Middle Childhood

Middle childhood has unique developmental challenges and difficulties. Whilst some variance in age ranges occurs in the literature, it is usually defined as between ages 6 to12. This coincides with the most significant change during the period, the attendance at primary school. This new environment offers a range of new learning experiences and social situations that are rewarding and challenging. Some key developmental challenges include requirements of being a participant in a rule-governed environment, and the increased cognitive changes with advanced academic rigour (Wicks-Nelson & Israel, 2015). In addition, an expanded social focus from parents to peers and teachers leads to greater self-awareness leading to self-perception and self-esteem concerns (Hutchison, 2008). Middle childhood difficulties are linked to social and academic challenges at school; the ability to apply coping strategies may determine adaptive or maladaptive pathways (Sotardi, 2017; Wilmshurst, 2014). Whilst there are many biopsychosocial difficulties that can occur throughout this period, in Australia, one mental health disorder is by far the most prevalent, attention-deficit hyperactivity disorder (ADHD; Goodsell et al., 2017).

Attention Deficit Hyperactivity Disorder

According to Gibbs (2021) 8.2% of all Australian school children have ADHD. Categorised as a neurological disorder and defined by inattention and/or hyperactivity, it is characterised by an inability to stay-on-task, clumsy or less precise motor skills and disorganisation; the effects are pervasive (APA, 2013c).

In schools, the inattention/disorganised facets of ADHD appear as the child appearing not to listen, being unorganised, often losing materials or being unprepared; the hyperactivity/impulsivity facets show as fidgeting, impatience, inability to sit still or stay seated and the intrusion into other people’s activities or personal space (APA, 2013c). These deficits have impacts on cognitive, social, and emotional domains across the home and other environments.

In adulthood, symptom severity tends to decline, particularly regarding hyperactive/impulsive behaviours (Young et al., 2020); however, symptoms can still impair academic, social and occupational functioning (APA, 2013c).

Many students with ADHD also have a specific learning disorder; and it is frequently comorbid with autism spectrum disorder and the externalising disorders of oppositional defiant disorder and conduct disorder (APA, 2013c).

Evidence of Symptoms

The DSM-5 outlines specific symptoms required for the diagnosis of ADHD across two subdomains: inattention and hyperactivity/impulsivity. Those under 17 years need to demonstrate at least six symptoms from each subdomain; for those over 17 years, five symptoms are required (APA, 2013c). Symptoms need to be present prior to age 12, exist across two or more settings, be limiting to social, academic or occupational functioning and must not be a result of another disorder or difficulty (APA, 2013c). Based on the number of symptoms, diagnosticians determine if the diagnosis meets standards for combined presentation, predominately inattentive presentation or predominately hyperactive/impulsive presentation; additionally, severity is judged as mild, moderate, severe or in partial remission (APA, 2013c).

ADHD symptoms and impairment varies by age, domain, and subdomain (Zoromski et al., 2015). Inattentive behaviours include difficulties sustaining attention, ignoring details, making careless errors and being easily distracted by extraneous stimuli (APA, 2013c). Often the child can appear as if they are not listening; they may not finish tasks or can avoid or are reluctant to participate in tasks that require sustained mental effort (APA, 2013c).

Students with ADHD perform poorly on measures of working memory, processing speed, inhibition and shifting (Moura et al., 2019). In addition, mild delays in language can often co-occur with ADHD, and individuals may exhibit cognitive difficulties on tests of attention, executive function or memory (APA, 2013c).

Hyperactivity and impulsivity behaviours are usually obvious. Talking incessantly, fidgeting, tapping feet, squirming, general on-the-go behaviour and reluctance or inability to engage in quiet leisure activities are all examples (APA, 2013; Carr, 2015), as is impatience, difficulty waiting in line, blurting out answers or completing people’s sentences (APA, 2013c). These behaviours can often intrude on others; examples include butting in on conversations and taking things without permission (APA, 2013c).

There is no medical test for ADHD; it is diagnosed by observing behavioural symptoms. While some hypothesise that ADHD results from dysfunction in the pre-frontal-striatal circuitry resulting in deficits in executive function (Moura et al., 2019), to date, no biological marker is apparent (APA, 2013c). Current theories suggest that the aetiology of ADHD involves biological, environmental and cultural influences (Young et al., 2020).

In Australia, diagnosis is completed by a paediatrician, psychologist or child psychiatrist, and school staff are often required to assist in the collection and collation of data. Whilst their use should be only for data collection purposes, guidance officers can administer approved psychoeducational tests such as the Conners 3, a multi-informant assessment aligned to the ADHD DSM-5 criteria, which shows functioning across settings and identifies specific challenge areas (Conners, 2008). Behaviour and functioning checklists such as the National Initiative for Children’s Healthcare Quality (NICHQ) Vanderbilt Assessment Scales (NICHQ, 2002), can also be used, and functional behaviour assessments and observations can be conducted. The Wechsler Intelligence Scale for Children (WISC) provides information regarding cognitive strengths and weaknesses (Moura et al., 2019).

Reviewing existing school data and conducting interviews with parents and class teachers can determine academic levels, concerns, behaviours, and symptoms across different settings, it may provide a valuable medical history and will develop positive home/school connections. Parents with ADHD are more likely to have children with ADHD (Young et al., 2020). Employing a systems-based framework that considers personal maintaining and protective factors along with personal and contextual predisposing factors will ensure a thorough picture is gained (Carr, 2015).

Throughout these processes, teachers and guidance officers need to be aware of gender bias. Some evidence suggests that the ratio of male to female diagnoses is 2:1 (APA, 2013c), which is likely due to the lack of recognition of females’ symptoms, and therefore referrals (Young et al., 2020). Whilst behavioural problems may be present in girls, they are less common. Social problems may be particularly impairing, emotional dysregulation and general impairments in intellectual function may be common (Young et al., 2020). Girls are more likely to present with primarily inattentive behaviours (APA, 2013c). In addition, compensatory and coping strategies may mask symptoms and result in a delayed or non-referral (Young et al., 2020).

Impact on the Individual and Interactions

Individuals with ADHD are significantly more likely to develop a conduct disorder in later years, potentially increasing the risk of substance abuse (APA, 2013c). ADHD is associated with reduced behavioural inhibition, constraint, and novelty-seeking behaviours, which may account for increased traffic accidents and violations.

ADHD also has an impact on other people in the student’s life. Communication is a fundamental aspect of social participation and socially, ADHD influences the building and maintaining of relationships. Primary deficits of ADHD can cause impairments in social communication and ensures functional limitations of social participation (APA, 2013c). Hyperactivity and impulsivity behaviours are often disruptive. In research identifying teacher-reported symptoms most associated with impairment, ‘often leaves seat’ had the strongest link with impairment of relationships with peers and teachers (Zoromski et al., 2015).

The family domain is where the most significant impact on functioning occurs with17.3% of children reporting a severe impact within the family environment, including issues such as communication, planning within the family, conflict, and emotional and practical support levels (Goodsell et al., 2017). Whilst not causal, there is a strong relationship between the level of family functioning and the prevalence of ADHD. In families where functioning is reported to be dysfunctional, more than one-fifth of children have ADHD (Lawrence et al., 2016).

ADHD attracts controversy in the community. Some believe that it is over-diagnosed, and Australia has become a ‘medication nation’; others that diagnoses are the medicalisation of normal life and that the thresholds are too low (Price-Robertson, 2018). One Queensland study found that 78.3% of participants thought that too many children are diagnosed who do not have it (Price-Robertson, 2018). Regardless of opinion, the financial impact of ADHD is massive. The average health care cost per child with ADHD is $1170 per year; this incorporates the highest contribution per person of any mental health disorder to the Pharmaceutical Benefits Scheme for medication totalling $16.25 million a year (Le et al., 2021).

ADHD behaviours have a significant impact on the school environment. It is associated with reduced academic attainment and academic functioning, social rejection and elevated personal conflict; individuals with ADHD obtain less schooling and have poorer occupational achievement (APA, 2013c). Hyperactivity/impulsivity is a stronger predictor of classroom functioning at the pre-school level; however, this changes during MC, when inattention becomes a more significant and a stronger predictor of classroom functioning (Zoromski et al., 2015). In addition, ADHD students’ difficulty in organising becomes a significant predictor of academic impairment (Zoromski et al., 2015).

Suggested Interventions

As with most educational support, early intervention is vital. Individual interventions should be based on the data collected for that individual, their presentation subdomain, and be evidence-based. Any individual support plan should be strengths based and individualised. The strengths possessed by students with ADHD can offer certain advantages, in a recent survey, 73% of teachers believe that the strongest strength of students with ADHD can be very knowledgeable on specific topics (Gibbs, 2021).

Whilst a majority of Australian teachers believe that they have knowledge of ADHD and can recognise children in their class with symptoms, they also believe that they are unsure or do not know how to support students with ADHD (Gibbs, 2021). Providing professional development on strategies to support teachers is an area in which A Guidance Officer (GO) could assist at a whole-school level.

Programs or interventions that are collaborative have been shown to be more effective (Carr, 2015). Collaborative Life Skills is a 12-week psychosocial program consisting of behaviour targets that could be introduced by a GO individually or in a small skills group, then supported in classroom interventions and parent training groups; terminology is reinforced across all settings and results have shown statistically and clinically significant improvements in the severity of organisational, academic, and social impairments (Pfiffner et al., 2016). Implementing a program like this could have benefits for the teacher, the parents, and the child.