When is ‘Lack of Attention’ a “Disorder?”

By Lisa Webb, D.Psy, MPH

Those of us with children have all experienced having to ask our child multiple times to complete a chore, assignment or task. One common answer to our requests may be “I didn’t hear you” or “I’ll do it in just a minute” to only discover the task was “forgotten” or only partially completed before another activity with greater interest level took priority. But when do these behaviors actually become an attention “disorder” and not merely just an issue with a lack of focus?

Diagnosis
Attention Deficit/Hyperactivity Disorder (ADHD) is a chronic condition that includes some combination of difficulty with attention, hyperactivity and impulsive behavior. ADHD affects millions of children and teens and often persists into adulthood. Adolescents with ADHD may also struggle with low self-esteem, troubled relationships, substance abuse and poor performance in school.

Diagnosis of ADHD is best made by a good family history and school history, with parents and teachers describing behavior that is consistent over time. For a valid diagnosis, a child must show hyperactive, impulsive symptoms or inattention symptoms in more than one setting—if it were only happening at home, for instance, or only at school, the behavior isn’t likely to be ADHD.

To address parents’ concerns about over-diagnosis, a good clinician is careful to screen out children who are just exhibiting normal impulsivity, normal hyperactivity, and normal inattention. A child with ADHD will score 3 times higher than typical kids on rating scales for these behaviors, and they will be seriously interfering with his ability to function in school, with friends and with his family.1 While we can assume that some kids are misdiagnosed, a much bigger problem is the many children who are not diagnosed and not treated, who are failing in school, in conflict with friends and families and at risk for dangerous behavior.

Treatment
There’s limited evidence that play therapy and talk therapy could assist to alleviate ADHD symptoms in real-life settings. What we find to be most beneficial is to work with teachers and parents to develop environments for the child to be successful. We also use specialized behavioral therapy—with systematic reinforcement—to help kids learn to focus their attention, and reel in their impulsive and hyperactive behavior.2

Organizational skills training is also an important part of treatment, where we prompt kids to pack their backpack, check that it’s packed properly then reinforce the child for success. It might seem obvious how to pack a backpack, but kids with attention issues need a lot of help building “executive function skills”– planning and organizing and following through.3

Those are some of the latest treatments on the behavioral end. Another very important element is Parent-Child Interaction Therapy,4 which can be amazingly successful in helping parents and kids together manage the disruptive behavior that often comes with ADHD. On the medication end, we have an increasing number of options. The most common and most effective treatment for ADHD is stimulant medication. There are also non-stimulant medications that help some kids who don’t respond to stimulants, or who experience negative side effects from them. However, medications rarely should be used as the first treatment implemented. Twice as many parents will refuse any additional type of treatment for their ADHD child when a medication is prescribed first (and is ineffective), than when a parent first tries their child on a behavioral approach.5 Research has also shown that most parents prefer a behavioral approach (or a combined behavior and medication approach) over medications alone. A combined treatment approach also has shown that children can gain as much value from medications at significantly lower doses. Since ADHD medications have been linked to stunted childhood growth (height and weight), lower doses are generally preferred. The need for a medication prescription should be determined following initiation of behavioral treatments, and its timing will generally depend on severity of the ADHD and responsiveness of the child to the behavioral interventions.

Parental Roles in Treatment
Parents are central to behavioral treatment for kids with ADHD. It’s the parents, working with the clinician, who will coordinate sending and receiving the daily digest of behaviors that serve as a foundation for treatment.6 Parents will coach their kids about behavior expectations and then reinforce that behavior at restaurants, church, temple, family gatherings, etc. It’s the parents who will help children learn to prioritize, and give them feedback.

That’s why it’s critical that parents and children with ADHD have a healthy relationship. If a child’s distraction, hyperactivity, and impulsivity have him on a collision course with parents—if his behavior is out of control— it’s important that the family restructure their relationship through a program like PCIT. Parents can learn effective techniques for reinforcing appropriate behaviors and discouraging negative ones. Kids can learn to more effectively rein in behavior, so they can be happier at home and at school.

Above all, children need their parents to not give up on them. Children with ADHD can be demoralized or stop believing in themselves. Children appreciate parents and teachers who they know won’t give up on them.

ADHD is Classified into Three Categories:7
1.    ADHD, Predominantly Hyperactive-Impulsive Type
Symptoms: Fidgets frequently; often leaves his seat in the classroom or in other situations when remaining seated is expected; constantly feels restless; acts before thinking–makes choices based on immediate rewards instead of working toward a larger delayed reward; feels a need to be busy all the time; talks excessively, blurts out the answers before questions have been completely asked; frequently has difficulty waiting for his turn; and often interrupts or intrudes on others’ conversations.

2.    ADHD, Predominantly Inattentive Type
Symptoms: Often fails to pay close attention to details or makes careless mistakes in schoolwork or other activities; often has trouble sustaining attention during tasks; seems not to listen even when spoken to directly; has difficulty following through on instructions and often fails to finish schoolwork, chores or other tasks; often has problems organizing tasks or activities, avoids or dislikes tasks that require sustained mental effort, such as schoolwork or homework; frequently loses needed items, such as books, pencils or tools; can be easily distracted; often forgetful; and appears careless and disorganized.

3.    ADHD, Combined Type
Exhibits symptoms from both Hyperactive-Impulsive and Inattentive Types.

1  Heavily adapted from article by Zwolinski, R., Zwolinski,C. (2013) Parent-Child Relationship Central To Treatment Of ADHD, accessed: http://blogs.psychcentral.com/therapy-soup/2012/04/3410/
2  Becker, S., Luebbe, A., Langberg, J. (2012) Co-occurring mental health problems and peer functioning among youth with attention-deficit/hyperactivity disorder: a review and recommendations for future research. Clin Child Fam Psychol Rev, 15 (4): 279–302
3  Ibid
4  http://www.pcit.org/
5  Brown, T. (2006) Attention Deficit Disorder: The Unfocused Mind in Children and Adults. Yale University Press.
6  Grohol, J. (2009). Comprehensive Treatment of Childhood ADHD. Psych Central. Retrieved on August 8, 2014, from http://psychcentral.com/lib/comprehensive-treatment-of-childhood-adhd/0001747
7 American Psychiatric Publishing. (2013) Attention Deficit/Hyperactivity Disorder.  Accessed:
http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf