---

The next article, written by Ruth Palatnik from Israel, describes the profile of difficulties that her daughter Rina experienced, and which finally led to her being diagnosed as having ADHD as well as Down syndrome. This led me to do a search of the literature to see what information there was on this particular dual diagnosis. The answer is – very little. We found only 4 articles mentioning either attention difficulties or hyperactivity in individuals with Down syndrome – with widely differing estimates and interpretations of their findings. One reason for this will be that a paediatrician or child psychiatrist will be reluctant to make the diagnosis when a child already has a developmental disability. In addition, checklists may overestimate ADHD symptoms if the rater does not take account of the child's level of developmental delay.

However, in my practical experience with many children with Down syndrome over many years, I do think that we see children with ADHD and that they would be helped if they did get a diagnosis and correct treatment. This view is supported by Rina's story and the fact that she is helped by medication as well as appropriate management strategies. Other parents may think their children have a similar profile so we have included some basic information on ADHD here. There are many useful websites to consult for more information listed below. In my experience, children with Down syndrome and ADHD may develop difficult and sometimes aggressive behaviour, which can be very difficult to manage at home and at school, therefore it really is important to consider this diagnosis for an unusually difficult child.

What is ADHD?

There are three main sets of symptoms of ADHD described in typically developing children. These are:

• problems with concentrating or paying attention (attention deficit)

• being very active (hyperactivity)

• acting before thinking (impulsivity)

The diagnosis is made by a psychiatrist on the basis of agreed diagnostic criteria which are descriptions of behaviours. There is no blood test or truly objective way of agreeing that a child has ADHD. It is thought to be very common among children, with estimates suggesting 3% to 8% of children may have ADHD in the UK ^[1] and USA.^[2] Boys are about 3 times more likely to have ADHD than girls and some research indicates that there may be a genetic component to the condition.

It is suggested that there are three types of the disorder, the inattentive type, where attention and staying on task is the main problem area, the hyperactive-impulsive type, where the child is very active and often acts without thinking, and the combined type, where the child is inattentive, impulsive and too active.

ADHD is even more difficult to diagnose reliably in children with additional difficulties. In the typical child, a judgement is made as to whether the child is more inattentive, active or impulsive than would be expected for his or her age. In a child with Down syndrome, allowance will also have to be made for developmental delay and speech and language delay.

Are there effective treatments for ADHD?

There are two main approaches to treatment, behavioural management and medication. The behavioural management strategies include praising 'good' behaviour i.e. praising the child for attending or for sitting still, and using visual prompts and timetables whenever possible, to help the child to plan and anticipate demands. These strategies may sound familiar to parents of children with Down syndrome and their teachers. Medication may involve the prescribing of Ritalin, Dexedrine, or similar acting drugs. Often both approaches to treatment are used and parents describe that the medication calms the child so that they can attend and benefit from behavioural and educational programmes.

As it may be difficult for doctors to be sure that a child does have ADHD, a trial of medication may be part of the way to reach a diagnosis. There is an unfortunate anti-medication culture among parents and others in a number of countries, which may deny children the benefits of drug treatment. It may not be necessary to take the drug for long periods and the drug can always be stopped if there is no benefit or any distressing side-effects. The only way to find out if a drug will help is to try it. A child who is unable to control his/her attention and behaviour is denied the social and learning opportunities that are essential to his or her development. If you have views on this issue and any positive or negative experiences please do send them to us.

References

1. ADDiss: ADHD Information Services. (2003). Retrieved 20 February, 2006, from http://www.addiss.co.uk/adhd.htm
2. Centre for Disease Control and Prevention. (2005). Mental Health in the United States: Prevalence of Diagnosis and Medication Treatment for Attention-Deficit/Hyperactivity Disorder - United States, 2003. Morbidity and Mortality Weekly Report. 54(34), 842-847. Retrieved 20 February, 2006, from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a2.htm

Useful website information on ADHD:

http://www.besttreatments.co.uk/btuk/conditions/10235.html

http://www.mentalhealth.org.uk/information/mental-health-a-z/adhd

http://www.ldonline.org/ld_indepth/add_adhd/add_nichcy.html

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a2.htm