3.3 T HE DEVELOPMENTAL COURSE OF ADHD
3.3.1 Early childhood through to preschool
“Normal” development
According to Hughes (2000), with regard to physical development, by about age 2 most children have shown a preference for using either their right or left hand.
Between the ages of 4 and 7, improvements in visual acuity result in a greater ability to identify the finer distinctions between stimuli. Towards the end of the preschool years visual abilities have advanced well enough for the child to begin learning to read. Co-ordination of abilities controlled by more than one part of the brain is also learned. Preschoolers learn and master a number of new gross motor skills, such as climbing stairs, riding tricycles, running, jumping and hopping. Fine motor improvements in their hands and fingers enable them to dress themselves and to manipulate objects such as scissors, puzzle pieces, and other small toys. They also begin to express themselves through drawings.
With regard to cognitive development, the stage of preoperational thought, occurring between the ages of 2 and 7, introduces more systematic use of mental representations as children create an understanding of the world around them. Pre- school aged children are, however, not yet able to apply more sophisticated mental operations such as logic as they develop these understandings. Preschoolers have short attention spans, are easily distracted, and tend to organise their focus on
factors with interest value rather than pragmatic value. Their short-term memory is limited early on, but by the end of the preschool years its capacity is almost as large as an adult’s. Their long-term memory storage and retrieval are limited by their lack of practice at remembering, not knowing what is important to commit to memory, and having a smaller pool of general knowledge and language networks to supply retrieval cues. Preschoolers’ intelligence test scores begin to approximate their long- term IQ scores. Language skills advance more during the preschool years than at any other stage of development, and preschoolers learn as many as 20 new words a day. Preschoolers learn a number of the basic rules of grammar as well as the rules of conversation, although their conversation skills are limited in part by their immature theories of mind.
With regard to social and emotional development, the preschool years are a significant window for development of a sense of conscience and gender identity.
Relationships with peers provide substantial social and emotional training and practice. Preschoolers begin experiencing in themselves, and recognising in others, more complex, socially based emotions such as pride, shame, guilt, envy and embarrassment. They also begin learning how to regulate emotions and express them appropriately. Moral development can be influenced more during the preschool years than at any others stage of development. At first, preschoolers see moral rules as absolute, applying to the consequences of the act, and inevitably intertwined with punishment. As children mature to school age, they learn that rules are actually created and enforced by people, and that moral judgements address a person’s intent rather than the actual behaviour. Preschoolers’ self-concepts are at first based in their roles and behaviours, then progress towards recognising that aspects of their inner character are constant. Their self-esteem at first overestimates their abilities, then is shaped by feedback from their environment
ADHD children
ADHD often reveals itself first in infancy. As infants, children with ADHD are often very active, have difficult temperaments, or show irregular feeding and sleeping patterns (Teeter, 1998).
As preschool children, they are in perpetual motion, quickly moving from one activity to another (Sigelman & Rider, 2003). Since most young children are energetic and have short attention spans, behaviour must be evaluated in terms of developmental norms. The appearance of significantly inattentive and overactive behaviour by age
three to four years by itself is not indicative of a persistent pattern of ADHD into later childhood or adolescence in at least 50-90% of children so categorised (Barkley, 1998). Palfrey, Levine, Walker and Sullivan (1985), in a follow-up study of preschool- age children from birth to second grade, found that approximately 5% of their total sample of children, or about 10% of those with concerns about inattention, eventually developed a pattern of persistent inattention to be predictive of behaviour problems, low academic achievement and need for special education services by second grade. Campbell (1990) also showed that among difficult-to-manage three-year olds, those whose problems still existed by age four years were much more likely to be considered clinically hyperactive and to have difficulties with their hyperactivity as well as conduct problems by ages six and nine years. Therefore, both the degree of ADHD symptoms and their duration determine which children are likely to show a chronic course of their ADHD symptoms throughout later development.
Parents of children with this durable pattern of ADHD in this age group describe them as restless, always up and on the go, acting as if driven by a motor, and frequently climbing on and getting into things (Barkley, 1998). They are more likely to encounter accidental injuries as a result of their overactive, inattentive, impulsive and often fearless pattern of behaviour. “Childproofing” the home at this age becomes essential to reduce the risk of injury, as well as to protect family valuables. Persistent in their wants, demanding of parental attention, and often insatiable in their curiosity of their environment, ADHD preschoolers pose a challenge to the child-rearing skills of their parents (Barkley, 1998). Such children require far more frequent and closer monitoring of their ongoing conduct than do normal preschoolers. Although temper tantrums may be common instances even for normal preschoolers, their frequency and intensity are often exacerbated in ADHD children. Mothers of these children are likely to find themselves giving far more commands, directions, criticisms, supervision and punishment than do mothers of normal preschoolers (Barkley, 1988b; Battle &
Lacey, 1972; Campbell, 1990; Cohen & Minde, 1981). Although the mothers of ADHD preschoolers are likely to report feeling competent in their sense of knowing how to manage children, this finding will progressively decline as these children grow older and parents find that the typical techniques used to manage normal children are less effective with ADHD children (Mash & Johnston, 1983). The coexistence of additional difficulties such as sleep problems, toilet training difficulties, and/or motor and speech delays in a small percentage of ADHD children is likely to further tax the patience and competence of many of their parents.
Should such a child happen to have a mother whose own mental health is compromised by psychiatric problems, such as depression, anxiety or hysteria, or whose marriage is in trouble, the combination of negative child temperament with a psychologically distressed caregiver could be potentially explosive and increase the risk of physical abuse to the child (Barkley, 1998). This same situation may also arise when the father of this child is alcoholic, antisocial, or highly aggressive within the family.
Placement of these children in day care, a progressively increasing practice for preschool children in our society, is likely to bring additional distress as day-care personnel complain about the child’s disruptive behaviour, aggression toward others in many cases, and difficulties in being managed (Barkley, 1998). Such children are often noted to be out of their seats, wandering the classroom inappropriately, disrupting the play activities of other children, excessively demanding peer interactions, and being especially vocally noisy and talkative (Campbell, Endman &
Bernfield, 1977; Campbell, Schleifer & Weiss, 1978; Schleifer, Weiss, Cohen, Elman, Cvejic & Kruger, 1975). It is not uncommon to find the more active and aggressive among these ADHD children to actually be kicked out of preschool (Reebye, 1997) - so begins the course of school adjustment problems that afflict many of these children throughout their compulsory educational careers. Other ADHD children, especially those who are not oppositional or aggressive, who are milder in their level of ADHD, or who are intellectually brighter, may have little or no difficulties with the demands of a typical day-care or pre-school program.
Difficulties in obtaining babysitters for their ADHD children, especially the more severely ADHD and oppositional among them, is reported by mothers of children at this age during clinical interviews (Barkley, 1998). This may result in a greater restriction of both socialisation with other adults and the ability to carry out the typical and necessary errands within the community needed to care for a household. For single parents of ADHD children, these limitations may prove more frequent and distressing, as there is no other adult with whom to share the burden of raising such children.
As ADHD preschool children approach entry into formal schooling, research suggests they are already at high risk for academic failure. Not only does their symptom picture predispose them to be less ready to learn in school, but also they are more likely to be behind in basic academic readiness skills (e.g. pre-reading
abilities, simple mathematics concepts, and fine motor skills) (Mariani & Barkley, 1997; Shelton, Barkley, Crosswait, Moorehouse, Fletcher, Barrett, Jenkins &
Metevia, 1998).