Clinical Picture

Early Childhood

The three components that constitute the basis for the diagnosis of ADHD, both at school age and earlier, are inattention, impulsiveness and hyper-activity. Nevertheless, levels of activity and attention in infancy are totally different from those at the kindergarten or school stage. In most cases, a suspicion of ADHD is not raised before the age of 2 years. When a 1-year-old baby is very active, does not sleep very much during the day, wakes up frequently at night, does not have regular biological rhythms and does not play on his/her own, the tendency is to diagnose a difficult character, in other words, a variation within the norm, and not ADHD, which is a deviation from the norm. When there is in addition a disturbance in senso-motor regulation, a diagnosis of regulation disorder will usually be made [26].

In a longitudinal research study from birth until the age of 7 years, Palfrey et al. [27] found that only 3% of parents of infants up to the age of 14 months expressed concern regarding inattention or hyperactivity problems in their children, compared to 13% of parents of children aged 14 to 29 months. Forty percent of children showed varied levels of ADHD up to kindergarten age, while only 5% continued to suffer from it later on.

The diagnosis should include physical, emotional, cognitive/developmental and family examinations. Blackman [28] suggests the following criteria for distinguishing between troublesome behaviours and ADHD in early childhood: (a) a cluster of hyperactivity, impulsiveness and/or distraction that is higher in intensity and frequency than what would be expected at the child's age and developmental stage; (b) the symptoms are prolonged for over 12 months; (c) the symptoms should be evident in different situations and in the presence of people who are not the child's parents; and (d) there is a decline in social and familial functioning as a result of these symptoms.

Elementary School Children

Understanding the situation at this age is based on what we call the ''pearl model'' [29]. A pearl evolves as a result of a grain of some substance penetrating into an oyster, while layers are built up around it as a result of interaction between the irritant and the body of the oyster. The perception nowadays is that ADHD is fundamentally organic, i.e. it results from a minor change in the brain's structure and its functioning. Due to continuous interactions of the child with him/herself and the outside world, layers of psychological and social characteristics are formed around the organic grain, that eventually shape a clinical picture.

The ''classical'' child with ADHD is one who got through the early developmental years with no difficulty. Parents frequently describe him or her as an easy child, at times a bit naughty, but certainly not beyond the normal range for his or her age. An intelligent child will frequently be described as concentrating well when the child has an initial interest in the subject at hand and determines the rate of progress. Typical examples of this are television, computers and Lego, in all three of which the problem of mobilizing and sustaining attention is circumvented, since they provide changing stimuli that are intrinsically interesting to the child and two of them include a defined scenario, which in itself enables attention to be mobilized.

The first period in which difficulties begin to be reported for these children is when academic demands begin. As attention, memory and organizing abilities gain in importance, difficulties begin to surface. In accordance with this, the peak period for diagnosing ADHD is during elementary school, especially in the lower grades. The most common case is of a child who arrives apparently with no former problem or difficulties (apparently - since a retrospective analysis reveals that slight difficulties and attention problems were evident but were ignored), and suddenly finds himself or herself in a situation in which he or she starts to have difficulties and to fail.

The Educational Aspect

The educational aspect mainly involves frustration and underachievement that may not always be apparent on the surface. When we are dealing with overt underachievement, the frustration is greater, but the difficulty is easier to detect, so that a referral may be made for diagnosis and treatment. On the other hand, covert underachievement may remain undetected, or may only be detected at a much later stage, when there has already been irreparable damage to motivation and learning habits. The major protective factors are high IQ, motivation, strong family support and the earliest possible diagnosis and treatment. Among the major risk factors are other learning disabilities, concealment, denying that there is difficulty and comorbidity in the child or in the family.

The Social Aspect

With entry into elementary school, the sudden shock and decline in learning proficiency is frequently accompanied by a parallel decline in social functioning. It is possible to divide ADHD children into two types. The first group of children has good social skills and abilities that serve as a protective factor. These children use their social acumen as a compensation and disguise for their learning difficulties. The self-esteem of these children is less damaged and their inner perceptions are much better. Despite this, it is not uncommon in conversation for them to express hurt and anger regarding matters connected with learning. They also consider themselves stupid, or at least ''unfit for learning'', and this is an ever-present weak spot in their lives and performance. The other, more problematic group includes those children who have both social and learning difficulties.

To sum up, the basic problem, which is organic in nature, is accompanied by social difficulties that are no less problematic, perhaps even more so, academically speaking. This is due to the fact that finding a solution to social problems is more time-consuming and complex, and dependent on how fixated the ADHD child is on his or her low social or academic status.

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