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Section 15
Characteristics of Children with ADD

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Attention deficit hyperactivity disorder, frequently referred to as hyperactivity or attention deficit disorder (ADD), is a severe and usually chronic disorder estimated to affect 3% to 5% of school-age children (American Psychiatric Association). ADHD is more prevalent in males, with boys outnumbering girls by a mean ratio of six to one in clinic samples (Barkley). Phelan notes that on average, one child in an elementary school classroom has ADHD. Moreover, he reports that approximately 40% of students manifesting problems are likely to be students with ADHD. Children with ADHD experience behavioral difficulties, which most often manifest in distractibility, inattention, impulsivity, or hyperactivity. In fact, ADHD children are most commonly characterized as having difficulty completing tasks or persisting at a play activity, difficulty concentrating on tasks requiring sustained attention, distractibility, and not paying attention (Hoza & Pelham). As a result, children with ADHD may develop emotional, social, developmental, academic, and/or family problems because of the frustrations and difficulties they commonly experience due to the disorder. In addition, the families of children with ADHD may experience pressures and stresses beyond those produced by normal developmental problems (Schwiebert, Sealander, & Tollerud; Sealanderetal). Although most children with ADHD exhibit the first signs of difficulty before the age of 4, most often ADHD is first diagnosed when the child is in elementary school. Moreover, the behaviors of ADHD children and the problems which result put the ADHD child at risk for the following: completing their education, substance abuse, poor vocational achievement, social rejection by peers, oppositional behaviors, and delinquency. However, with proper intervention and treatment, children with ADHD can learn how to cope with daily demands in the classroom, in social situations, in family situations, and with life in general. Therefore, it is essential that identification of children with ADHD occur early. This allows teachers, parents, healthcare professionals, and school therapists to work with these students to assist them with strategies and intervention techniques designed to facilitate adjustment to school and vocational situations, social situations, family situations, and life in general. It is important to note that while definite criteria exist for the diagnosis of ADHD, the experiences of children and families affected by ADHD may differ depending on the cultural lens through which ADHD is experienced. Expressions of ADHD by the child as well as familial recognition of and/or response to these behaviors may differ depending upon cultural and ethnic influences. To date, there is no research that attempts to define differences in the experience of ADHD by children with the condition and their families from a cultural perspective, it is, however, important for therapists to consider the effects of ADHD and the development of treatment interventions within the cultural context of the affected child and family. It is beyond the scope of this paper to address this topic. However, a discussion of the accepted criteria for recognizing and diagnosing ADHD are included below.

Characteristics of Children and Adolescents with ADHD
According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association) definition, ADHD consists of one of three subtypes--predominantly inattentive type, predominantly hyperactive-impulsive type, or combined type--although most individuals will have symptoms of both inattention and hyperactivity-impulsivity. To be diagnosed with ADHD, the individual must exhibit the following symptoms:
A. Either 1 or 2: 1. At least six (or more) of the following symptoms of inattention have persisted for at least 6 months and to a degree that is maladaptive and inconsistent with developmental level: • Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities • Often has difficulty sustaining attention to tasks and play activities • Often does not seem to listen when spoken to directly • Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions) • Often has difficulties organizing tasks and activities • Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) • Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) • Often is easily distracted by extraneous stimuli • Often forgetful in daily activities 2. At least six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months and to a degree that is maladaptive and inconsistent with developmental level: •  Hyperactivity: often fidgets with hands or feet and squirms in seat, often leaves seat in classroom or in other situations in which remaining seated is expected, often runs about or climbs excessively in situations where it is inappropriate (in adolescents or adults, may be limited to subjective feelings or restlessness), often has difficulty playing or engaging in leisure activities quietly, is often on the go or acts as if driven by a motor, often talks excessively • Impulsivity: often blurts out answers to questions before questions have been completed, often has difficulty awaiting turn, often interrupts or intrudes on others (e.g., butts into others conversation or games)
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before the age of 7 years.
C. Some impairment from the symptoms is present in two or more settings (e.g., at school and at home).
D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic disorder, and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Although the DSM (American Psychiatric Association) specifies that diagnostic criteria must be present before age 7, difficulties associated with ADHD may persist well beyond the childhood years. Although their classroom behavior typically becomes less disruptive as they get older, children diagnosed with ADHD have problems that persist into adolescence. With respect to performance in the classroom, they remain impulsive, easily distracted, and have problems with tasks requiring attention and concentration (Fischer, Barkley, Edeibrock, & Smallish; Hinshaw; Sattler).

Currently, from. a legal perspective, ADHD alone is not a handicapping condition that qualifies children for special education services. Those students receiving special education services do so on the basis of a coexisting condition such as a learning disability (Teeter), or services may be provided in the regular classroom under Section 504, which requires accommodations and services be provided for children diagnosed with ADHD. The latter is less favorable for the school system as schools do not receive funding for these services. Because coexisting conditions have implications for service provision and the formulation of effective interventions, they are discussed below.

Coexisting Conditions
Academic underachievement is one of the most commonly reported correlates of attention deficit hyperactivity disorder. Learning problems are estimated to occur in from 9% to 48% of children with ADHD (Frick et al.). Teeter reports that up to 80% of children with learning disabilities also have hyperactive-attentional problems, are below expected levels academically, and are at higher risk for school failure. A learning disability can be classified as a disorder in areas such as oral expression, listening comprehension, written expression, basic reading skills, and reading comprehension. Success in these areas is related to advances in language. Co-existence of ADHD and language disabilities has been well documented (Cantwell, Baker, & Mattison; Wodrich). Cantwell and Baker conducted a follow-up study of 600 children with early speech and language delays. They found that there was an increased prevalence of learning disabilities and ADHD in this population.

Difficulties in oral expression and listening comprehension in language/learning disabled students includes the inability to maintain an overall organization of verbal information, process verbal information, and make evaluations or judgments regarding the information. Additionally, the inability to organize information with complex syntax and structure can impact the written expression as well as reading comprehension of students with language/learning difficulties (Shankweiler & Liberman). These deficit areas can be intensified when coupled with characteristics of attention deficit disorder. According to Hallowell and Ratey, characteristics of young adults with ADHD include difficulty getting organized, the tendency to say what comes to mind without regard to timing and appropriateness, and drifting in the middle of conversation. These characteristics affect the organization of spoken and written information, social interactions, academic functioning, and general daily functioning. Examples of other co-existing conditions include a diagnosis of Conduct Disorder (CD), delinquent behaviors (Frick et al.), general learning disabilities (Robins), reading deficits, and externalized behavioral problems (Hinshaw). Of 115 boys with ADHD referred to a university outpatient clinic, 39% also had a specific reading disability (Sealander, Schwiebert, Eigenberger, Little, & Ross). On a battery of cognitive and attentional measures, both ADHD groups (with and without a reading disability) performed at a lower level than a control group (August & Garlinkel). Other areas in which ADHD children are more likely to have difficulties are problem-solving strategies and organizational skills; problems associated with sleeping; and emotional disorders of various types.
- Schwiebert, Valerie A, Karen A Sealander, and Monica L Bradshaw; Preparing students with attention deficit disorders for entry into the workplace and post-secondary education; Professional School Counseling; Oct98, Vol. 2 Issue 1, p26

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 250 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about characteristics of ADD children.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 15
According to the DSM, what are the three subtypes of ADD? Record the letter of the correct answer the Answer Booklet.