Sandra Laujin

What is Attention Deficit Disorder / ADD / ADHD?

Attention deficit disorder, as the name suggests, can be defined predominantly by difficulties in concentration. These difficulties may, or may not, be accompanied by hyperactivity or impulsivity.

Attention deficit disorder is identified by being:

• Early onset: manifests before the age of 6
• Chronic or persistent: present for at least 6 consecutive months
• Permanent: present in a range of contexts such as at home and at school

Attention Deficit Disorder (ADD), with or without hyperactivity (ADHD), is a disorder that reduces in severity with age. Many people believe that the symptoms of hyperactivity disappear around the time of adolescence. In reality, many research reports show that it is highly unlikely that the symptoms disappear altogether. It is true that there may be fewer symptoms and they may be less intense, but in about 80% of cases, children diagnosed with ADHD will still have enough symptoms during their teenage years to receive the same diagnosis. Once they reach adulthood, the percentage remains between 50% and 65%, indicating that the difficulties do not disappear with time.

The fact that the symptoms do tend to last over time does not mean that they do not change the way in which they manifest themselves. For example, physical restlessness may become less intense, as may all of the symptoms. However, whilst the symptoms may seem to diminish, social expectations on the other hand, increase with age. This reality, unfortunately, prevents individuals with hyperactivity from behaving like their peer group. Taking the example of getting a driving licence: in some countries, the minimum age is 16, because this is considered to be the age required to have a sufficient level of concentration to be able to drive safely. Yet a hyperactive adolescent of this age will probably not yet have adequate control of his or her focus and attention to be a prudent driver.

Attention deficit disorder is complicated to diagnose. Healthcare professionals agree that a global overview of the symptoms is necessary as the attention disorder may be:

• A primary disorder – meaning one that stems from a developmental disorder
• A secondary disorder – meaning it may be the symptom of another disorder such as:
  • An emotional disorder: the child is anxious or depressed. In this case the lack of concentration and/or hyperactivity are a reaction the environment – a conflict between the child and its environment.
  • A disorder associated with another condition. For example, children with autism and psychosis suffer from attentional deficits in relation with their condition. In this case, the attention difficulty is a symptom of another disorder and not a disorder itself.

A case study in order to better understand the complexity of attention disorders

Let’s take the example of a boy with signs of an attention deficit disorder: he is struggling to concentrate in class, to do his work and is having academic difficulties. He feels like a failure. His attitude becomes defeatist regarding anything academic; he can’t motivate himself to try and disengages with his education. Medication and/or neuropsychological rehabilitation of his attention difficulties are not helping very much and so his parents decide to ask for a full psychological and neuropsychological assessment.

The results of the assessment highlight normal attentional capacities but an anxiety disorder. The parents and child therefore understand that the symptoms have a psychological rather than a neuropsychological origin. On a neurological level, the child is capable of concentrating but is being inhibited by psychological barriers. Initially everyone focussed on the symptom, but not the cause of that symptom. It’s as if we tried to treat the fever related to an infection with a painkiller. By not treating the infection and only the fever, the symptom is likely to last or even worsen.

Determining the origin of the symptom of attention difficulties enables the treatment to be correctly adapted.
In this case, the attention disorder is a secondary disorder linked to an emotional issue. The treatment suggestion would be child psychotherapy and parental guidance along with psycho-educative strategies aiming to build confidence at home and in the school environment.
In other cases, when the attention disorder is a primary disorder, the treatment suggestion might be neuropsychological rehabilitation along with psycho-educative strategies. When the symptoms are too intense, a medication can be associated (but the drug’s side effects must be considered first).

What are the signs and symptoms of attention deficit disorder, with or without hyperactivity?

Signs/symptoms of inattention in children with ADD / ADHD

In comparison with their peers, children with ADD / ADHD have difficulty focussing and maintaining their attention, whatever the activity. It often seems like they do not integrate instructions. They may suffer from difficulties:

• Engaging in an activity for any length of time. They will try to avoid activities that require sustained attention. Even whilst playing games they will be distracted.
• Finishing tasks, particularly if they require sustained attention: despite good intentions, they do not finish their homework or any activity.
• Paying attention to details and so often makes careless mistakes
• Listening when being spoken to: they often deem distracted
• Following their thoughts through
• Respecting verbal instructions: they often will not do as their parents or teachers say
• Respecting written instructions: they often will not follow the instructions given in their schoolwork
• Organizing their work and their activities, following systematically through the steps of a task
• Not forgetting things: they often lose items that are essential for school and daily life

Signs and symptoms of restlessness in children with ADHD

Children with ADHD seem restless and hyperactive both mentally and physically. They may have difficulties:

• Not talking excessively
• Developing language in a way that allows them to explain themselves clearly as they are more concerned by taking action
• Not fidgeting: they struggle to sit still, move their hands or feet continually, squirm on their chair in school or elsewhere
• Not being constantly ‘on the go’: they act as if they are wound up, climbing and running about without restrain
• Respecting other’s space and not invading it
• Being productive in their activities: they may behave in an aimless, disorganized and inappropriate manner

This hyperactivity is particularly noticeable during tasks requiring concentration (in the classroom for example), whilst in other contexts such as during break time, the child with AD(H)D may be hardly distinguishable from the others. They may, however, be boisterous, invasive or ready for a fight. Sometimes they are unpopular and rejected by their friends who can no longer tolerate their misbehaviour and incapacity to play by the rules.

Signs and symptoms of verbal and physical impulsivity in children with ADHD:

Children with ADHD may suffer from an overwhelming need to act or speak without being able to defer the urge. They have great difficulty being patient and so may:

• Struggle to wait in a queue or wait their turn in a game or any other social situation
• Blurt out an answer: they often reply to a question before it has been completed or they may reply in class without raising their hand.
• Interrupt others, intrude on their conversations and impose themselves
• Talk excessively with no regard for usual social conventions
• Not respect boundaries: struggle to follow rules and requests

Hyperactivity and impulsivity may make these children, who do not think before they act, who struggle to plan and anticipate their actions, take risks and put themselves in dangerous situations. This explains the amount of accidents they have at home or at school. Sufficient supervision is necessary. Their behaviour can mean that their families restrict the amount of family outings together through fear of them endangering themselves or others. They are often perceived to be unpredictable, disruptive, rude, noisy or undisciplined.

How to diagnose Attention Deficit Disorder with or without Hyperactivity?

Let’s start by taking a look at how the brain works…

At any one point in time, our brain is carrying out complex procedures to gather and process the information it encounters. In order to do so, it uses what are known as "cognitive functions". Cognitive functions can be defined as the cerebral activities that lead to knowledge (cognition). They include all types of mechanisms for acquiring information, namely:

• Functions non-focused on emotions: reasoning, attention, memory, language, motor skills, planning etc.
• Functions focused on emotions: functions known as affective and social

It is thanks to the efficiency of our cognitive functions that we can participate in the world around us and learn. When a child has difficulties learning or being in the world, it means that there are deficits or at least difficulties with one or more of their cognitive functions.

Due to the complexity of the brain and it’s functioning, an exploration of the different capacities that may have an influence on the relationship with the world and learning, is essential. For example, children with autism often display varying difficulties that should be assessed, such as emotional, social, attention, language-based and mobility impairments.

Full Assessment of psychological functioning

Assessment for children aged over 6 years old

In case of a suspected attention deficit disorder, for children from the age of 6 and above, a full psychological and neuropsychological assessment should be carried out. The full assessment links together cognitive development with emotional and affective development.

* Neuropsychological assessment examines cognitive development. It analyses the totality of the cognitive (brain) functions. By exploring the symptoms displayed by the child, it enables deficits of any of the brains functions to be identified.

• Attention: selective, sustained, divided / visual, auditory, audio-verbal
• Executive functions: planning, flexibility, working memory, speed of information processing
• Language: expression and comprehension
• Memory: visual, verbal, visuospatial etc.
• Reasoning: verbal, perceptual, crystallised, fluid
• Social and emotional skills: perception and comprehension
• Visuospatial skills
• Motor skills

* Psychological assessment examines emotional development. It allows the psychologist to identify the specificities of a child’s personality and whether or not any disorder is present. It examines the following psychological aspects of the child:

• Level of personality organization
• Level of adaptation to reality
• Level of emotional adaptation
• Level of social adaptation
• Individual issues
• Emotional state

Assessment for children under the age of 6 years

If an attention deficit disorder is suspected before the age of 6, a developmental assessment can be carried out. This involves assessment of the child’s stage of development in relation to that of other children of the same age. The following aspects are examined:

• Motor skills: fine and gross
• Language: expression and comprehension
• Intellectual capacities
• Life skills
• Social skills
• Autonomy

A developmental assessment enables the detection of deficits as well as helping to make diagnostic hypotheses and to orient the therapeutic care plan as well as psychoeducational strategies at school and at home.

Under the age of 6, the child is in a stage of phenomenal neuronal and psycho-affective development. The diagnostic hypotheses based on the developmental assessment should be verified around the age of 6 once the brain functions are not in such a major phase of development.

As the brain functions are still in the process of developing, we cannot expect, for example, a 3-year-old to have fully developed attentional capacities and to be able to concentrate. For this reason, this cognitive cannot be assessed. Certain cognitive functions cannot be assessed before the age of 6.

Therefore, a full psychological and neuropsychological assessment at the age of 6 allows for the diagnosis to be confirmed or otherwise and for an evaluation of the totality of the cognitive functions in depth. In the meanwhile, psychological treatment can be offered to assist the child in their development.

Assessment objectives

The assessment helps to respond to several questions.

What difficulties is my child being faced with?

The evaluation allows for difficulties to be identified and for a diagnosis or diagnostic hypothesis to be proposed. It enables:

• Understanding the nature of the difficulties faced by the child: are signs of cognitive and/or emotional/affective/mental deficits present?
• Evaluating the severity of the deficits and the level of skills
• Examining the consequences on the psychological functioning and the autonomy of the child of these deficits or disorders: are they affecting learning, social interaction, emotional regulation? If so, how and to what extent?
• Ascertaining the resources available to the child that can help them to develop

How to deal with these difficulties?

The evaluation can guide the follow-up treatment and maximise the learning potential and well-being of the child. The objective is to help the child to flourish on all levels - academic, social and emotional. The evaluation helps:

Parents to better understand their child, respecting the child’s limits and providing better adapted support

• To provide parents with the knowledge required to explain their child’s needs and get them help from the relevant services
• To develop an effective therapeutic care plan adapted to the child’s needs (benefiting from the services of neuropsychology, psychology, occupational therapy, speech therapy etc.)
• To develop an efficient individual education plan adapted to your child’s needs (psychoeducational strategies at school and at home, teaching assistants, collaboration with teachers etc.)
• To provide the child with a vocabulary that gives meaning to the difficulties faced. Better understanding of the causes of suffering can provide comfort. For example, a child who knows that they have difficulties learning or learns differently may feel like a failure. However if he or she understands their difficulties, they can accept them and approach things in a different way. The final stage is to help the child to feel capable of overcoming, to whatever extent is possible, their difficulties and therefore engaging in the treatment plans offered. Indeed, motivation is the central factor in the success of treatment.