Attention Deficit Hyperactivity Disorder (ADHD)

What is attention deficit hyperactivity disorder?

Attention-deficit/hyperactivity disorder (ADHD) is characterized by inattention , impulsivity ("acting before thinking"), and hyperactivity or uncontrolled motor restlessness. It develops in intelligent children, without being solely explained by a neurological or psychiatric condition. Other disorders, including learning disabilities, are often present, either associated with or part of ADHD. ADHD very often leads to academic difficulties.

For what ?

We find certain genetic predisposition factors (family history), biological factors (notably a deficiency in certain neurotransmitters - molecules that allow information to circulate between neurons -), psycho-social factors.... These elements seem to be able to alter the functioning of certain brain circuits (striatum, frontal lobe...), involved in the control of attention and the inhibition of spontaneous responses.

What are the symptoms and consequences?

Inattention, impulsivity, and restlessness are the main symptoms of ADHD. These signs are not specific to this diagnosis and can, for example, be observed in disruptive children, children experiencing academic difficulties, or children with educational deficiencies. However, if these symptoms are particularly intense and persistent (early onset and prolonged course), and if they manifest in various situations (at school, at home, during leisure activities, etc.) with significant consequences on the child's social, academic, and family life, they become suggestive of ADHD. Diagnosis requires gathering various elements, including interviews with the parents and the child, a clinical examination of the child, assessment questionnaires for parents and teachers (such as the Conners scales: see related document), a psychological and neuropsychological evaluation, and possibly various paramedical assessments (speech therapy, psychomotor therapy, etc.) depending on the identified difficulties. The diagnostic criteria are those of the DSM-IV classification, which is included in the appendix; six of the nine symptoms of inattention or six of the nine symptoms of hyperactivity and impulsivity must be present for at least six months. Inattention is the most consistent symptom , sometimes masked by restlessness and impulsivity, or at other times, conversely, taking center stage. It manifests as frequent difficulties in maintaining focus on classroom activities and games (the child is easily distracted by the slightest noise), as well as difficulties in following instructions and organizing oneself (losing materials, etc.).

Hyperactivity is often evident . The child is perpetually in motion; in class, they fidget in their seat, stamp their feet, move around constantly, or knock things over. Their restlessness can also manifest as excessive talking, constantly manipulating objects, or involuntary finger movements during the oath-taking maneuver (Prechtl's chorea), which explains the often irregular handwriting of these children.

Impulsivity manifests itself in a child who reacts too quickly, without thinking or considering the consequences of their actions, who doesn't wait for questions to be finished before answering, and who has difficulty letting their peers speak or participate. In cognitive activities, they tend to skip steps in the reasoning process.

Given the nonspecific nature of the symptoms, the initial examination should look for certain disorders that could cause secondary attention deficits (visual or auditory sensory impairment, sleep disorders, sleep apnea, fatigue related to a chronic illness, etc.) and rule out a global intellectual disability. It should also provide objective data on the severity and profile of the disorders: -

Quantify the attentional deficit and define its profile (assessment of sustained attention, selective or divided attention, visual attention, auditory attention, and executive functions). - Analyze specific cognitive disorders through psychometric tests and assessments according to the identified disorders (speech therapy, psychomotor therapy, orthoptics, occupational therapy, etc.) to determine the possible existence of learning disabilities (particularly in written language, but also in handwriting or arithmetic), which are frequently observed.

Assessing psycho-affective disorders : emotional disturbances, including anxiety disorders which are particularly common, oppositional behaviors (provocation, disobedience, defiance, temper tantrums, etc.), and sometimes conduct disorders (behavior that violates the rights of others and social rules). Loss of self-esteem is frequent. A rigorous initial assessment, ideally by a multidisciplinary team (pediatric neurologist, child psychiatrist, psychologist, speech therapist, etc.), is therefore necessary to confirm the diagnosis of ADHD, assess the impact of the disorder, identify the child's needs in the classroom and in daily life, and later to monitor the evolution of the disorder.

Some figures

ADHD affects 3 to 6% of school-aged children, or nearly 200,000 children between the ages of 4 and 19, across all socioeconomic classes. It is a disorder that predominantly affects males, with four boys affected for every girl. A learning disability is present in 60 to 80% of cases, which is 15 to 20 times more common than in the general population.

Treatment

The treatment of ADHD is always multifaceted and must be tailored to each individual case. It combines medication if the impairment warrants it, psychotherapeutic support if necessary, and the management of specific learning difficulties, if present; parental guidance is essential.

1. Drug treatment is based on methylphenidate (Ritalin®, Ritalin LP®, or Concerta®). It is indicated for children over 6 years of age with confirmed ADHD, present in multiple situations and resulting in significant difficulties with social integration (academic failure and/or impact on family life). When the indication meets the diagnostic criteria, its beneficial effects affect approximately 90% of treated children and are then dramatic within a few days, in all areas. The initial prescription must be issued by a hospital physician or a physician working in a healthcare facility (such as a Child and Adolescent Mental Health Center or a Child and Adolescent Early Intervention Center). Most often, with the newer delayed-release formulations, the treatment is administered once a day. This treatment is sometimes interrupted during school holidays.
2. The necessary support for learning difficulties includes, depending on the case, speech therapy and/or psychomotor therapy, occupational therapy....
3. The indication for psychotherapy depends on the associated symptomatology (low self-esteem, depressive syndrome, etc.).
4. Parental guidance, and in particular parent groups, are a remarkable help in facilitating the structuring and support of the young person and reducing the daily consequences of the disorder.

Consequences for school life

Learning difficulties are common among children with ADHD, even when their overall cognitive abilities are normal . Mainstream schooling may require specific accommodations to support learning, such as human support (AESH), technical assistance (computer), or pedagogical adjustments. These must be detailed in an Individualized Support Plan (PAP), and sometimes in an Individualized Education Plan (PPS) with the MDPH (Departmental House for Persons with Disabilities). In other cases, schooling within a specialized unit (ULIS) will be necessary. Specialized institutions do not appear to be suitable options for these children's difficulties.

When should you be careful?

Children with ADHD may experience social isolation. Because of their difficulties following instructions, taking turns, and concentrating on an activity, they are likely to be rejected by their peers. They may also suffer from repeated comments about their behavior and any academic difficulties they may have. A loss of self-esteem, a lack of self-confidence, and anxiety are therefore common, and it is important to be attentive to these issues. These feelings can sometimes be accompanied by a genuine depressive syndrome.

• It is important, as far as possible, to avoid factors that reinforce inattention and hyperactivity: noise, commotion, and stressful situations . Creating a calm and peaceful work environment promotes learning and helps break the vicious cycle of hyperactivity-reprimand-anxiety for the child-increased hyperactivity.

How can we improve the school life of sick children?

Several factors can help facilitate a student's adaptation to the demands of school activities, both in class and at home: - Create a calm and structured work environment, and establish a routine for the schedule; - Facilitate the child's integration and concentration through appropriate seating within the classroom; - Allow for socially acceptable expressions of the need to move around; - Offer alternative solutions to avoid noisy interruptions from the teacher when instructions are forgotten (raising a hand, discreetly asking a classmate, etc.); - Shorten tasks, break down requests into shorter, clear instructions given near the child, and reinforce these instructions to compensate for short attention spans and fluctuations; - Help the child develop organizational skills and acquire strategies; - Communicate with the child and establish a system of encouragement when they achieve something positive.

The future

Early diagnosis, medical and educational support, in close collaboration with teachers and parents, gives children with ADHD the best long-term chances of academic, professional, social, and family success. Teachers play a crucial role in assessing, along with various healthcare professionals and parents, the evolution of the child's behavior and progress in learning, which are very important indicators of their development.