ADHD Assessment

Millstream Paediatrics ADHD Assessments:

Are comprehensive.
Are completed by a Clinical Neuropsychologist Registrar in collaboration with a Clinical Psychologist.
Include strong consideration of all other related factors that may contribute to your child’s presentation including mental health, other neurodivergence, famililial and socio-emotional factors and other environmental factors.
With positive ADHD diagnostic outcomes an internal referral to the Paediatrician is offered.

Should you wish to assess with Millstream Paediatrics, please be prepared for different assessment diagnostic outcomes.

What is Attention-Deficit/Hyperactivity Disorder (ADHD)?

ADHD is a neurodevelopmental condition with hallmark features in persisting patterns of inattention and/or hyperactivity and/or impulsivity.

Symptoms develop in childhood.
ADHD occurs in 5-7% of children and 2% of adults.
ADHD is a genetic condition.
There is a rate of 30-90% of symptoms and impairment persisting into adulthood.
ADHD is often associated with other cognitive, social and emotional difficulties.
Emotional dysregulation is often a significant component of ADHD with affective reactivity and emotional lability and an inability to inhibit emotional expression, although it is underrepresented in ADHD.
ADHD commonly occurs with internalising conditions (anxiety and depression), externalising conditions (Oppositional Defiance Disorder and Conduct Disorder), and sleep problems.

Other ADHD Symptoms & Impacts

There are other symptoms not defined formally in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) related to ADHD. These can include vocal stimming, anxiety that may be associated with demand avoidance framed as a strong insistence for autonomy. Social Impairment is often a functioning impairment of the formally and informally recognised symptoms of ADHD.

Vocal Stimming & ADHD

Vocal stimming occurs when a child, adolescent or adult makes repetitive vocalisations or sounds related to self supporting their regulation and to feel a sense of comfort, focus, or calm.

These repetitive behaviours in ADHD, vocal or otherwise, are typically impulsive and are associated with a hyperactive presentation involving excessive physical and mental energy needs requiring an outlet. Vocal stimming is easily accessible and always available for self-supporting emotional regulation, impulsivity, focus, and hyperactivity.

Why Does It Occur?

A child with ADHD may stim to:

improve their focus
relieve boredom
lower anxiety or stress
express excitement
distract from sensory-based overwhelm
Sensory sensitivities can factor for children with ADHD outside of an autism context.

It is possible that if you stop one behaviour it will be replaced with another (e.g., humming replaced with throat clearing).

Overlap with Autism

ADHD-based repetitive behaviours are different to those associated with autism which typically occur for self-soothing reasons. Studies show that in autism, stimming is associated with self-soothe and reducing anxiety as opposed to self-regulation.

Overlap can exist across autism and ADHD, although they can be distinct based on the underlying reasons of why they occur.

Treatment

Vocal stimming can be disrupting and annoying to others but it doesn’t usually require treatment.

If it is associated with daily living impairment and interfering with everyday living, then working with a mental health professional such as an occupational therapist can be helpful to manage symptoms and reduce vocal stimming frequency.

Hours et al., 2022; ASD and ADHD Comorbidity: What Are We Talking About?

Kapp et al., 2019; ‘People should be allowed to do what they like’: Autistic adult’s views and experiences of stimming.

Stewart 2015; Repetitive Stereotyped Behaviour or “Stimming”: An Online Survey of 100 People on the Autism Spectrum

Vocal stimming examples may include:

making “silly” sounds
humming, babbling, cooing, growling
heard words or phrases
non-sense words
chanting, singing parts of songs or jingles
words in a sing-song tone
animal sounds, object sounds (e.g., cars), or learning (e.g., phonics)
blowing “raspberries”
throat clearing or coughing
whistling
tongue clicking

Request or demand avoidance can be a predictor of ADHD.

Studies show that approximately 70% of individuals with ADHD had markers of demand avoidance (Haire et al., 2023).

Demand Avoidance & ADHD

Although request or demand avoidance is often associated with autism, it can be a strong predictor of ADHD with or without co-occurring autism. Studies showed that 70% of individuals with ADHD had markers of demand avoidance (Haire et al., 2023). Anxiety is often a leading factor in this response.

Examples may include:

A child may push back on starting cognitively demanding tasks, or stopping their favourite activity, and they may lash out with these requests or demands.
Executive functioning impairment (e.g., difficulties with memory, understanding time, organisation, or following instructions can contribute to these resistances, as can being easily distracted.
This response provides the child with short-term relieve from anxiety associated with the increased demands.
This avoidance response serves to maintain the anxiety and the behaviour over a longer term, if not perpetuate it.

PDA or Pathological Demand Avoidance is not a diagnosed condition. It’s underlying base is that a demand/request is being asked and they feel controlled and react to preserve their autonomy.

Why may a child react to or avoid demands?

There are many reasons, some may include:

Anxiety
Mood disruption/depression
sensory overwhelm
fatigue
distractibility
frustration or anger
somatic issues or illness (sore tummy, headache)
temperature regulation issues (overheated)
cognition overload or lacking understanding of the request
low motivation or low engagement
inability to do the task and related lowered self-esteem
relational difficulties with the person requesting
feeling controlled or defending their autonomy

Intervention:

Working with a professional to:

Identify patterns and triggers
Working towards the child understanding their uncomfortable feelings
Teaching new and helpful ways to sit longer with these feelings and not react in the same ways.
Developing greater self-awareness and interoception skills (see OT page)
Developing greater insight of reactivity impacts on relationships
Working with parents to respond in ways to support their child’s regulation and distress.

Parenting Strategies To Break a Demand Avoidance Anxiety Cycle:

Identify your child’s triggers: Noticing shifts in their emotions, thoughts, and habits as soon as they happen and assisting your child to become aware of them (e.g., sensory impacts such as noisy environments with the demand).
Reduce the demands to reduce the anxiety: Make shifts to reduce the demands and ultimately the anxiety (e.g., add flexibility with requests or routines, ask the child to problem solve the issue, minimise unnecessary rules).
Promote helpful lifestyle changes: Having a good sleep routine with adequate sleep, healthy nutritious foods, daily exercise, social engagement, restrictions with screen access, promoting mindfulness, spending time with your child (e.g., shared reading, playing games).
Recognising Emotions/Feelings associated with requests/demands: For those with perfectionism tendencies, children may feel shame if they feel it is not achievable. Reduce time pressures and add flexibility and support.
Be Consistent & Predictable: Use “if-then” strategies (e.g., if you feel anxious about it, just work on it for 5 minutes and then take a 10 minute break).
Reward yourself: Factoring impulse control set delayed gratification rewards. Use positive attention and reinforcement as a reward and be specific (e.g., “I liked the way your tried your best on that question” or “I liked they way you didn’t get upset when you couldn’t answer that question”).
Assist with restructure negative cognitive-behavioral patterns: Challenge your child’s thinking (e.g., “You said you couldn’t do it and look how far you have come”; “Even though things didn’t go as expected, it was okay”). This allows your child to sit with uncomfortable feelings at greater levels and know they are going to be okay – the basis of emotional resilience.
Remain Non-judgmental: Identify behaviour as a communication such as overwhelm or anxiety. Offering support is helpful.
Seek support: Reaching out to ADHD support groups and professionals may help you find the support you need to fully address your day-to-day demands.
Make environmental modifications: Setting up your environment for success (e.g., morning routines that include avoid distractions).
Build skills: Such as executive functioning and social skills to avoid distractions, self-organise and stay on track.

Anxiety can be implicated in inattention, including difficulties with:

concentrating
remembering
following instructions
organising
engaging
staying on task
finishing tasks
remaining focused and still
getting a good nights sleep

Children with Anxiety can appear:

restless
agitated
like they aren’t interested in what you are saying
not listen
distracted
fidgety
not to value relationships
moody/irritable/short
avoidant of requests/tasks

Anxiety and/or ADHD?

ADHD & Social Impairment

Social impairment frequently occurs with ADHD. For example, for children who struggle with attention:

Adults and peers may perceive a child with ADHD is not listening to them or doesn’t understand what they are saying.
A child with ADHD may appear socially disinterested due to them cycling for novel activities and interests, or leading in play.
Social cues can be missed due to distractibility and difficulties maintaining focus.
A child with ADHD may present with an intrusive or domineering social approach as part of difficulties regulating and this can disrupt their ability to make and keep friends.
A child with hyperactivity and/or impulsivity can get caught up in an activity or moment and lose social connection with the individuals around them.
Difficulties with time contribute to difficulties staying on task and this can be associated with relational difficulties with parents who often engage in high efforts to maintain morning routines successfully.

Social challenges related to impulsivity and hyperactivity can include interrupting, finishing others’ sentences, speaking or acting without thinking, talking excessively, using people’s things without asking, intruding on personal space and intruding on others activities.

Social challenges related to inattention can include not actively listening, becoming distracted in conversation, forgetting to maintain contact and struggling in group work.