Childhood

The Australian Institute of Health and Welfare (AIHW, 2020a) estimated that 4.7 million children aged 0 to14 represented 19% of the Australian population. Despite using statistics describing childhood between birth and 14-years-old, the AIHW (2020a) consider the developmental period of childhood as occurring between birth and 12-years-old. Childhood is characterised by rapid physical, cognitive, emotional, and social development (Tully, 2020). The developmental changes that occur between birth and 12 years old are dramatic and extensive, and this can coincide with a range of developmental challenges. Childhood developmental challenges can be influenced by rate of development (e.g., when children develop at normatively different rates to their peers), the presence of distinct developmental differences and delays (e.g., related to a physical condition such as hearing loss, or neurodevelopmental disorder such as autism spectrum disorder [ASD]), or by the presence of mental health problems or disorders (e.g., depression or anxiety-related disorders; Kelly & Allen, 2015). Due to their developmental immaturity and dependence on others for care and support, children are also particularly vulnerable to environmental influences (e.g., parenting practices, teacher and peer relationships, exposure to health/welfare agencies, and/or physical environment; OECD, 2019). Childhood is therefore a critical period for health monitoring and intervention to promote positive outcomes into adulthood.

Attention Deficit Hyperactivity Disorder 

Many mental health and neurodevelopmental disorders onset in childhood and can influence cognitive, emotional, and social developmental outcomes across the lifespan (Jones, 2013). The term “neurodevelopmental disorder” refers to a condition that onsets in the developmental period (i.e., infancy, childhood, or adolescence) and is characterised by stable neural deficits that impair an individual’s functioning (APA, 2016; Morris-Rosendahl & Crocq, 2022).

Attention deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder of childhood, affecting approximately 5 to 9% of children worldwide (Adler et al., 2015; APA, 2016). Deloitte (2019) reported prevalence rates of ADHD in Australia to be approximately 5.8% for boys and 2.3% for girls (aged 0 to14). Research suggests that ADHD is commonly underdiagnosed for girls, rather than simply occurring at lower rates for girls (Hinshaw et al., 2022). There are also associations between risk factors for adverse childhood experiences (ACEs); e.g., parental psychopathology, low socioeconomic status) and the prevalence and severity of ADHD (Margari et al., 2013; Russell et al., 2014). Research suggests symptoms of traumatic stress can be misattributed to ADHD and this may also complicate diagnoses (Brown et al., 2017).

ADHD is characterised by inattention, hyperactivity and impulsivity that impacts with functioning and development (APA, 2016). To meet the diagnostic criteria for ADHD, several symptoms of inattention and/or hyperactivity must be present before the age of 12, persist for more than 6 months, present in more than one setting (e.g., school and home), and not be better explained by another condition (APA, 2016).

The cognitive impairments associated with ADHD surpass typical challenges associated with childhood development (Adler et al., 2015). Research suggests that ADHD cannot be reliably diagnosed in children younger than 4-years-old due to normal developmental variation in early childhood related to attentional control and increased motor activity (Felt et al., 2014). Thus, ADHD is often diagnosed in middle childhood (aged 6-12) when the cognitive and behavioural demands of school increase, and these demands begin to exceed the child’s personal, social, and/or academic functioning (Adler et al., 2015; Felt et al., 2014).

Research indicates that many symptoms of ADHD (e.g., impaired attention and impulse control, increased distractibility and hyperactivity) involve dysfunction in the circuitry of the prefrontal cortex (Arnsten & Berridge, 2015). The prefrontal cortex guides many attention, action, emotion, and memory functions; it is also highly dependent on neurochemical state, and this explains how pharmacological treatments for ADHD can improve behavioural and cognitive symptoms (Arnsten & Berridge, 2015).

Evidence of Symptoms

The two patterns of behaviour associated with ADHD are inattention and hyperactivity or impulsivity (APA, 2016). Inattention may present in childhood as careless mistakes in academic work, appearing “off-task” or “absent”, inability to follow multiple steps of a task, poor organisation of personal belongings (e.g., losing items), excessive distractibility, and/or forgetfulness in daily activities such as chores and school activities (APA, 2016). Hyperactivity or impulsivity may present in childhood as excessive fidgeting with hands or feet, difficulty remaining seated for extended periods, difficulty remaining quiet during activities, excessive talking, interrupting others in conversation, appearing to be constantly “on the go”, and/or inability to wait their turn in an activity (APA, 2016).

These behavioural presentations are a result of underlying cognitive impairments in basic processes such as distractibility, and higher order functions of executive function, working memory (Butzbach et al., 2019; Kofler et al., 2016). Research indicates that underdeveloped working memory may interfere with “listen-and-wait” behaviours that are required for pro-social interactions (Kofler et al., 2016). Thus, cognitive impairments associated with ADHD can contribute to behavioural symptoms such as interrupting others in conversation, and contribute to a corresponding social impairment (Bunford et al., 2015).

It is important to note that behavioural, cognitive, and social features may differ significantly between children diagnosed with ADHD (Kofler et al., 2016). Data collection techniques that can assist in identifying evidence of different symptoms and diagnosing ADHD in childhood include psychometric measures, such as the Conners 3rd Edition (C3; Stein et al., 2015). The C3 is an assessment tool designed to measure cognitive and behavioural issues associated with ADHD and common comorbid disorders. It includes rating scales to be completed by parents and teachers (for children aged 6-18 years) and a self-report scale for children aged 8-18 (Conners, 2008). Research suggests that parents and teachers often have different expectations, references, and samples of behaviour, and that interviewing both parties can identify if symptoms are present in different settings (Stein et al., 2015). Other psychometric measures include additional Conners indexes (e.g., Conners Early Childhood, Conners Comprehensive Behaviour Rating Scales) and the Achenbach System of Empirically Based Assessment (ASEBA; Stein et al., 2015). Functional behavioural assessments (Northup & Gulley, 2001) may also be a useful tool for data collection and analysis relating to ADHD-associated behaviours (Miller & Lee, 2013).

Impact on the Individual and Interactions

Individual differences in symptoms can vary the impact that ADHD has in childhood. Adaptive skills allow children to complete age-appropriate tasks, including communicating and learning, forming and maintaining friendships, regulating and managing emotions, behaviour, health, and personal safety (Weiss, 2015). ADHD is typically associated with deficits in one, many, or all of these skills; and this can result in functional impairment.

ADHD has high rates of comorbidity, and this can contribute to a substantial impact to childhood mental health. Research indicates that approximately 40 to 50% of children with ADHD also meet criteria for one or more mental health, sleep, or learning disorder (Adler et al., 2015). Many children with ADHD also have problems relating to emotional regulation (e.g., anxiety, oppositional defiant disorder, or conduct disorder) thought to be related to prefrontal cortex deficits and/or traumatic stress related to ACEs (Arnsten & Berridge, 2015; Brown et al., 2017). Research indicates that comorbid symptoms contribute to increased parental stress and mental health impairments, which can increase the risk of ACEs and negative outcomes for children with ADHD (Martin et al., 2019).

Research indicates that children with ADHD and those around them (e.g., their parents, families, teachers, and healthcare professionals) commonly hold negative perceptions towards ADHD behaviours (Bisset et al., 2022). ADHD has been associated with lower rates of school completion and academic achievement (e.g., reading and math standardised test scores), and increased rates of grade retention, detention, and expulsion (Weiss, 2015). However, research indicates that interventions (e.g., effective education adjustments) can reduce the gap between academic performance, which may be impaired by ADHD symptoms, and a child’s actual academic potential (Arnold et al., 2020; Weiss, 2015).

Suggested Interventions

Pharmacological and behavioural interventions have been shown to reduce symptoms and improve quality of life and family functioning for school-aged children aged 6 to12 years (Manos, 2015). Effective behavioural interventions can be applied across settings and include parent training, classroom management, and peer interventions (Felt et al., 2014). A key role of a Guidance Officer (GO) is to support student mental health and wellbeing in a school setting (Department of Education [DOE], 2021b). If a child with ADHD presents with behavioural challenges at school, a GO may take steps to develop an Individual Behaviour Support Plan (IBSP) in collaboration with teachers, parents, and the student (where possible; DOE, n. d.). The IBSP process begins with data collection (DOE, n.d.). This typically involves a Functional Behaviour Assessment. Suitably qualified GOs may also use a Conners index if they require further information about specific areas of functioning related to ADHD (DOE, 2021a). The support team can then identify and implement long- and short-term goals, teaching strategies for alternative behaviours, antecedent and consequence strategies (DOE, n.d.). Specific strategies may include teacher-led adjustments to classroom routine and structure, use of a token economy to reinforce target behaviours, and/or daily “check-ins” to monitor progress and provide regular feedback to the child and members of their support team (Evans et al., 2013). The IBSP process includes regular data collection, monitoring, reviews, and adjustments as needed to ensure effective student support (DOE, n. d.).