PRESCHOOLERS WITH ADHD
GENERAL
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KEY ISSUE 1: DIAGNOSIS
1. Developmentally Inappropriate Symptoms on DSM-V
• DSM-V symptom criteria has not been changed for preschool aged children (Dias et al., 2013).
• Presentation of ADHD changes with development, and because certain symptoms are impacted by changing demands such as entry into a mainstream school, the application of a single list of symptoms to all ages has raised concern. For instance, hyperactivity is predominant during the preschool years as compared to inattention and impulsivity (Curchack-Lichtin, Chacko, & Halperin, 2013)
• Symptoms are difficult to distinguish from highly variable normative behaviours before 4 years of age (Curchack-Lichtin et al., 2013; Dias et al., 2013).
• Application of school-age-based criteria to pre-schoolers can be problematic. For example, “Avoids tasks requiring sustained mental effort” and “Makes careless mistakes” cannot be gauged when preschool children are not yet required to attend to tasks that requires a lot of attention and details (Curchack-Lichtin et al., 2013).
• The degree to which some ADHD symptoms may represent normative behaviour in preschool children has also been debated; Preschoolers are more active than older children, and children who are overly active as toddlers oftentimes normalize as they age. Fidgeting or squirming is common and may be problematic because these behaviours are frequently reported in young children with and without the disorder (Curchack-Lichtin et al., 2013).
2. Reliability and Validity of ADHD
• There is evidence that the diagnostic criteria for ADHD can be applied to preschool-aged children. However, there are added challenges in determining the presence of key symptoms Due to the pervasiveness of impairment across situations, the use of multiple informants is strongly recommended in ADHD research.
• Unfortunately, preschoolers and young children are not likely to have a separate observer if they do not attend a preschool or child care program, and even if they do attend, staff in those programs might be less qualified than certified teachers to provide accurate observations (American Psychiatric Association, 2013; Dias et al., 2013; Daley, Jones, Hutchings, & Thompson, 2009)
3. Unclear Delineation
• The DSM-IV and DSM-V address the issue of development by stating that for a symptom to be endorsed it must be “inconsistent” with the child’s developmental level This requires clear delineation of what is developmentally appropriate. In the absence of clear guidelines, ambiguity remains over what is considered normative versus pathological (Curchack-Lichtin et al., 2013).
4. Uncertainty over Early Diagnosis
• Professionals and parents, alike, struggle to decide between early intervention or a wait-and-see approach. Clearly, the extent to which symptoms are impairing is an important issue in determining whether or not to intervene. Nevertheless, some clinicians avoid diagnosing ADHD prior to age six altogether, potentially delaying much-needed treatment (Curchack-Lichtin et al., 2013).
• Some professionals may also not be confident of their ability to successfully diagnose and treat ADHD in a child because of the child’s age, co- existing conditions, or other concerns (American Academy of Pediatrics, 2011).
5. Subthreshold ADHD
• In the recently published DSM-5 ‘‘Other Specified Attention-Deficit/Hyperactivity Disorder’’ and ‘‘Unspecified Attention-Deficit/Hyperactivity Disorder’’ are categories which apply ‘‘to presentations in which symptoms characteristic of ADHD that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for attention-deficit/hyperactivity disorder’. Unfortunately, both categories do not provide a further clear, uniform criteria with an exact number of symptoms, which would be important both to clinicians and researchers to build a common language (Balázs & Keresztény, 2014).
• Children with subthreshold ADHD (ADHD symptoms that do not meet the six-symptom threshold for a diagnosis) may still experience severe consequences as compared to those without any symptoms (Hong et al., 2013).
• Although further research is certainly still required, the consideration of subthreshold ADHD as a valid clinical syndrome ought to be considered in future clinical and research contexts (Balázs & Keresztény, 2014; Hong et al., 2013)
KEY ISSUE 2: HETEROGENEITY OF ADHD
In the case of ADHD, six symptoms are required for an individual to meet diagnostic criteria. Because the criteria are subdivided into symptom domains (inattention and hyperactivity/impulsivity), it is possible that two individuals diagnosed with ADHD do not have the same group of symptoms. As children with ADHD vary significantly from one other, there may be a need to understand the symptoms first before the provision of interventions (Dias et al., 2013).
KEY ISSUE 3: MANY REMAIN UNDIAGNOSED
There is evidence that many children with ADHD remain undiagnosed and do not access these interventions. Left untreated, ADHD can result in impairments in multiple domains, including academic performance and parental productivity. It can also increase the risk of conduct and personality disorders, substance misuse and impaired social adjustment in adulthood (Wright et al., 2015)
• Underdiagnosis of children with ADHD – Inattentive Subtype, especially girls result in a lack of support at early ages (Biederman et al., 2005). This may lead to deeper issues such as low self-esteem in the long run.
KEY ISSUE 4: COMORBIDITY
In clinical settings, comorbid disorders are frequent in individuals whose symptoms meet criteria for ADHD. Chief among these co-morbidities are conduct problems, prevalent in 30–70% of children diagnosed with ADHD. Children with co-morbid conditions are more likely to have poorer outcomes, experience more impairment, more peer rejection, and their parents are also more likely to meet higher levels of psychosocial adversity (American Psychiatric Association, 2013; Daley et al., 2009).
KEY ISSUE 5: CULTURAL DIFFERENCES
Cultural differences in the diagnosis and treatment of ADHD are an important issue, as they are for all paediatric conditions. Because the diagnosis and treatment of ADHD depends to a great extent on family and teacher perceptions, these issues might be even more prominent an issue for ADHD (American Academy of Pediatrics, 2011).
KEY ISSUE IN MEDICATION
1. Side Effects
• ADHD is commonly diagnosed amongst school-age children with a high prevalence rate of about 5%. However, recent research indicates that the symptoms of ADHD may begin to emerge in children at a younger age than what was previously thought. Updated guidelines from the American Academy of Pediatrics (2011) state that it now possible to diagnose ADHD in children starting from 4 years old as compared to previous guidelines which recommended a diagnosis starting from 6 years old. In view of the earlier age of onset, it is imperative for early intervention to be provided in order to reduce inappropriate behaviours and promote healthy development in young children with ADHD. Medication is often used as a first step treatment. However, the Preschool ADHD Treatment Study discovered that side effects of medication such as stunted growth, insomnia, anxiety and retardation may be greater in preschool students than that which is experienced by older children (Daley et al., 2009)
KEY ISSUES IN BEHAVIOURAL PARENT TRAINING
1. Low ‘take-up’ and high ‘drop-out’ rates compromise the effectiveness of BPT
• Barkley et al.’s (2000) evaluation at post intervention showed no significant treatment
effects of the parent-training program, which was largely attributed to the poor attendance. High attrition rates not only limits the effectiveness of BPT for families but it is also associated with lower levels of engagement and may result in early termination (Dumas et al. 2007).
2. Barriers and Other Issues
• Both parents and practitioners highlighted a range of situational barriers, including being a single and/or young parent, having several children or having an unsupportive family or partner. Barriers noted were inconvenient session times and locations, child care issues and the lengthy duration of programmes. Practical reasons for missing sessions included illness and medical appointments, work commitments, and difficulties relating to their child’s behaviour. Other factors, mainly mentioned by practitioners, included; lack of education, cultural issues, domestic violence and financial difficulties (Koerting et al., 2013; Smith et al., 2014).
KEY ISSUES IN CLASSROOM-BASED INTERVENTIONS
1. Lack of Teacher Training
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In general, teachers have good knowledge of the symptoms of ADHD but lack understanding of the aetiology and treatment of ADHD (Barbaresi & Olsen, 1998; Jerome, Gordon, & Hustler, 1994; Ohan, Cormier, Hepp, Visser, & Strain, 2008; Sciutto, Terjesen, & Bender Frank, 2000). They tend to view the presentation of ADHD to be due to external causes. As a result, teachers consider poor behaviours a deliberate act of defiance and thus view these children in a negative light.
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Lack of training for teachers in managing children with ADHD. In Singapore, only 23.3% of teachers in Singapore reported having received some form of training to teach a child with developmental needs (Yeo, 2012).
2. Need for Early Screening
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Longitudinal studies show that the academic under achievement and poor educational outcomes associated with ADHD are persistent. Academic difficulties for children with ADHD begin early in life. Symptoms are commonly reported in preschool-aged children (Gadow, Sprafkin & Nolan, 2001), and preschool children with ADHD or symptoms of ADHD are more likely to be behind in basic academic readiness skills (Mariani & Barkley, 1997; DuPaul, McGoey, Eckert & VanBrakle, 2001). Dupaul, McGoey, Eckert & VanBrakle (2001) also highlighted the need to assess the preacademic skills and preschool classroom behaviour of young children with ADHD as they may be important targets for treatment beyond the amelioration of symptoms.
3. Classroom Accommodations
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Loe and Feldman (2007) posited that most available treatment outcome studies have not been conducted in general education classroom settings and have focused on reducing problematic behavior rather than on improving scholastic status. They postulated that classrooms are often noisy and distracting environments. (1) small class size; (2) reducing distractions; (3) specific academic intervention strategies; (4) increased physical activity; (5) alternative methods of discipline; and (6) systems change may be effective in improving the behaviour and academic achievements of children with ADHD. Research has also generally indicated that colour novelty (Rugel, Cheatam, & Mitchell, 1978; Zentall, 1985, 1986), novel setting of assessments and games (Zentall, 1980) improves sustained attention performance
4. Other Issues
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Bilingual context of Singapore makes it even harder for teachers to identify children who may have ADHD. It
is difficult for teachers to determine if inattentive/hyperactive behaviors are due to lack of exposure to a
language or genuine difficulties with attention.
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According to a study on teachers in Singapore (Yeo, 2012), barriers to implementation of ADHD-specific pedagogies include time constraints (64.7%), class size (29.9%), completion of syllables (25.9%), and lack of knowledge (13.8%) (see Figure 1).
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INTERVENTION APPROACHES
INTERVENTION APPROACHES
Figure 1. Factors affecting implementation of ADHD-specific pedagogies in Singapore.
Note. Adapted from Teachers’ Perception of Their Own Efficacy in Managing Children with ADHD in the Classroom, p. 55, by S. L. C. Yeo, 2012, Singapore: National Institute of Education. Adapted with permission.