Dr. Sanne te Meerman is a researcher in the Faculty of Behavioural and Social Sciences at the University of Groningen in the Netherlands. In “ADHD: a critical update for educational professionals” he and his colleagues outline vital ‘need-to-knows’ about ADHD, one of the most prevalent childhood psychiatric diagnoses.
What is ADHD?
The DSM-5 (American Psychiatric Association 2013) describes ADHD as a neuro-developmental disorder with a persistent behavioural pattern of severe inattention and/or hyperactivity/impulsivity. The behaviours must be uncharacteristic for the developmental age of the child, be manifest in different settings (for example at home and at school), have started before the age of 12, be present for at least 6 months and interfere with social and academic performance.
Why should school staff be cautious when considering ADHD as a cause of a child’s challenging behaviour?
In the UK between 2000 and 2018 ADHD diagnoses increased 20 fold – This study, by University College London, found that amongst boys aged 10-16, 1.4% had an ADHD diagnosis and 0.6% had been prescribed ADHD medication in the year 2000. By 2018 this figure had risen to 3.5% and 2.4% respectively.
In the US, the explosion in ADHD diagnoses and medicalisation has been described by specialists in the field as “an unreal epidemic” and “a national disaster of dangerous proportions”.
Dr. Meerman points out that teachers and other school staff are often the first to suggest the diagnosis of ADHD in a child. However they may be doing this based on misconceptions about ADHD and because the classification is a convenient ‘catch-all’ for unruly behaviours they lack confidence in managing.
In addition, Dr. Meerman questions whether a diagnosis of ADHD and associated medicalisation is in the best interests of the individual and highlights some of the negative longer-term outcomes for those diagnosed with ADHD.
What are some misconceptions educators have about ADHD – and what can we do to improve our responses to children and young people displaying challenging behaviours?
1. “Immature behaviours indicate ADHD.”
Dr. Meerman refers to several studies which show that overall, the youngest children in class are twice as likely as their classmates to receive a diagnosis of ADHD and medication. Apparently, health care professionals and teachers tend to classify relative immaturity as ADHD yet are unaware of the significant association between relative age and ADHD diagnoses.
What can education professionals do?
- Be cautious when judging behaviour – when considering a child who is more restless and less focused than classmates, take their relative age into account.
2. “ADHD is the cause of inattention and hyperactivity.”
Meerman notes, “Seeing ADHD as the cause of inattention and hyperactivity is in fact a logical fallacy as it is circular…Unfortunately, confusing naming and explaining is a common error with regard to behavioural problems.”
There are in fact no conclusive causes of ADHD, and many possible factors linked with the behaviours we commonly associate with it. These factors interact and do not always imply causality. Some are: divorce, parenting styles, lack of sleep and poverty, among others.
In addition to the factors described by Meerman, education professionals should note that ADHD behaviours can overlap significantly with symptoms of developmental trauma and attachment difficulties. Children who have experienced early adversity, inconsistent caregiving, or chronic stress often display hyperactivity, difficulty concentrating, and emotional dysregulation – behaviours commonly attributed to ADHD.
What can education professionals do?
- Be aware there are many potential causes of a child’s unruly behaviour. These interact in complex ways.
- Be cautious regarding claims made about the causes of ADHD (e.g.brain size, genetics), as these are disputed.
- Rather than immediately pursuing an ADHD diagnosis, schools should first investigate potential attachment needs and trauma history. A child who appears “hyperactive” may actually be hypervigilant due to past experiences. “Inattention” could reflect a survival-based focus on scanning for threat, rather than an inability to concentrate.
3. “ADHD is best treated with medication.”
The Multimodal Treatment of Attention Deficity Hyperactivity Disorder study, the first and largest study in child psychiatry ever, seemed to confirm the biomedical view that ADHD is a highly heritable disorder with visible anatomic and neurochemical differences in children diagnosed, which was best managed with intensive medication.
However Meerman explains that follow-up studies of the long term effects of medication 3 years and 8 years later showed that the outcomes between the different experimental groups converged over time, until, on average, no significant difference between medicated and non-medicated children remained after 8 years.
Other longitudinal studies have also reported no long-term benefits or even worse outcomes and adverse effects of long-term stimulant use.
What can education professionals do?
- Be aware of the pitfalls associated with neat ‘one cause, one solution’ thinking, which identifies medication as The Treatment for those diagnosed with ADHD. Medication may help a small group of children in the long run, however most will not benefit from it.
- Investigate and implement trauma-sensitive practices: consistent routines, clear boundaries, emotional co-regulation, and relationship-based interventions for example. These approaches benefit all students, while specifically supporting those with behaviours associated with ADHD.
4. “Having an ADHD diagnosis is in the best interests of children.”
Meerman notes how an ADHD diagnosis can open the door for a child to receive certain support and services. He argues this may have promoted a ‘search for pathology’ for children diagnosed with mild or moderate problems. In cases like these, he questions whether the advantages of a confirmed diagnosis outweigh known disadvantages, which include:
“low teacher and parent expectations that become self-fulfilling prophecies (the Golem effect); prejudice and stigmatization of diagnosed children; children applying stereotypes to themselves leading to self-stigma and low self-esteem; and decline of self-efficacy; a less effective and potentially counter-effective focus on fixed traits instead of behaviours; a more passive role towards problems; difficulties getting life and disability insurances later on in life; and the risk of overlooking contextual, social and societal explanations, due to the specious explanation offered by labelling.”
What can education professionals do?
- Take time to consider all the factors above when considering requesting an ADHD diagnosis for a child. The disadvantages may outweigh the advantages in all but severe cases. As Meerman observes, “Many obtrusive children at risk of falling under the ADHD catch-all umbrella simply display a difficult temperament.”
If your school needs support to manage challenging behaviours associated with ADHD or difficult temperaments, contact Dynamis by clicking here.
We can help you grow in confidence and skills to manage difficult behaviours effectively and keep people safe.