Attention-deficit/hyperactivity disorder (ADHD) refers to a constellation of inappropriate behaviors found in many children. The essential feature of ADHD is apersistent pattern of inattention and/or hyperactivity-impulsivity. Thesefeatures are more frequently displayed and more severe, than typically observedin a child at comparable level of development. They may be unusually activeand/or impulsive for their age. Children with ADHD have trouble payingattention in various settings like at school, athome or at work. These behaviors may contribute to significant problems insocial relationships and learning. For this reason, children with ADHD aresometimes seen as being "difficult" or as having behavior problems.
Although there is no single, comprehensive and concise definition ofADHD. There are specific elements of Attention-deficit/hyperactivity disorder.
The symptoms should be inconsistent with developmental level and should have persisted for at least 6 months, to a degree that is maladaptive and inconsistent with developmental level and causes impairment. The symptoms should be present in 2 or more settings (e.g. at school or work, and at home) and there must be clear evidence of clinically significant impairment in social, academic or occupational functioning.
Symptoms of ADHD appear gradually over the course of many months, often with the symptoms of impulsiveness and hyperactivity preceding those of inattention. Parents may seek help when the child's hyperactivity, distractibility, poor concentration and impulsivity begin to affect performance in school, and social relationships with other children or behavior at home. In order to meet the diagnostic criteria, the abnormal behaviors must be excessive, long-term, and pervasive, as described below. Although the behaviors must appear before the age of seven years and continue for at least six months;the child should be at least 6 years old before a diagnosis of ADHD can be made with certainty. A crucial consideration is that the behaviors must create areal handicap in academic and social settings of a child's life.
Some common symptoms of ADHD include:
· Often fails to give close attention to details or making careless mistakes
· Often has difficulty sustaining attention to tasks
· Often appears not to listen when spoken to directly
· Often fails to following structions carefully and completely
· Loses or forgets important things
· Feels restless, often fidgets with hands or feet
· Runs or climbs excessively in inappropriate situations
· Often talks excessively
· Often blurts out answers before hearing the whole question
· Often has difficulty in waiting for his/her turn while playing
The DSM-IV TR diagnostic criteria list the common clinical features which are helpful in making the diagnosis.
Early pointers of ADHD
There are some unusual features in the behavior of the child even in early years of childhood which may hint towards this disorder.
Toddlers and pre-school children
- Always moving
- Being on the go
- Changes the focus of activity frequently
- Appears to be without purpose or goal
- Marked clumsiness, accident prone
- Shifts activities unpredictably
- Behavior may be disruptive and dangerous even without provocation
- Does not listen to parents
- Does not learn from mistakes
- Unresponsive to praise or punishment
- Easily distractible
- Does not complete activities
- Cannot play alone
- Very disorganized
Cannot deal with complex stimuli in a planned way
Example: The child cannot concentrate on a single activity for more than a few minutes and shifts to another activity frequently.
However, since these features may be a reflection of the upper limit of normal development (for that age) or inappropriate parental responses to maladaptive behavior, it is imperative that the child is not labelled as suffering from ADHD until he is at least 6 years old.
BROAD PRINCIPLES OF MANAGEMENT
Management of primary problem
There are various treatment options for symptoms of inattention and hyperactivity which may be given concurrently. These are mentioned in detail below.
Behavioral and Psychological Treatment
This is an integral component of management and complete elaboration is beyond the scope of this module. Readers may refer to relevant texts. Some of the techniques that are used are:
· Reinforcement of positivebehaviors by praise or by providing incentives like (gold star or ‘happy face’)in daily consistency charts
· Provide a distraction-free environment in school and at home for children
· Social skills training
· Adapting tasks to the child’s abilities
It includes use of:
· Stimulant Medications: Methyl phenidate and Nor epinephrine re uptake inhibitors (Atomoxitine)
· Non-stimulant Medications: These are useful in around 30% of children who may not tolerate or respond to stimulant medicines. These include Tricyclic antidepressants, selective Serotonin Receptive Inhibitors etc.
Management of associated problems/ co-morbidities:
· Specific learning disability: special education and remedial teaching
· Oppositional Defiant Behavior (negativistic, defiant, disobedient, and hostile behavior toward authority figures): Behavior modification techniques and management.
· Conduct Disorder: Behavior modification and appropriate medication
· Anxiety and depression: Medication and psychological intervention
· Epilepsy: use of anti epileptic drugs
· Tourette syndrome (A disorder of recurrent, multiple motor and vocal tics with onset before the age of 18years): Pharmacological treatment has some role.
Steps for prevention:
Primary - Avoiding environmental risk factors such as maternal smoking during pregnancy and Lead exposure.
Secondary - Early identification of the symptoms and early institution of appropriate treatment.
· There are no special benefits for children with ADHD except in the State of Maharashtra, where extra time and writer for examinations are allowed.
Support to the family with an affected child
· The multidisciplinary team can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other.
· Assist the family in finding better ways to handle the disruptive behaviors and promote change.
· In a young child, parents should be taught techniques for coping with and improving the child's behavior.