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Where Do We Go From Here: The Future of the Child with ADHD

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Reasons for Positive Change

Two processes account for the overall healthy outlook for children with ADHD. These are physical maturation and learning.

Physical Maturation

First, biology is on the side of the child with Attention Deficit. Research points to ADHD being caused by dysfunctions in certain portions of the brain. In fact, the problem very well may be disordered communication between different areas of the brain and its organizational, or control, center.

The human nervous system is incompletely developed at birth. While all the nerve cells and fibers are in place, they are not insulated from each other by the natural nerve insulator, myelin. From birth onward, a process of myelination occurs. Slowly, but inevitably, myelin is deposited about the nerves in the brain and spinal cord. As this happens more and more circuits come into action allowing more neurological function. Therefore, we observe the natural progression of child development in which motor skills, speech, and reasoning progressively develop with each day, week, month, and year of growth.

While the bulk of the myelination occurs during the early years, this process continues right through puberty. During the elementary school years, new circuits are becoming available to the brain’s “computer”. This allows the brain to find additional ways of doing its many tasks.

This process of physical maturation in the central nervous system provides the brain with the opportunity to use alternate pathways to perform functions which are blocked by dysfunctional brain development.

Learning

Another very important process is going on at the same time physical maturation is occurring. Learning is happening. The child learns over time how to compensate for the various functional disabilities. This process is essentially unconscious at first. It becomes more a conscious, deliberate process in the teen and adult years. The child learns techniques, procedures, and mental tricks which help him overcome, or work around, weaknesses.

For instance, the child who has a terrible time with organizing learns to make, and follow, lists from morning to night. The one with sequencing problems learns to outline his total day. The child with poor spelling carries a dictionary to every college class. The one with writing problems learns to type or use the word processor. The impulsive child learns to count to ten before reacting.

Through the combination of physical maturation and learning most children with ADHD do compensate, at least partially, for their dysfunctions and move on to varying levels of success as they approach the teen and adult years.

No, children do not outgrow ADHD. They, however, can, and do, overcome it.

There Is a Catch!

There is one catch in this scenario of progressive improvement, however. Without proper management, the child with ADHD finds himself in constant conflict with his environment. The child’s inefficiency in learning, general disorganization, and disruptive behavior results in failure to meet the expectations of parents, teachers, and peers. The relationship between the child, his parents, and teachers is often strained. There are few opportunities for reward and praise. Receiving predominantly negative feedback, he becomes progressively more aware of not pleasing important people in his life. This leads to loss of self-confidence and self-acceptance which, in turn, leads to anxiety and frustration. Since he is not getting many positive strokes in his daily life, he is likely to adopt acting out and attention getting behaviors– showing off, arguing, deliberate disobedience–in a vain attempt to get the attention and recognition he so dearly wants. But this type of behavior only leads to more conflict and frustration.

The child whose ADHD is unrecognized and untreated is at high risk of developing an intense sense of failure and inadequacy leading to low self-esteem. Thus emotional adjustment problems arise about the time the original neurological dysfunctions are resolving. In the long run, these secondary emotional adjustment disorders are more limiting and crippling than the original neurological impairments. A new cycle of failure and identity confusion can result.

In previous blogs we have mentioned that many factors work together to determine a child’s behavior and achievement. The child’s gifts (i.e., temperament), the level of disability (in this case, the degree of attention dysfunction present) and the child’s environment (home and school life) all play a part in determined the child’s eventual success.

As mentioned earlier, co-morbid conditions such as learning disabilities, conduct disorders, depression, etc. are factors which increase the risk of future problems. When present, these conditions must be evaluated and treated in order to facilitate future success.

ADHD and the Pre-School Child

The Note

Bobby’s parents came to see me because he was having a difficult time in pre-school. Following his fourth birthday in the summer he had been enrolled in preschool three months ago. The teacher had already requested several conferences with the parents regarding Bobby’s work and play habits as well as his behavior in the classroom.

His mother brought along a note his teacher had recently sent home: “Bobby has trouble sitting for more than two minutes before he is up and running about the classroom. He is restless at circle time and wanders around the room. He disrupts the other children who are trying to work. He cannot concentrate for more than a minute or two on a task because he is so easily distracted.”

Bobby’s Story

I learned that Bobby was the first child in his family. His mother reported that he had always been difficult to manage at home. Always active and restless, he had difficulty staying at the table through a meal and getting to sleep at night. He acted without thinking and was repeatedly in trouble for things like jumping on the furniture or getting into places that were off limits.

When his cousin of the same age visited, he pushed and shoved and was over-excited. But he was not angry and seemed genuinely sorrowful when confronted about what he had done.

His mother had noted these behaviors but did not know what to make of them since Bobby was here first child. “I thought maybe it was because he was a boy.”

Once he began to have persistent trouble at preschool the parents suspected that something was not right. “The teacher suggested that he might be hyperactive,” the father volunteered.

“But I thought he was too young. Doesn’t that problem only occur in older kids?” his mom asked.

In fact, most children with attentional problems and hyperactivity are not recognized until early elementary school.

However, the characteristic symptoms of ADHD are typically present from early in life. Often parents as they present a detailed history of the older child recall that the one with ADHD was different from early in life. These difficult behaviors at the time were not clearly different form the typical toddler and preschool pattern. Because no one could put a finger on these differences, they were ignored, or at least tolerated, during the early years. Confusing the picture is the fact that toddlers and preschoolers are by nature active, impulsive, and easily distracted. So the child with developmental problems may be somewhat difficult to separate out at this age.

But, then, along comes a Bobby whose restlessness, impulsiveness, and pure motor hyperactivity cannot be ignored. Such a child has problems paying attention, following directions, and participating in cooperative play appropriate for their age. They are overstimulated easily in large groups or when excited. In a one-on-one situation they may be more attentive and cooperative but even here the short attention span is likely to be noticeable.

For instance, they may have difficulty sitting still at the table through a meal. They will want you to read to them but may listen for only a few minutes before they are up and running or asking for another book. They may hit, push, and shove impulsively, but yet, they are not angry or mean. One common symptom at this age is an incessant need to talk without any control.

The Diagnosis

Indeed, Bobby did have attention deficit disorder.
After a detailed observations were obtained from his parents and teachers, developmental tests were administered. He was cognitively advanced being particularly strong in verbal skills. However, his motor skills were mildly delayed. The examiner noted that he had a very hard time keeping Bobby focused on the tasks.

Following this evaluation, Bobby was treated with a small dose of stimulant medication. There was marked improvement in his activity level and degree of impulsiveness. He was much more controlled in school as well as in the home setting.

His teacher later wrote: “Now Bobby is able to realize when he has done something wrong. He more often chooses positive options. He is able to sit and concentrate. He is choosing to ask for work which requires that he sit for 10-15 minutes at time. The amount of detail in his daily journal has changed tremendously. Before, he would draw just few lines with dark color in his interpretation was usually something violent and aggressive. This week, however he is taking his time and the colors and the details of his drawings are bright and clear.”

Management

The management of the young child with ADHD is certainly more difficult and complicated than with older children.

First, as we have discussed, it is not always easy to separate the attentional behaviors from those behaviors which are typical of preschoolers. Not only is the initial diagnosis more confusing but it is also more difficult for parents to decide how to respond to a specific behavior.

Secondly, the preschooler is not sufficiently mature cognitively to understand the consequences of his disruptive behaviors. Thus verbal signals are often not well understood or received. Parents find themselves constantly interrupting and re-directing behaviors.

The excessive impulsiveness leads the preschooler to behaviors that can be dangerous to themselves and others. Parents must be on their guard for things like climbing to dangerous heights, playing with matches or fire, running into the street, etc. The children must be watched compulsively.

To complicate all of this, the preschooler’s response to stimulant medication is more erratic and unpredictable. Many physicians simply will not attempt to treat the young child with medication because they have had bad experiences with it or they are uncertain about how to administer it to this age child.

The Use of Mediation With the Preschooler

Recent studies, however, have verified the fact that, indeed, preschoolers can be effectively and safely treated with stimulants with good response when the medication is managed appropriately for their age. The main problem is the narrow window between effective dose and side effects. However, by starting with a low dose and gradually moving upward, side effects can usually be avoided while finding that effective “therapeutic window.” One practical issue which complicates the administration of stimulants to preschoolers is the fact that the medication comes only in pill form at this time. Today, many forms of the medication comes as capsules containing time-released beads. These can easily be scattered on a food such as apple sauce, yogurt, etc.

Other Management Steps

In addition to medication when needed, other management steps are extremely important.
✇It is important for the home and school environment to be as calm and under-stimulating as possible while providing opportunities for learning. A consistent routine of living: eating, sleeping, play time, nap time, school, etc is essential.

✇An effective behavior modification plan is also important. Often behavioral counseling for the parents will be necessary to help them formulate discipline strategies and techniques to hand the specific bothersome behaviors of their preschooler. A developmental psychologist who understands preschoolers in a great help.

✇The preschooler with ADHD will often benefit from enrollment in a preschool at age three or four. The school should be quiet, structured, yet affirming in its atmosphere. Consistent behavioral management should be used.

✇Most of all, parents need relief. The supervision of the preschooler with ADHD is a very demanding, full-time job. This job can easily over-whelm the most energetic and well-meaning parents. Parents need to make good use of a competent preschool and mature sitters and relatives to get away and recharge their own batteries. Otherwise, they will collapse, emotionally, if not physically.

When confronted with the preschooler with ADHD we need to remember the natural tendency of the symptoms of ADHD to improve with chronological maturity. By providing the right combination of management at this early age, we set the stage for healthier growth later.

Have you met one of these children?

My five-year-old is always into things. He can’t seem to sit still, he can’t pay attention to any activity for more than a few minutes, and he is always acting before he thinks. He is in trouble constantly. What have I done wrong?

My nine-year-old has tried hard. But she has barely scraped by in school. She can answer questions orally, but when given tests or homework she seldom finishes. When she does, she makes many errors. She is not very organized. Maybe she’s not as smart as I once thought?

I have tried everything but Jimmy is still a difficult, unpredictable child. He is lovable but is getting into trouble all the time. He tries to obey but he has so much trouble following directions. Am I a failure as a parent?

==

If you know, or it you live with, one of these children, then this application is for you.

None of these situations may match yours exactly, but I suspect you have many of the same feelings, hopes, frustrations and questions shared by these parents.

Over the years, I have worked with thousands of children with behavior and learning problems and their parents. As I have listened to their stories, I find a common thread: a string of unanswered questions.

These key questions nagging parents are:

    Is there anything really wrong with my child?
    What caused this problem?
    What can we do to help?
    What does this mean to my child=s future?

This application will point you to proven and practical answers to these critical questions

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