 |
Topic Editor: Russell Schachar, MD, University of Toronto, Canada
Diagnosis
ADHD is usually first identified and treated among school-age children. However, the presence of hyperactive-impulsive or inattentive symptoms during the preschool years is considered central to establishing the diagnosis. Direct observation of the child can suggest the diagnosis but even the most symptomatic child can be calm and attentive in an unusual setting such as in the doctor’s office. Consequently, assessment should focus on obtaining a history of the child’s behaviour at home, at play and in school from early childhood to the time of the assessment. A typical clinical interview allows an opportunity to discuss how parents and teachers have responded to the child’s difficulties and to identify strategies that have worked and those that have not. Assessment should not be limited to ADHD symptoms but should enquire about associated symptoms that might also be evident such as anxiety, mood or conduct problems. Parents are not always aware of how much stressful circumstances can upset their child; therefore, a direct interview with the child can be an important part of the assessment. Concurrent disorders are an important focus of treatment and their presence can alter the effectiveness of therapy.
Many clinicians find that parent and teacher rating scales are helpful in the diagnostic process as a way of obtaining a description of the child’s behaviour that can readily be compared to age norms. Some children with high levels of restlessness, inattentiveness and impulsiveness have medical problems or developmental delays that must be identified as part of the assessment. Children with learning difficulties may be symptomatic at school and during homework sessions because they are struggling with the academic material. Other children may be symptomatic at home only suggesting some parenting, social or environmental problem. It can be very difficult to identify which children have specific learning difficulties in the doctor’s office. Consequently, consultation with an educational psychologist can be very helpful in getting a complete picture of the child’s strengths and difficulties.
Interventions
Stimulant medication (such as methylphenidate, RitalinTM) in various short and long acting preparations plays an important role in the treatment of ADHD. More recently, non-stimulant medications, such as Atomoxetine, have become available and play an important role in treatment. These medications can help a large number of affected individuals by improving their attentiveness, impulse control and reducing their activity level. Also effective are intensive behavioural interventions that involve a combination of self-control training for the child and education in parenting strategies for the parents. Positive parental attention, rewards for appropriate behaviours, and negative consequences for misbehaviours (e.g., prohibiting children from playing with their favourite toy) are recommended procedures in behavioural treatments. Teachers can also apply similar strategies within their classrooms. Available evidence indicates that the best interventions are a combination of medication, behavioural interventions and school-based programming for behaviour and learning. These treatments have to be intensive and long term to have their optimal impact. Direct training of cognitive functions such as working memory (that ability to hold and manipulate information in short-term memory) has shown promise as a potentially effective intervention. Some children may show improved behaviour upon removal of certain foods from their diet although the generality of this effect is not known and training of the brains electrical activities may improve alertness and behaviour in some children. That said a major issue with these treatments pertains to the generalization of improvements across settings. Future research examining factors that affect treatment outcomes (individual and contextual) should be conducted to improve children’s treatment gains over time and in different contexts.
See also...
|
|