Attention Deficit Hyperactivity Disorder (ADHD)
ADHD is now often being overdiagnosed or wrongly diagnosed so that some children who actually need help are not getting it. In 1996 it was demonstrated that ADHD was slightly more common in twins than in their siblings, although no other behavioral problems are. This plus the association with reading problems make it an important topic to raise. There is much controversy over ADHD and both causes and treatments. Here we follow the guidelines of the National Health and Medical Research Council of Australia and do not deal with some of the “alternative” explanations and interventions such as diet. These may have a role for a minority of children, but large-scale studies in Victoria, Australia show this really is a small percentage of those diagnosed.
What is ADHD?
Despite all the media hype about ADHD, it is not new. In 1902 it was described as “defective moral control”. We may laugh at the name but the symptoms described were very similar to what we now identify as ADHD. It went through many permutations of the name including “minimal brain damage” and “minimal brain dysfunction”, all the absence of any evidence of brain disturbance. But there is still disagreement over the definition.
Differences in the definition of ADHD
There is such variation between countries and over time in the definition of ADHD that it is no wonder people are confused. A brief history lesson is needed. The USA and Australia have gone mainly with the DSM (Diagnostic and Statistical Manual) classification developed by US psychiatrists to ensure people were diagnosing behavioral and psychiatric problems in the same way. In 1987, DSM-III-R recognized just one form of ADHD, where children had to have 8 out of 14 attention and activity problems. Many clinicians felt this was not right and that not all children with ADHD were the same. So DSM-IV came out in 1994 with three types of ADHD, a purely Inattentive type, a purely Hyperactive/Impulsive type and Combined type who had both sorts of symptoms. The first had to have six of the nine Inattentive symptoms, the second six of the nine Hyperactive/Impulsive symptoms and the third six of each.
The diagnosis was not just based on having symptoms but on having these to the extent that quality of life was impaired in at least two situations (home, school, etc) At the same time, the sub-division of diagnoses recognized the three types have different patterns of comorbidity, that is of problems with reading disability, clumsiness etc that justify the distinction.
Europe has gone much more with the ICD-10 classification, the International Classification of Diseases which is a more extensive classification system that covers not just behavioral problems but also physical ailments. Without being too precise, to be diagnosed with ADHD in this system one must have both Inattention and Hyperactivity/Impulsivity symptoms (so it is more like the DSM-IV combined type) and problems must be identified by two sources (for example, teachers AND parents). Thus this classification is much more restricted and restrictive.
So now you know psychologists and psychiatrists are only just starting to converge on a definition of this problem. What does it mean for the family and the school?
- the DSM-IV diagnosis means there will be many children who have attention problems that are not being recognized. They have none of the hyperactive signs that are so often shown by the media as being key to ADHD- hyperactive children make better footage than inattentive ones! In fact, the purely Inattentive type is the most common in all population studies and the purely Hyperactive/Impulsive the least common, with the Combined type somewhere in between.
- but surely all children (and many adults) have attention and activity problems? In 1997 we showed that the symptoms of ADHD were a continuum throughout the population. Yes, we all have some symptoms but few of us have so many and have them to the extent they are so disruptive that the label of ADHD is warranted. It is where to draw the line that causes the controversy. Yet we accept such cutoffs in everything from the diagnosis of intellectual disability or high blood pressure to speed limits.
- think comorbidity. It may not be ADHD but all the other things that can accompany it, such as conduct disorder, a history of reading problems plus intervention and clumsiness that make this such a problem for the family. These are some data from our Australian Twin ADHD Project
|ADHD category||Reading Therapy||Speech Therapy||Conduct Disorder||Separation Anxiety|
What is conduct disorder? It is not just naughtiness. “We asked the mother of young MZ twin girls if they were ever cruel to animals (one of the routine questions). After a pause, she said, one had sat on the cat while the other cut off its ears…..”
Actually, conduct disorder is no more common in multiples than in singletons, even though it has some association with ADHD.
Separation Anxiety refers to the “clinginess” that most children show at some time and again it is only when this becomes disruptive that it is an issue. It may be a little more common in young multiples as they try to find ways of getting parental attention. It may also be more common in all young people with ADHD as they rely more on their parents. As explained below, ADHD often means you have few friends and thus you may not want to be away from the parents who are the ones you can rely on.
These results illustrate how comorbidity differentiates the subtypes:
- the Hyperactive/ Impulsive subtype has no more problems with speech or reading than the twins without ADHD but more Conduct Disorder and Separation Anxiety
- the Inattentive and Combined types have higher rates of speech intervention and almost half have had a reading intervention. The Combined type has much more Conduct Disorder than the others.
Why is ADHD more common in multiples?
Firstly it is only a little more common in multiples, whereas speech and reading problems are generally more common. So, it is important not to jump to conclusions. If a multiple is not doing well at school, this does not mean ADHD. Intervention for learning problems alone may be quite different from an intervention for ADHD. There are some multiples where there have been significant problems before or at birth that may have contributed to their symptoms, but for most multiples, this is not the case. No one really knows why the difference happens, but we suspect it has to do with developing along with one or more siblings the same age. How can you learn to concentrate when the other(s) are always around, playing with things at your developmental level and diverting your attention? So think about the common statement
“Well, they always have each other to keep themselves amused”
They also have each other to stop them learning to concentrate on something and seeing it through until it is finished. And the behavior of one multiple does influence the others. Our recent Australian studies showed that twins become more similar in their Hyperactivity symptoms as they grow to adolescence, but do not necessarily become more similar in their Inattention symptoms. This makes sense. It would be difficult to ignore the behavior of your overactive siblings, while their inattention does not have the same influence on you.
At the same time, we need to think what life is like with and for multiples. As Hugh Lytton showed 20 years ago, twins are better than single-born children at recognizing rapidly spoken speech. Parents will recognize why! But there are key implications if ADHD is an issue. With multiples, there is often not the time to give each instruction by itself. So the children are told to “Brush your teeth, make sure your shoes are clean, get your schoolbag and collect your lunch money”. This sequential list is too much for children with ADHD and parents and teachers need to make allowance if not everything is done.
Self-esteem and ADHD
The issue of self-esteem has already been raised with Reading Disability and many of the same issues will arise, like ADHD and Reading Disability as so often comorbid (See, you are learning the jargon!)
But there are three specific things about ADHD
(i) rejection by peers. Young people with ADHD often have few friends because of subtle things about their behavior. They may not attend to social cues in conversation and their impulsivity means they may butt in at inappropriate times. Thus other kids may not want to engage with them. In addition, the parents of other children may discourage friendships, sometimes not allowing their children to associate with children perceived as “trouble-makers”. Such children often find that they are not invited to birthday parties or to other children’s houses.
(ii) our Australian studies show that up to 70% of children with ADHD have comorbid problems with motor control (clumsiness). This has a major impact on sports and for example, who is chosen for the cricket team-you do not want someone who misses every catch. So while this may not be an academic issue for the school, it is a significant issue for the pupils.
(iii) medication at school. The role of drugs in treating ADHD is too big a topic for this website, except for one point. The drugs used in ADHD in the UK and Australia wear off very quickly, which is one argument as to their safety in that the body does metabolize them in a few hours (the US has legislated to allow newer drugs which last longer). This medication has to be given again during school time. This is bad enough for any child or any teacher but it is worse for multiples, as yet again your need for medication may distinguish you from your cotwins or higher multiples.
Managing ADHD in the classroom
This is an issue to be addressed at a local level where multiples are only part of a larger plan. As ADHD is being increasingly recognized, then each region of each state or country (in some cases each school) is developing its own policies and these cannot obviously all be covered here. There are some basic questions all multiple-birth parents should ask in such a situation:
(i) what is the school policy for children recognized with ADHD? The following are some essential “survival” tips for the teacher and the class.
Strategies for the Classroom
- sit the child close to the teacher, away from distractions
- workload and attention span should coincide
- keep the work periods short but frequent, helping the children to be aware of time so that they can pace their work
- provide clear instructions, but avoid too many sequential instructions
- if the child goes off task, redirect them in a positive and unobtrusive way
- make sure they succeed at something in class
- prompt their attention and also their inhibition-“stop, think act”
- clear guidelines on finishing work-taking it home if it is not finished are not the answer-it just penalizes the ADHD child further
(ii) how will the school respond to the fact that one or more of my multiples has a problem with ADHD? There are still schools that maintain ADHD “does not exist” or is “just an excuse”. The whole family and not just the multiple(s) with ADHD may get a poor hearing in such a school.
(iii) can we take ADHD into account in deciding whether our multiples will be separated? There is no way that simply separating multiples into different classes will help the one(s) with ADHD. But issues of self-esteem may make it better for all multiples irrespective of ADHD to remain in the same class.
“Andrew was so upset when they suggested he should move. It is not so much being moved from Sean (his twin). His ADHD makes it difficult for him to get and keep friends and having Sean around helps. With the two of them, a lot of the kids like Sean and so accept Andrew. We can’t imagine Andrew in a new class with no friends. It is like he is being punished for having ADHD”.
On the other hand, ADHD behaviors may be so embarrassing, it may be better for unaffected multiple(s) to be apart from those with ADHD. ADHD is a “disability” and many of the issues addressed in the section on families with a disabled multiple apply.
Introduction to downloading the questionnaire
Do our multiples have ADHD?
The Disruptive Behaviours Questionnaire covers the key DSM and ICD questions for ADHD, Oppositional Defiant Disorder (ODD) which overlaps extensively with ADHD, as well as Separation Anxiety and Conduct Disorder. This questionnaire is not meant to be definitive. A proper diagnosis needs consideration of
- the number and intensity of symptoms
- whether they occur in more than one situation and are seen by more than one person
- whether they impair the young person’s functioning
- at what age the symptoms began
This checklist is merely an opportunity for parents and/or teachers to consider just what the behavior of this child is like and to decide if a more thorough assessment is needed. In assessing multiples, it is important to consider three things
(i) that the views of parents and teachers may well differ. Is there something about the home or about the school that may contribute to some signs of ADHD being seen in one environment but no the other? The parent may be seeing a child who can sit engrossed in front of the computer for hours, so feels there is no problem with inattention. The teacher may see the same child struggling with schoolwork and doing everything but what they are supposed to be doing. This leads to
(ii) differences between the multiples. Some studies have found multiples to be assessed by the parents as being even more different from each other in ADHD than are single born brothers. The argument is that parents contrast their twins, the “quiet” one and the “active” one. Not all studies show this and it does seem to depend on which measure of ADHD is being used it does not tend to happen so much with the checklist we have here. However, it is something to consider when multiples are being assessed on any measure of behavior. To what extent are they being assessed as an individual and to what extent relative to the other multiple(s)?
(iii) “better than average”. Most checklists are designed to identify problems. But some young people actually do much better than most on their attention and activity. To class them just as “average” is doing them a disservice. There are some questionnaires that are just being tried with multiples that have categories such as “better” and “much better” than average. While not included here, they do make an important point about the assessment of all young people that we need to focus on their strengths as well as their weaknesses.
References: See here