Middle Childhood

Middle childhood, which is approximately the time between six to twelve years is when most children start formal schooling and thus, are exposed to academic, behavioural and social expectations. Therefore, this is also the age when most developmental and behavioural difficulties are identified (Carr, 2015). In this period, growth rates slow down and the average child gains about two and a half to four kilograms of weight and five centimetres of height per year. Children’s torso usually grows longer which lets them appear slimmer than during early childhood. Muscles develop and the capacity of the lungs increases. Therefore, in middle childhood, youngsters have more endurance and can be active for longer (Papalia et al., 2009). Cognitively, children start to understand tangible aspects of the world around them, begin to categorise objects in various ways and grasp the concept of reciprocity (Papalia et al., 2009). In terms of social development, school-aged children continue to shape their sense of self, which is highly influenced by the diverse systems the child is surrounded by, such as family, peer group, class community and neighbourhood (Bronfenbrenner, 1979). With the start of schooling, children constantly learn new social skills, like communication, negotiation and problem-solving. They are immersed in society’s rules as well as behaviour and language conventions (Henderson & Thompson, 2011). As a result, developmental challenges are likely to occur and identified during this period. Some key challenges primary school-aged children experience due to measuring processes are learning difficulties, such as dyslexia, dyscalculia and attention deficit hyperactivity disorder (ADHD). Conduct disorders and diagnosis of autism spectrum disorders are also likely due to the exposure to stricter rules and societal expectations in educational settings (Henderson & Thompson, 2011).

Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) is a complex neurodevelopmental condition which is typically diagnosed during middle childhood and substantially impacts a child’s personal, physical, social and academic functioning. Typical features include developmentally inappropriate inattention, hyperactivity and impulsivity. ADHD is the most prevalent mental health condition amongst school-aged children in Australia, with around five percent of children in this age group affected. ADHD, according to the current Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013b) appears in different forms: the inattentive type (ADHD-I), the hyperactive-impulsive type (ADHD-HI). However, the disorder can occur with combined symptoms (ADHD-C). ADHD-C is the most diagnosed subtype, which however could be due to the high co-existence with externalising conditions, such as oppositional defiance disorder (ODD) and conduct disorder (CD) (APA, 2013b).

Key indicators for the inattentive form of ADHD include making thoughtless mistakes, having problems focusing on tasks for a sustained period of time, appearing to not listen when spoken to, inability to follow instructions and to finish chores or school-related activities, disorganisation, being distracted and unwilling to attempt tasks that require continuous effort. This type is the most common one, however, often not diagnosed, because children with inattentive symptoms are typically quiet and withdrawn. In girls this is the most common form of ADHD. The hyperactive impulsive type of ADHD shows through constant fidgeting, squirming, moving hands and feet, inappropriate climbing and running, difficulty to stay seated, excessive talking, interrupting others when they talk and not being able to wait for turns (APA, 2013b).

Evidence of Symptoms 

ADHD affects executive functions. These are the mental processes which control self-regulation, control thoughts, speech, feelings and behaviour (Brown, 2019). Hence, executive functions are responsible for organisation, concentration and sustained attention, inhibition of responses, problem solving, intrinsic motivation, foreseeing consequences of actions, handling social interactions and aligning emotional responses with those expected by society (Brown, 2018). When these executive functions are impaired, as it is the case in children with ADHD, all mental tasks involve more effort than for children without the condition. As asserted by Barkley’s model (1998, 2006; as cited in Wick-Nelson & Israel, 2012), hyperactive-impulsive behaviours are caused by misfunctioning response inhibition. This means, children with ADHD are unable to inhibit their responses to distractions. Additionally, four other key executive functions are affected. These are the working memory, speech internalisation, non-verbal regulation of feelings and emotions and reconstructing novel behaviours. Therefore, children with ADHD have problems regulating their own behaviour and adapting to new situations.

Furthermore, secondary features of ADHD impact on the child’s life in various ways. Barkley (2015) claims that young people with ADHD seem clumsy and perform lower in sports that involve complex, progressive movements, like gymnastics and some ball sports. Self-help skills are also affected. According to Goldstein (2011), children with ADHD, although understanding societal expectations, fail to align their behaviour appropriately. Additional impacts include sleep disturbances and risky behaviours which entail a higher risk of accidents and injuries (Wicks-Nelson & Israel, 2012). Research, however, also reveals a variety of strengths in people with ADHD, such as the high capacity to focus on an activity or task of interest, high energy, creativity, inventiveness, curiosity, great imagination skills and the ability to think outside the box, (Parents for ADHD Advocacy Australia, 2019).

In Australia, ADHD can be diagnosed by paediatricians, psychiatrists as well as clinical psychologists. Paediatricians and psychiatrists can determine treatment and prescribe medication while clinical psychologists can refer the child to a specialist but cannot prescribe medication (Thriving with ADHD, 2017). The process of assessment includes various components, like family interviews to attain a medical and developmental history, medical information about the parents, child-specific symptoms, strengths and level of social and academic impairments (Burdick, 2015). Current research suggests a combination of a semi-structured and standardised interview, like ‘The Diagnostic Interview for Children and Adolescents’, which allows for reliable multidimensional information. It involves questions about a variety of elements of the child’s life, such as parent- child interactions, triggers for specific behaviours, trauma, socialisation and success at school (Burdick, 2015; Cooper & Thapar, 2016). Thereby, the child is included and observed in terms of speech, non-verbal interactions and appearance. Teacher interviews are another pivotal source of information, as these provide a different perspective (Mitsis et al., 2000). Standardised tests, as for example Conners Parent and Teacher Rating Scales are used to identify symptoms of ADHD and to identify co-occurring disorders, such as ODD and CD (Burdick, 2015). In addition to interviews and rating scales, direct observations in the child’s natural settings, like home and school, can reveal invaluable information, since ADHD behaviours typically refer to specific situations. Such observations can also support the decision about treatment approaches (Wicks-Nelson & Israel, 2012).

Impact on the Individual and Interactions

The impacts of ADHD on executive functions cause behaviours, such as bullying and rule breaking, restlessness, interrupting others as well as verbal and physical aggression. These behaviours negatively impact on peer relations, family life and child-teacher relationships (Nijmeijer et al., 2008). Other children often reject or ignore individuals with ADHD, families are more stressed than control families and teachers tend to be more authoritarian with students living with ADHD (Mikami et al., 2010).

As educational settings expect particular behaviours and academic performances from children, the characteristics of ADHD, including impulsive outbursts, short attention spans, poor inhibition and low working memory have detrimental effects on the child’s wellbeing at school. According to current studies, in comparison to their peers, children with ADHD perform lower in terms of academics (Birchwood & Daley, 2010; Young Minds Matter, 2017). Beside these academic shortages, young people’s mental health and self-esteem are also immensely affected, particularly by peers’ and educators’ responses to their behaviour. According to Parents for ADHD Advocacy Australia (2019), teachers do not understand ADHD and its consequences for individuals enough to support students to achieve to their fullest potential. Considering the high number of children with ADHD, on an average basis, at least one student per class lives with the disorder and thus, needs specific help or an Individual Education Plan (IEP) with altered curriculum content and teaching strategies (Graham et al., 2018).

Suggested Interventions

The main goal of treating ADHD is to enhance self-regulation. The most commonly applied treatments are stimulant medication and behavioural interventions or a mix of both (Cooper & Thapar, 2016). In educational settings, guidance counsellors play a crucial role to support teachers who have students with ADHD in their class and initiate processes, such as developing an IEP. This plan might include suggestions about a suitable classroom organisation and clearly defined procedures and routines as well as a calm and predictable teaching style. In addition, a focus on the reinforcement of positive behaviours is vital (DuPaul et al., 2014; Rief, 2016). As students with ADHD struggle with verbal instructions, auditory and visual cues, such as chimes, picture prompts, signing and visual timers, can be effective replacements for words (Poulton, 2019). Students with ADHD should be placed close to the front, where they are least distracted (OnLine Training Ltd., 2020). The IEP should include shortened instructions and assignments and strategies used by the educator to support the student to stay focused and provide feedback regularly throughout the task. Tactile resources and videos, music and colours must be used increase the attention span and focus level (Poulton, 2019).

Another valuable aspect of the IEP is the incorporation of regular movement and brain breaks within each lesson. These give students with ADHD with the chance to release excess energy (Rief, 2016). Regular dances and walks through the school yard, gardening and playing outdoor will benefit all students (DuPaul et al., 2014). Additionally, passing out books and worksheets, cleaning the board, delivering messages to administration, yoga and meditation are beneficial strategies to ensure children with ADHD get to release surplus energy. Besides supporting teachers and families with the development of an IEP, a guidance counsellor can refer families to specialists, link them with relevant parent groups and parenting programmes and provide all school staff with links and handouts.