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ADHD: Leave the diagnosis to the doctor

Ms. Estelle looks up from reading The Very Hungry Caterpillar to her 4-year-olds.
“The caterpillar ate three plums and was still hungry,” she says. “How could he do that?”
“I ate three bowls of cereal,” says Jenny. Other children recount similar experiences.
At the back of the circle, Josh is twisting and pulling fibers in the rug. Without warning, he blurts out: “I have a new soccer ball.”
Ms. Estelle pauses. “Wow, that’s great, Josh.” She turns to the group: “We’ll finish the story this afternoon. Let’s stand up and stretch for a few minutes.”
During nap time, she writes notes about the children’s behaviors. On the page for Josh, she records his unrelated comment during story time. She also notes that he gave up working a puzzle, dumped blocks on the floor, and then tried to pry safety plugs out of an electrical outlet.
“He seems unusually restless today,” she thinks. “Is he angry or anxious about something? Am I seeing a pattern of behavior that might be ADHD? Do I need to be concerned?”

It would be hard for anyone to interpret Josh’s behavior. In early childhood, most children have trouble paying attention, sitting still, finishing a task, and focusing on a topic.
Some might characterize Josh as “hyperactive.” But that characterization is misguided for two reasons. First, only a physician can diagnose the condition known as attention deficit/hyperactivity disorder, or ADHD. Second, a child’s behavior before age 6 can be challenging and still fall within a normal range.

What is ADHD?
ADHD is defined by the American Psychiatric Association as “developmentally inappropriate attention and/or hyperactivity and impulsivity so pervasive and persistent as to significantly interfere with a child’s daily life” (Reiff 2004).
Scientific evidence suggests that ADHD is a biologically based condition in the brain. The cause is unknown, but the condition seems to run in families. Unfortunately, there is no brain scan, X-ray, blood test, or other medical procedure that can establish that a child has ADHD. Instead, a diagnosis is based on reports about a child’s behavior and functioning.
For many children, ADHD is a combination of inattention and hyperactivity/impulsivity. Some children, however, have problems mostly with one or the other.
In evaluating a child, a physician will conduct a physical examination, take a family medical history, and consider whether symptoms might indicate another disorder. Observing a child for a few minutes in a medical office cannot produce a diagnosis. Instead, the physician will pore over information about the child’s behavior collected from parents and teachers and will often consult a psychologist or neuropsychologist who specializes in testing children.
The testing specialist will usually perform a battery to tests to augment the information collected from teachers and the parents. The specialist will attempt to answer specific diagnostic questions, such as:
Is the child really inattentive, hyperactive, and impulsive?
Are there family or social stresses that are causing anxiety and therefore inattention?
Does the child have learning problems that are causing the inattention, hyperactivity, and impulsivity?
The younger the child, the harder it is to establish a diagnosis of ADHD with certainty. Similarly, it is hard to be certain of learning disabilities until the child is in elementary school. The range of what is age-appropriate behavior in young children is wide. For that reason, most physicians resist making a diagnosis of ADHD before a child is 7 years old.
For a diagnosis of ADHD, a child must have symptoms for longer than six months, and some symptoms must have existed before age 7. The symptoms must interfere with the child’s functioning in two or more settings, such as home and school, and be more pronounced than for most children at the same level of development.

What’s the teacher’s role?
A caregiver or teacher is responsible for knowing the strengths and needs of every child in the group and accommodating those needs in the day home or classroom. If Tanya is allergic to peanuts, for example, the caregiver will modify menus to eliminate peanut products. If parents cannot afford books to read to their children, the teacher may set up a lending library so families can take books home for short periods.
Discerning the strengths and needs of each child requires a knowledge of child development and experience with children. It requires communicating with parents, observing a child over time, and documenting the child’s behavior using written notes, checklists, and other tools.
Documentation must be objective; that is, it reports facts, not judgments or opinions. “He was hyperactive again today” is an opinion. “During story time, Josh sat at the back of the circle and fidgeted with the rug for 3 to 4 minutes” is an observable fact.
Documentation must also be consistent and methodical. A teacher observes and jots notes about the behavior of all the children. She takes notes at regular intervals, dates them, and keeps them in a confidential file.
If a pattern of problem behavior appears, the teacher first analyzes the schedule and environment. Perhaps she is expecting Josh to do tasks for which he is not developmentally ready. She might try adding simpler puzzles to the manipulatives center, offering calming materials like play dough and sand, and reading with him one-on-one, for example.
All the while, the teacher stays in regular communication with parents about what’s happening at school and any changes at home that might affect his behavior. Under no circumstances does a teacher label the child or make a judgment about the child’s condition.
In many cases, the parents also may have concerns or questions about their child’s behavior. At that point, it’s helpful to schedule a parent-teacher conference. The teacher can review her notes about the child and refer the parents to a physician or an Early Childhood Intervention (ECI) program for a screening.
While a child is under evaluation, the parents may give permission for the teacher to share her notes with the physician’s office or ECI staff.
A screening may reveal a problem or group of problems other than ADHD. The child may have a hearing impairment, an auditory processing impairment, an anxiety disorder, or an overactive thyroid, for example. A screening may indicate some behaviors that fit ADHD but not enough to warrant a diagnosis, particularly if the child is younger than 6.
If a child is eventually diagnosed with ADHD, the treatment may include medication, behavioral therapy, parent education, and other services. The caregiver or teacher may be invited to participate in the treatment team, particularly in helping the child improve behavior and learning in the classroom environment.
It’s important to realize that parents may already feel overwhelmed and even guilty about their child’s behavior. It is not the teacher’s role to criticize the parents’ child-rearing practices, suggest a particular diet, or urge the use of a medication or vitamin supplement. Treatment is the physician’s responsibility.
A number of alternative treatments for ADHD exist, but their effectiveness remains to be proven. In the absence of medical evidence, the American Academy of Pediatrics recommends a best-practice approach. Best practices are based on the consensus of what experts consider the best advice for dealing with the disorder.

How to deal with overly active behavior
Regardless of a screening outcome, caregivers and teachers can respond to the overly active behavior of children of any age.
Focus on the child’s strengths and interests. The more a child experiences success, the more the child will feel confident and ready to learn. If Josh is interested in soccer, for example, provide books about soccer and offer physical games with a soccer ball outdoors.
Talk with the parents about what the child likes and does well at home. Offer a variety of activities until you discover those that are enjoyable in a classroom setting.
Simplify the environment. Many children feel overstimulated by the noise and activity of daily life—TV, video games, traffic snarls, blaring music on the radio, flashing billboards.
Identify things that distract children, remembering that the distractions may be different for individual children. You may consider muffling noise and softening lights, for example. Or you may rethink the number of activities in each learning center and change centers less often.
Organize the environment. Set clear boundaries for learning centers, and keep traffic paths open. Limit the number of children in each center, and provide enough toys and learning materials to avoid squabbles. Have specific places for storing materials and children’s belongings.
Provide predictable routines. A consistent schedule is important for all children and essential for those who are overly active. Knowing that the day always begins with free play, circle time, and snack, for example, helps children feel secure.
Be realistic about your expectations. Notice when a child seems to lose interest, even with ordinarily pleasant, enjoyable activities and interactions. You may need to shorten circle time, break up a task into smaller chunks, and avoid activities that require waiting or watching.
Find ways to accommodate the child’s high activity level. Set aside a space indoors for intensive movement and energy release. But avoid self-esteem damaging signals that broadcast the child as different or troubled.
Give active children assignments that require movement like passing out supplies or arranging floor mats for circle time.
Structure activities so you can provide close supervision. Instead of a cooking activity for the whole class, divide children into small groups. At circle time, encourage an overly active child to sit near you and away from distractions such as windows and hallways. Your proximity gives you the ability to respond quickly to redirect or refocus a child who is distracted.
Use charts and checklists. Children often need reminders about rules and routines. To help a child learn the procedure for washing hands, for example, make a chart with pictures that show wetting the hands, applying soap, scrubbing long enough to sing “Twinkle, Twinkle Little Star,” rinsing, drying with a paper towel, and tossing the towel into the trash.
Give clear directions. Call the child’s name to get attention, and make eye contact. A clear direction is a statement (“Lie down on the cot”), not a question (“Would you like to lie down on the cot now?”)
Keep directions simple and brief. “Put the paper towel in the trash can under the sink.” It may help to have the child repeat the direction to ensure hearing and understanding.
Remember to squat or kneel to get to the child’s eye level before you give the direction.
If the child interrupts or is distracted, you may need to shorten the direction: “Towel in the trash.” To regain attention, touch the child’s arm or take a hand. Say only what needs to be said.
Focus on effort, not outcome. “You worked hard in fitting those puzzle pieces together.” “You listened carefully when I read how the train chugged up the mountain.”
Impose as few rules as possible. Instead of 30 classroom rules, have two: “We treat everyone kindly, and we keep the room clean and neat.” Explain the rules and point out examples. “When Damian gave Elyse a turn on the tricycle, he was treating her kindly.”
Acknowledge positive behavior immediately. “Thanks for putting away the paint pots.” A smile, a pat on the back, or a thumbs-up can work equally well. A reward system in which children earn stars or stickers is sometimes useful.
If only part of a behavior is positive, focus on that. “You dried your hands with the paper towel. Great! Now put the wet towel in this trash can.”
Ignore negative behavior if it’s not dangerous and you can tolerate it. Negative behavior is sometimes a bid for attention. When you encourage the positive and ignore the negative, children will discontinue the negative because the positive is more pleasant. Of course, the negative may increase for a time until children see that you are consistent.
Stop dangerous behavior immediately. If a child is about to poke a pencil into someone’s eye, grab the child’s hand and remove the pencil. Explain what you’re doing. “If you poke a pencil into Ben’s eye, we’d have to take him to the hospital. It would hurt him a lot. I won’t let you hurt anybody.”
When you see unacceptable behavior, respond immediately with clear directions that tell the child what to do. “Josh, freeze! Blocks are not for throwing. Use the blocks for building. Can you build a barn for these farm animals?” A child may hear and understand what’s expected but may not be able to think ahead and plan actions accordingly. Children learn through experience and can often modify their behavior to avoid unpleasant consequences.
One effective consequence for overly active preschoolers and school-agers is a time-out or cooling-off period. Some teachers have the child sit in a chair facing a corner with no distractions. Some programs encourage teachers to sit with the child and talk through the behavior, brainstorming appropriate solutions to a problem.
The maximum time for time-out is one minute per year of age. A 4-year-old would be in time-out no longer than four minutes, for example. Remember that young children cannot comprehend time, so set a timer. “Take a few minutes to calm down and rest. The timer is set for four minutes. Think about what activity you’d like to do when you rejoin the group.”
Another effective consequence, particularly for school-age children, is loss of privilege. For Josh, it might be playing with materials other than blocks for part of the morning. Always make consequences logical—related to the undesired activity or behavior—and immediate. Denying Josh the privilege of playing soccer in the late afternoon isn’t a logical or immediate consequence to his morning block throwing.
Make consequences clear and give a warning before imposing the stated consequence: “Blocks are for building. If you continue to throw the blocks you’ll have to give up your turn in the construction area.” If the behavior stops, acknowledge the child affirmatively with a simple nod. If it doesn’t, carry through with the stated consequence.
When stating rules and warnings, speak calmly and firmly. Avoid looking or sounding angry. Help children understand that rules enable us to live in harmony and that breaking a rule is the child’s choice.
Remember that children’s behavior changes as they get older. Even children who are eventually diagnosed with ADHD can learn to manage their behavior with the support of informed, caring adults.

Provide a safe and friendly environment
ADHD is surrounded by a great deal of confusion and controversy. As responsible caregivers and teachers, we do not use terms like “hyperactive” and “ADHD” lightly. Our job is to recognize the strengths and challenges of every child in our care and respond in ways that can best help children grow and learn.

References
American Academy of Pediatrics. “Children’s Health Topics: ADHD.” www.aap.org/healthtopics/adhd.cfm.
Reiff, Michael I., M.D., ed., with Sherill Tippins. 2004. ADHD: A Complete and Authoritative Guide. Elk Grove Village, Ill.: American Academy of Pediatrics.

Editor’s note: Thanks to Walter B. Kuhl, MD, and Julia Kirby, Sharon Stone, and Rachel Moyer-Trimyer at ECI who reviewed this article.