", the little boy who couldn't sit still,
and in fact ended up falling off his chair.
But less commonly known is another type of presentation
in the clinic, that is children who are inattentive.
This is "Johnny-Head-In-The-Air",
that Heinrich Hoffmann described
as a daydreamy, little bit forgetful, person,
who tended to fall over things.
The first medical description was interpreted as,
"a problem of moral control",
by Dr. George Still in 1902,
who presented a series of lectures.
And this is published in the medical journal
called The Lancet.
So the problem hasn't changed.
Just the names, maybe, have changed.
Many people have thought that, perhaps,
ADHD is due to bad parenting,
and this simply is not the case.
What we know is that ADHD tends to run in families.
So, if you have a child with ADHD,
the parents of that child have a 2 to 8-fold
increased risk of having ADHD themselves.
The siblings have a 3 to 5-fold increased
risk of having ADHD.
If we look at twins we know that,
if you have an identical twin,
the other twin is highly likely to have ADHD,
compared to non-identical twins.
But, importantly, there is no genetic test
at this point for ADHD.
Some people have also suggested that ADHD
might be caused by junk food,
such as lots of sugar in the diet,
food additives in the diet,
and what the studies have consistently shown
is there's no evidence that too much sugar
The situation is somewhat different
for things like food additives,
and a recent large-scale epidemiological study
has examined the contribution of food additives,
sugar, etc., in the diet of a large population
And what that study had found was that
the increased food additives to the diet,
might somewhat increase the hyperactivity
and concentration problems in all children--
but that does not mean it causes ADHD.
However, there are other environmental factors
that may play a critical role.
And one role is about maternal smoking during pregnancy.
Children with ADHD are at least 2 times as likely
to have had mothers who were smoking in pregnancy.
And what we know from the research studies is that
youngsters with ADHD may start smoking as early as eight.
Moreover, they become habitual smokers
at twice the rate of their peers.
Why might this be the case?
Well, to some extent speculation,
but growing evidence this may be
what we call a "self-medication hypothesis".
That smoking allows them to perhaps concentrate more,
to focus more,
and perhaps that is why they're smoking.
[Do children outgrow ADHD?]
At one point, many physicians believed that children
grew out of ADHD by their teenage years,
however we know that's not the case.
ADHD continues in about 60-80% of children
who receive a diagnosis, continue to meet
the diagnosis in adulthood years.
What changes is how it manifests.
And that is, with children, it manifests
both as a lot of restlessness,
as well as inattention.
However, across adolescence and into adulthood,
inattention is the primary feature.
And the hyperactivity, the overt behaviour,
really diminishes, and is experienced
more as inner restlessness.
If we think of the profile from preschool years
right through into adolescent,
there's a different emphasis of the concerns.
In preschool years, youngsters with ADHD
are already experiencing some cognitive difficulties.
So these children, when they enter kindergarten,
are already at a disadvantage
despite good ability.
In preschool years, the major concerns are
the youngster running around, bumping into things,
getting into dangerous situations,
perhaps having more injuries than other preschoolers.
The primary concern in the school age years,
in elementary school,
is the hyperactive/impulsive behaviour.
Jumping out of seat, difficult to manage behaviour.
However, although that's the most salient problem,
the real concern is the inattention.
Which, it's harder for people to see this.
But what we know from research is that
inattention is actually the strongest predictor
of all of the cognitive difficulties,
that we know is associated with ADHD.
So it's inattention that we get concerned about.
Inattention, we know also is associated
with poor academic achievement.
And academic underachievement is a major concern
for school age children.
By contrast, as we shift into adolescence,
yes, indeed, the problems continue,
with the difficulties of inattention,
the inner restlessness.
The complaints have been that the children
are less motivated in their schoolwork,
but there are also more concerning issues as well.
And what we know about adolescents
is the concern about driving.
ADHD doesn't disappear
when the youngster gets behind the wheel.
And that is, we know from the research that
youngsters with ADHD are about 4 to 6 times
more likely to have serious road traffic accidents,
car crashes of which they are the cause.
Stephen, you have Attention Deficit
Hyperactivity Disorder, right?
They call it ADHD.
What part of that do you understand
that you have... how's it affect you?
I know that it affects my learning abilities,
my attention span, of course...
It's like with Geography--sometimes, it takes
me a lot longer to learn that,
because I'm not really interested in it.
Even when I want to listen,
it just goes through my head.
What are some of the things, though,
that you've found that your teachers
have worked with you?
And is there a particular teacher that's made a real difference?
I would say... Ms. Taylor.
Because she was one of the only teachers
that actually related to me.
She actually knew what I felt about science,
and how she was teaching it,
and she actually changed it to fit,
to make it so that I would be able to listen to it.
Do you use some sort of summary book,
like for studying for tests?
For studying for tests,
I take the stuff that I'm supposed to study for
and I write it down into a summary form,
and then I read off of that.
That is how I study.
"Can you lead a band?"
"Are you a big liar?"
To learn all these lines in this play, The Music Man,
how did you even begin to learn all those?
By just saying it over and over and over?
Yeah, it was... anytime when I had my book with me,
I just read it.
"I'm a Conservatory man, myself.
Gary Indiana Gold Medal Class of '05."
If someone found out they had ADHD,
and they were kind of all upset about it,
what would you say to them?
I would say...
"Make the best of it.
Just do what you can with it,
and just work with it."
[ADHD and the Brain]
What we know now is that ADHD
is more than just the behavioural
symptoms that we can see.
It's more than meets the eye.
What we know from neuro-imaging studies,
is that there are subtle differences
in structure of certain parts of the brain.
For example, the cerebellum,
which is important for precise timing
and coordinated movement,
is altered in ADHD.
Also, the prefrontal cortex,
which is essential for planning and organization,
as well as for working memory,
which controls attention
and resists distraction,
is altered in ADHD.
Furthermore, the neural networks that connect
the various parts of the brain,
interact differently in people with ADHD.
So, if we are to understand individuals with ADHD,
and to help them,
it is essential that we understand
their cognitive difficulties.
And the particular difficulty I want to focus on,
is working memory.
[Understanding Working Memory]
Working Memory is often referred to as
an Active Mental Workspace.
It's a cognitive system that allows us to hold
and manipulate information on-line
for a few seconds during problem solving
or other cognitive activities.
And it's this internal representation
in working memory that we use
to guide our decision-making,
so that behaviour and actions
are not dominated by immediate
sensory cues in the environment.
Let me give you a couple of real-world examples.
The cocktail party.
It's quite amazing that we can get a busy environment,
with everybody chatting and partying,
and we can concentrate and focus on
the conversation at hand.
That is, until some salient little bit of information
captures our attention and draws us away,
such as one's name.
And, although this phenomenon has been known
for some time,
recently, scientists have gone back
to investigate this aspect.
And what they've found is that it's actually
only about a third of the population
whose attention is drawn away by their name.
About the third, in fact, that have been shown
for some reason, to have a more limited
working memory capacity.
That is they're less able to filter out
that distracting information.
Another example is something that we call
"Driven to Distraction", a wonderful study
conducted just recently,
where they were trying to understand
the impact of using cellphones on driving.
And again, what the researchers found
is that individuals,
when they were driving,
they could cope with listening to the radio,
having, perhaps, a gentle conversation
with somebody in the car,
but if it involved an in-depth conversation
via cellphone, that actually interrupted their driving.
So they were actually more likely
to go through a red light,
and if they stopped, it took longer to stop.
And it's this concern that it is perhaps
those individuals with a more limited
working memory capacity
that are at risk of being distracted
by what's going on around them
rather than concentrating on driving.
What we know about working memory therefore
is that it provides this continual, on-line,
updated source of information
that allows us to resist distraction,
to focus on the relevant information.
In more complex activities
in everyday life, such as following a conversation,
following a complex set of instructions,
planning ahead, all require working memory.
So, what does this mean for teachers in the classroom?
As all teachers know,
teaching is a balancing act.
Balancing the demands of the curriculum
with the students' abilities.
This is well-known by all teachers.
We know that aspects of the curriculum
can be intrinsically very complex and demanding.
How the teacher delivers that information,
the activities a child would have to do,
all provide a cognitive load.
On the other hand, we have the student.
And teachers are well-used to thinking about
the student's abilities, and their knowledge,
but one aspect of the student's abilities
that is considered rarely, I think,
in education at the moment,
is Working Memory capacity.
And what happens is that, if in fact,
the cognitive load of the curriculum
exceeds this youngster's working memory capacity,
there's an imbalance.
And so the youngster is in a position of
and is unable to learn.
What is critical, though, is we can do
something about this. In education.
That what we know is that the teachers can make
different instructional choices to help restore
this balance again.
To accommodate the youngster's difficulties,
challenges, with working memory.
And so to recap:
ADHD has a genetic basis.
ADHD persists into adulthood.
ADHD is neurocognitive disorder,
not just a behavioural disorder.
Inattention is associated with poor academic performance.
And working memory is one cognitive impairment in ADHD
that is important in education.
So what we've learned is ADHD is more than meets the eye.
It's time to rethink ADHD, and to rethink the classroom,
for students with ADHD.