Providing the right support at home and school for children and young people with ADHD
Attention deficit hyperactivity disorder (ADHD) is a complex condition characterised by symptoms of inattention, impulsivity and hyperactivity. Symptoms of ADHD occur in multiple settings, and ADHD can seriously affect a child’s concentration, behaviour and learning. Perhaps as a result of the widespread use of the internet, more families are recognising the symptoms of ADHD and asking for help early on from professionals.
ADHD is one of the most common medical conditions underlying behavioural difficulties and educational underachievement in children and young people. It affects approximately three to five per cent of school-aged children in the UK. This means that in a class of 30 children, one or more will have the condition. ADHD is also three to four times more common in boys than in girls, though symptoms of ADHD in girls may be harder to spot. It is now known that ADHD persists into adolescence and adulthood.
What causes ADHD?
The exact cause of ADHD is unknown, though studies have shown that it may be due to some form of chemical imbalance in certain areas of the brain. It is widely believed that ADHD runs in families; it is not uncommon to diagnose two or more members of the same family with ADHD.
ADHD is not caused by bad parenting, too much sugar or a bad diet. Research has shown, though, that harsh or inadequate parenting may worsen symptoms of ADHD.
Alcohol, smoking and drug misuse during pregnancy can increase the risk of a child developing ADHD. Babies who were born premature, or were very ill soon after birth, may develop ADHD later in life. Significant head injuries in children can also be a risk factor for developing ADHD.
ADHD and other conditions
ADHD commonly overlaps with other conditions. Indeed, the MTA study of 20011 revealed that ADHD alone (with no overlapping disorder) occurs in only around 31 per cent of children. The study found that ADHD overlapped with oppositional defiance disorder in 21 per cent of cases, with anxiety disorder (ten per cent), with conduct disorder (seven per cent), and also with a range of other conditions including tic disorders and substance abuse.
ADHD can also be associated with autism spectrum disorders, dyspraxia, attachment disorders and other neuro-developmental conditions. Some medical conditions may also mimic ADHD symptoms.
Prevention and public health
Good health in pregnant mothers and babies can reduce the risk of ADHD later in life. It is important to educate the public and pregnant mothers about the dangers associated with smoking (active and passive), alcohol and drug misuse on the brain of the developing foetus.
Good and early antenatal care can prevent the transmission of certain disease-causing viruses from the mother to the developing foetus. Good post-natal care by midwives, and early recognition of disease in the newborn by paediatricians, GPs and health visitors, are essential. Successful childhood immunisation programmes will also prevent common childhood diseases.
Health visitors should be available to support new parents and deliver health promotion programmes.
Supporting those with ADHD
Early recognition of symptoms
Recognising the symptoms of ADHD in very young children can be difficult. It is important to distinguish between normal active toddlers with challenging behaviours and those with genuine symptoms of ADHD.
Training and education
Specialist ADHD teams should be involved in offering training programmes to primary care professionals and schools. Knowledge about ADHD will enable recognition, support and early referrals to specialist services.
Families of children identified with ADHD should be referred to parent support and behavioural programmes. These structured programmes can enable parents to effectively manage their child’s behaviour. A number of programmes have been shown to be effective in managing and supporting challenging behaviours in young children.
ADHD care pathways
The 2008 NICE guidance on ADHD2 encourages ADHD specialist teams to develop ADHD care pathways. These pathways capture each stage of a patient’s journey and enable vital multi-agency working. Clear and robust care pathways facilitate early identification of children requiring specialist intervention or support and identify gaps in existing services.
Clear transition pathways from paediatric specialist services to adult mental health services are instrumental in supporting young people with ADHD.
Early identification and referral
Identifying symptoms of ADHD can be difficult. However, persistent and impairing symptoms of hyperactivity, impulsivity and inattention occurring in more than one setting and significantly impacting on a child’s ability to function effectively, and on people around him/her, should be referred to health professionals.
Extreme cases of ADHD can affect behaviour and attention to the extent that they disrupt a child’s learning experiences. Children often become isolated from their peers and experience low self-esteem. This, in turn, increases the risk of developing mental health disorders later in life.
Those with suspected ADHD should receive support to help them overcome their difficulties and to make it easier for them to access the school curriculum, improve relationships and achieve to their full potential.
Pre-school children with challenging behaviours and suspected ADHD should undergo multiple observations by trained professionals within the nursery or pre-school and home settings. Parents and staff with concerns should discuss them with health professionals.
Parents should be referred, in the first instance, to structured parenting programmes, as symptoms may improve with the right support and intervention. It is important for parents/carers to receive advice and support from all relevant professionals. Referral to specialist services is warranted if symptoms persist despite adequate behavioural support and intervention. Voluntary ADHD support groups are instrumental in providing further support and advice to parents and professionals.
Suspected ADHD within the educational setting should initiate a response in accordance with the setting’s existing SEN systems and practices, and the SEN Code of Practice.
SENCOs and teachers play a vital role in collating the necessary information for initial assessments. Schools need to work closely with school health teams within their localities, who will signpost families to relevant community intervention programmes and provide strategic support.
Schools should provide enhanced behaviour and learning support to children struggling with the academic curriculum. Some children may need to be referred to social skills and anger management programmes.
Specialist ADHD services
Children and young people with impairing and persistent symptoms, despite adequate support, should be referred to specialist ADHD health services.
Those with suspected ADHD will receive a comprehensive assessment, which may lead to a diagnosis of ADHD. Referral to specialist behaviour programmes is made post-diagnosis.
Children with severe symptoms of ADHD may be started on medication to help control their symptoms. Regular ADHD reviews within specialist services and primary care should occur after diagnosis, especially if medication is involved.
Effective psycho-education3 plays a vital role in supporting children and young people with ADHD and their families. ADHD psycho-education involves the simple dissemination of information on ADHD and its management in ways which are easily grasped by children and young people (and their families). The aim is to empower the children and young people (and their families) by providing them with necessary skills and information about the condition.
Psycho-education may be done individually or in small groups, but professionals should be aware that different children use different learning styles – such as visual, auditory or kinaesthetic – to access learning. Professionals should also use a range of different tools and approaches, including story-telling, play, pictures, audiotapes, computer CD ROMs and smart phone apps for older children. Parents should be encouraged to use the same techniques at home with children with ADHD and their siblings.
When delivered effectively, ADHD psycho-education will increase awareness and understanding of ADHD in the child or young person, resulting in increased self-esteem and impacting positively on peer and family relationships.
Supporting ADHD in the home
By ADHD Nurse Specialist Lynn Hall
For support strategies to be successful, professionals should rally around the child or young person and his/her family. It is crucial that parents are provided with appropriate information regarding ADHD management.
Parents and carers should:
- access ADHD support groups or websites to increase their knowledge about the condition
- be good role models for their children, and encourage family bonding by doing things together
- avoid giving multiple instructions to the child, and remember to sustain eye contact when giving instructions. Instruction should be broken down into easy-to-remember chunks
- plan the day so the child knows what to expect, and break this down into structured steps
- provide immediate positive feedback and reward for good behaviour
- help the child with everyday organisation of things such as homework
- set a good bedtime routine. Sleep hygiene information can be obtained from the ADHD nurse specialist, school nurses and health visitors
- watch for warning signs. If the child looks like s/he is becoming frustrated, over tired and about to lose self-control, try to intervene by distracting him/her calmly. If parents or carers lose their temper, this will not help matters
- be consistent and firm when setting rules
- avoid confrontation. Adults should avoid locking horns with a child with ADHD, as this can produce a battle of the wills and lead to damaged relationships. A back-up plan is always useful in situations of possible conflict.
If parents and professionals work together slowly and steadily, change should come, but it is important not to expect too much too soon.
Supporting ADHD at school/college
By ADHD Nurse Specialist Michelle Atherton
Schools should work closely with parents and health professionals in supporting children and young people. School health teams and trained school staff are instrumental in administering and monitoring ADHD medications in school, where appropriate. Schools should have access to regular and up-to-date ADHD and medication information and training programmes.
ADHD nurse specialists have the important role of bridging the gap between specialist ADHD services, schools and families. They frequently offer support and training to children and families, schools and professionals within primary care.
The following strategies can help support students with ADHD at school.
- sit the pupil at the front of the class, near to the teacher and away from any internal or external distractions. Ensure that the table/desk s/he is working at is also free of any distracter items, and that there is a place to go for quiet study
- sit the pupil with other pupils who will provide good role models. This will provide an environment for observational learning to take place, which will hopefully result in imitation of the desired behaviour
- divide tasks into smaller, more manageable segments and reduce task choices to no more than two
- as soon as the pupil has finished each part of his/her task, use positive reinforcement to praise the pupil for completing each segment of the task and for staying focused
- keep classroom rules clear and simple, and instructions brief, and only give one instruction at a time. In order to avoid the pupil being inflexible, keep routines fixed so that the day’s events are organised and easy to forecast
- to help the pupil follow instructions, first gain his/her attention and then give the instruction. Repeat the instruction using a variety of methods (such as verbal and written), ask the pupil to repeat it, and then repeat the instruction at regular intervals and ask the pupil to continue to repeat the instruction to him/herself.
- provide pupils with short periods of physical activity during task segments
- when the pupil needs to calm down, have activities ready that are structured, easy and enjoyable for him/her to do, and that allow him/her to move around either in the classroom or within the school grounds.
- help pupils to become aware of how their behaviour affects themselves and others. Ask them to explain a number of times what they have done, what they think would have been a more acceptable way to behave and why they think others around them have responded in the ways they have.
Ensuring good health in pregnant mothers and children may help to reduce the risk of ADHD.
Children and young people with ADHD should receive coordinated support at home, at school and in the community. ADHD awareness, leading to early identification and referral to health services, when appropriate, is essential. Early referral can also help to ensure more effective support with ADHD management, social skills and behavioural programmes.
ADHD care pathways should enable effective multi-agency working and identification of service gaps.
ADHD psycho-education should use a variety of techniques and approaches, and should be delivered in a manner suited to the learning style of the individual. Through active participation in education and training sessions with professionals, children and young people can more fully understand their ADHD, and become better motivated to take responsibility for managing their disorder as they get older.
Dr Susan Yarney is a regular speaker on ADHD management and the author of Can I tell you about ADHD? A guide for friends, family and professionals and other works. Dr Yarney is Consultant Community Paediatrician and ADHD Service Co-lead at East/North Hertfordshire NHS Trust:
Lynn Hall and Michelle Atherton are ADHD Nurse Specialists at East/North Hertfordshire NHS Trust .
1: Jensen, P. S. et al., J Am Acad Child Adolescent Psychiatry, 2001; 40 (2): 147-158.
2: National Institute for Health and Clinical Excellence, Sep. 2008. Attention deficit hyperactivity disorder. Diagnosis and management of ADHD in children, young people and adults. Quick reference guide. Nice Clinical Guideline 72.
3: Montoya, A., Colom, F., Ferrin, M., Is psychoeducation for parents and teachers of children and adolescents with ADHD efficacious? A systematic literature review. European Psychiatry, Volume 26, Issue3, 166-175.