ADHD symptoms in infants

Although ADHD is a neurodevelopmental disorder, virtually nothing is known about its early onset and manifestation during infancy. This is because there is no specific diagnostic test for ADHD at any age, including infancy. During a child assessment for ADHD, parents often report that in infancy their child was "difficult to regulate and manage," or that the doctors had detected minor neurological problems in preschool years (for example, the child had problems with fine motor coordination). What is known at present is that:

• Regulatory problems (such as irritability and sleeping and feeding problems) in infants do not necessarily lead to ADHD in early childhood, although they are often associated with a range of emotional and behavioural problems.
• The presence of minor neurological problems in the preschool years is associated with an increased risk for ADHD, which supports the notion that ADHD is a neurobiological disorder.
• Infants of fathers with ADHD show neurodevelopmental immaturity and some subtle cognitive problems, but it is not known yet whether these infants will grow up to have ADHD themselves.

ADHD in preschool and kindergarten children

Teachers of preschool-aged children identify classroom behaviour problems, including those caused by ADHD, as important detriments to the daily functioning of the class and to student progress. It is estimated that about 2% to 5% of preschoolers meet criteria for ADHD. Although many doctors are reluctant to give a diagnosis of ADHD at this young age, there is growing evidence that early behavioural problems do not dissipate and that marked inattentiveness in preschools predicts later academic underachievement. For example:

• Symptoms of inattention in kindergarten are associated with poor reading readiness skills. This in turn has a strong negative effect on reading abilities in the first grade.
• Inattention in the first grade is predictive of reading underachievement, even when other factors are taken into account (such as kindergarten reading achievement, IQ, and parental involvement).

Preschool children with ADHD stand out markedly from their non-ADHD peers on a variety of behaviours and abilities:

• unable to sit through games, stories, and circle time; may roll around floor or crawl under tables
• constantly asking questions but racing off before the answer is given
• constantly running and on the go and stopping only when they collapse from exhaustion
• seemingly unaware of preschool routines, rules, and expectations, even after several months in school
• failing to meet academic and social expectations of preschool and kindergarten environments
• cognitive weaknesses in working memory, inhibitory control, speed of processing information
• problems in understanding the "instructional language of the classroom" and producing organized and focused spoken responses to teacher's questions
• banging into objects and people, climbing and jumping off furniture
• frequent injuries often requiring hospitalization (head injuries, fractures)

ADHD in school-age children

Although children with ADHD vary in the severity and types of problems shown at school, they typically stand out from their classmates in many ways. For example, in addition to showing the behavioural symptoms of ADHD, they:

• generally act much younger than their age, despite having average intellectual ability
• often act as the "class clown" and by so doing gain the attention of other children and disrupt their work — this is much more common among boys with ADHD
• talk excessively when they are not supposed to, but may become silent or monosyllabic when called upon by the teacher to respond
• often do not have any close friends or have difficulty reciprocating and sustaining friendships
• typically (but not always) have problems with their school work and homework despite good intellectual abilities (for example, not able to work independently, unable to start or to complete in-class work or homework)
• often show great difficulty in or even avoid written work, so they write little or nothing down on paper
• often obtain lower academic achievement scores and are at high risk for failing the grade level, despite average intellectual ability
• are at increased risk for accidental injuries at school and home (particularly injures such as bone fractures, due to falls, bicycle accidents, and pedestrian accidents)

Academic failure is more closely associated with the Inattentive and Combined subtypes of ADHD, whereas the Hyperactive/Impulsive subtype is most often associated with co-occurring oppositional behaviour and conduct problems, but not academic problems. Thus, it appears that the dimension of inattention (common to both Inattentive and Combined subtypes) is what predicts poor academic outcome.

ADHD in adolescents

Adolescence is a developmental stage in which risk-taking and rebellion are considered normal behaviours in Western cultures. However, it is a particularly perilous period for adolescents with ADHD as they may take these actions too far. A recent study of the everyday lives of adolescents with ADHD found that:

"ADHD characteristics were associated with behavioral patterns and contexts that may promote peer deviancy training, unhealthy lifestyle behaviors, and vulnerability to nicotine dependence."

One study revealed that compared to their non-ADHD counterparts, adolescents with ADHD (and those who exhibited symptoms but did not meet criteria for a full diagnosis) reported:

• more frequent negative moods (for example, higher rates of anger, anxiety, stress, and sadness)
• lower rates of happiness, alertness, and well-being
• less time with family and more time with friends
• more time pursuing entertainment than achievement-oriented activities
• more tobacco and alcohol use

Moreover, growing evidence indicates that adolescents with ADHD are at significant risk for a number of adverse outcomes compared to their non-ADHD peers, including:

• lower academic achievement
• less formal schooling (they leave school approximately two years earlier)
• higher rates of tobacco use (an adolescent with ADHD is three times more likely to be a daily smoker) and beginning smoking earlier
• substance abuse and antisocial behaviour
• teen pregnancy
• higher rates of adverse outcomes while driving (traffic citations, motor vehicle crashes in which they are at fault)

ADHD in college students

Special education and disability laws in the U.S.A. and Canada have enabled many qualified students with disabilities (such as specific learning disabilities, ADHD, and other psychiatric disorders) to graduate from high school programs and enroll in post-secondary education programs in colleges and universities. For example, a recent survey of university students in the U.S.A. and other countries indicated that 2.9% of male students and 3.9% of female students report significant ADHD symptoms that would be consistent with a diagnosis of ADHD.

On the one hand, these findings are encouraging because they indicate a positive outcome for a substantial proportion of students with ADHD. On the other hand, it is clear that college life poses more challenges to students with ADHD compared to those without disabilities. Problems typically experienced by young people with ADHD are often compounded by college living conditions, which may mean a dramatic change in the student's access to familiar support systems such as family, peers, teachers, and the structure of high school. Life in a university residence hall is often full of distractions, crowded, and noisy; there may be very little privacy and few quiet places.

College students may handle their problems associated with ADHD in different ways:

• "Fresh start": these students do not disclose their diagnosis of ADHD since they feel no-one at college will know them and/or that they no longer have problems. They may abandon all forms of treatment that helped them gain entry into the college, deny or fail to recognize that they are running into problems, and resist seeking help from student support services.
• "Uninformed, unprepared": these students have also been diagnosed prior to college and may have been receiving pharmacological treatment, but they have no understanding how ADHD affects them, how it might impact on their college life, or how medication and other treatment help their ADHD symptoms.
• "De novo ADHD": prior to college entry, these students have never been diagnosed with ADHD. They have been able to cope despite their symptoms, and have reached this level of academic achievement with tremendous effort and a supportive environment. However, during college they become overwhelmed by the level of independent functioning that is required and suddenly realize that something is amiss.

Impediments to success at the college level include issues that are both academic and/or personal. In particular, it appears that ADHD leads to poorer college adjustment by lowering self-esteem, which in turn results in poorer adjustment.

Academic issues may include:

• taking on too heavy a course load, due to problems estimating the multiple demands on one's time
• poor organization and time management skills, which may result in "crash and burnout" (staying up all night and sleeping all day after studying, partying, or both)
• reading problems resulting from difficulty concentrating and focusing, inability to read fast, and the frequent need for re-reading to be able to recall what has just been read
• poor note-taking or writing skills, resulting in course failure, low marks, and a low grade point average

Personal issues may include:

• high frustration levels or poor self-esteem
• inappropriate social skills or too much time socializing
• procrastination and problems persevering at a task
• lack of sleep and difficulty getting up in the morning

Teachers in high school are well-positioned to play a substantial role in helping college-bound students with a diagnosis of ADHD prepare for the transition from secondary to post-secondary education.

ADHD in adults

Some individuals with ADHD continue to be inattentive, disorganized, impulsive, and moody in adulthood. Although adults with ADHD can demonstrate significant success in life, research has shown that adults with ADHD are at risk for a range of negative outcomes. Compared to their non-ADHD counterparts, adults with ADHD tend to:

• make significantly less income and experience higher stress levels than a non-ADHD adult with similar levels of education
• have lower ranking occupations
• have greater emotional and social problems
• have higher divorce rates
• have a less positive self-image

Further, adults with ADHD may have greater difficulty in the role of parent, especially if they are parenting one or more children who also have ADHD. Some parents with ADHD may find it difficult to stick to schedules and routines and/or may find it difficult to squeeze more into their daily routines.

From a teaching perspective, parents with ADHD may pose challenges to the communication between home and school

Possible Challenges Communicating with Parents who Have ADHD

Inattention

• May forget to sign their child's planner, permission slips, or homework
• May miss parts of the conversation during parent-teacher interviews
• May not follow through on an agreed plan between the school and home
• May come late or on the wrong day to parent-teacher meetings

Impulsiveness/hyperactivity

• May dominate the conversation or frequently interrupt parent-teacher interviews
• May tap pencil, fidget, or shift position frequently during parent-teacher interview
• May appear impatient, irritated, or uninterested
• May treat every incident involving their child as a major crisis
• May fail to modulate voice or tone during parent-teacher interview (that is, may sound angry, irritated, accusatory, etc.)

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