Medical Conditions

Managing Chronic Health Needs in Child Care and Schools—Attention-Deficit/Hyperactivity Disorder (ADHD)

What is attention-deficit/hyperactivity disorder (ADHD)?

Attention-deficit/hyperactivity disorder (ADHD) is a behavior disorder characterized by attention problems and/ or hyperactivity and impulsivity.
Attention-deficit/hyperactivity disorder is usually diagnosed in childhood. The symptoms of ADHD, when present, are almost always apparent in some form by the age of 7 years.
The type of ADHD that just involves inattention may not be evident until a child is expected to meet some of the higher expectations of third or fourth grade.

How common is it?

Estimates suggest that between 3% and 9% of all children have ADHD.
It is more common in boys than in girls, with the ratio estimated at approximately 4:1.

What are some characteristics of children with ADHD?

Many children, especially preschoolers, can appear very energetic, active, and impulsive.
In children with ADHD, the symptoms of inattention, impulsivity, and hyperactivity are more extreme. These symptoms interfere with learning, school or preschool adjustment, and the child's relationship with family and friends. These symptoms may persist through adolescence and into adulthood. The most common symptoms of ADHD include
- Inattention
  - Short attention span for age
  - Difficulty listening to others
  - Difficulty attending to details
  - Easily distracted
  - Poor organizational or study skills for age
  - Forgetful
- Impulsivity
  - Often interrupts others.
  - Has difficulty waiting for his turn in school or social games.
  - Acts before thinking; often takes risks.
  - Tends to blurt out answers instead of waiting to be called on.
- Hyperactivity
  - Always in motion, as if "driven by a motor."
  - Has difficulty remaining in her seat even when it is expected.
  - Fidgets with hands or squirms when in her seat.
  - Talks excessively.
  - Has difficulty engaging in quiet activities.
  - Inability to stay on task; shifts from one task to another without bringing any to completion.
Attention-deficit/hyperactivity disorder is the most commonly diagnosed behavior disorder of childhood.
- The diagnosis can be made by the primary care provider in the medical home, developmental-behavioral pediatrician, child psychiatrist, neurologist, psychologist, or qualified mental health professional.
- A detailed history of the child's behavior from parents and teachers, a physical examination, and observations of the child's behavior contribute to making the diagnosis of ADHD.
- Psychological or educational testing may help define co-occurring behavioral or learning disabilities.

Who is the treatment team?

The treatment team for children with ADHD includes their primary care provider in the medical home, parents, teachers, mental health professionals, educational specialists, and other professionals who are involved with an individual child.
Treatment should include education for children and their families, as well as behavior and medication management if indicated.
Primary care providers should also establish a long-term plan for systemic follow-up support (a medical home), as with any chronic condition.

What are some elements of a Care Plan for ADHD?

Behavior management skills that can be included in a Care Plan include

Praise for appropriate behaviors that are being worked on
Using active ignoring when undesired behaviors occur that are not dangerous or intolerable
Using praise and ignoring in combination with each other
Point or token systems for behavior rewards and consequences
Preferential seating in a classroom to decrease distraction
Daily report cards or communication logs to travel between home and school

What adaptations may be needed?

Medications

Medication for ADHD is used for the purpose of balancing chemicals in the brain to help the child maintain attention and control impulses.
Stimulant medications are the most frequently used medications for ADHD. There are short-acting (4-hour), intermediate-acting (6- to 8-hour), and long-acting (12-hour) stimulant medications.
Some children require a medication dose during school or child care.
These medications may have side effects including decreased appetite, trouble sleeping or napping, headache, or stomachache.

Physical environment

Children with ADHD may be eligible for accommodations in school or child care through Section 504 of the Rehabilitation Act of 1973. This may allow a child preferential seating in the classroom, the ability to take a test in a quiet room, or other structures and supports that will allow him to succeed in school or child care.
If ADHD symptoms significantly interfere with learning, an Individualized Education Program can be requested as part of the Individuals With Disabilities Education Act.
Develop strategies for accommodating children with ADHD. Suggestions include
- Provide children with a consistent routine to the day and structure to the environment. Let them know when the routine is changing or something unusual is going to happen, such as a class trip or a special visitor.
- Give the child clear boundaries and expectations. These instructions and guidelines are best given right before the activity or situation.
- Devise an appropriate reward system for good behavior or completing a certain number of positive behaviors, such as a merit-point or gold-star program with a specific reward, like a favorite activity. The strongest rewards are often "Good job!" right at the time that the positive behavior occurs.
- Avoid using food and especially candy for rewards.
- Use a timer for activities to build and reinforce structure.
- As much as possible, give clear instructions and explanations for tasks throughout the day. If a task is complex or lengthy, break it down into steps.
- Communicate regularly with the child's parents/guardians so that behaviors can be addressed before they become disruptive.
- Children with ADHD need role models for behavior more than other children, and the adults in their lives are very important in this regard.

What should be considered an emergency?

Attention-deficit/hyperactivity disorder does not have any specific emergencies associated with it.
Emergencies may occur if an overdose of medication is given. Call parents if a known overdose of medication is given at school or child care, or for sudden erratic changes in a child's behavior.
Emergency medical services/911 should be called if a child on medication becomes overly drowsy or lethargic.

What are some resources?

Caring for Children With ADHD: A Resource Toolkit for Clinicians, American Academy of Pediatrics, www.aap.org/ bookstore, 888/227-1770
Children and Adults with Attention Deficit/Hyperactivity Disorder, 8181 Professional Place, Suite 150, Landover, MD 20785, 800/233-4050, 301/306-7090 (fax), www.chadd.org

Source: Managing Chronic Health Needs in Child Care and Schools: A Quick Reference Guide.

Products are mentioned for informational purposes only. Inclusion in this publication does not imply endorsement by the American Academy of Pediatrics.

Listing of resources does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.