Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neuropsychiatric conditions of childhood and adolescence affecting 4-12% of children, with a significantly higher percentage of males being diagnosed. ADHD is a persistent problem, manifesting its core symptoms throughout the life cycle, with impairments reflected in a child’s academic performance, peer relationships, family functioning, self-esteem and overall quality of life.
Despite its high societal cost, the syndrome is poorly understood. The intent of this article is to educate parents and teachers about the signs and symptoms of ADHD leading to early diagnosis and consequent early intervention.
ADHD is a syndrome, reflecting a cluster of symptoms, which are grouped under three broad categories- inattention, hyperactivity and impulsivity. Both the DSM-5 and ICD-10 (manuals for diagnosing mental disorders) share these core clinical criteria. It is important to remember that the symptoms should be maladaptive and inconsistent with the development of the child.
ADHD is a condition which is pervasive and persistent: it pervades into a wide variety of situations over a long period of time that disturbs functioning and lowers quality of life. The symptoms should have been present continuously for 6 months by the time the child reaches the age of 7 years.
Inattention symptoms include: not paying close attention to details or making careless mistakes in work, failing to sustain attention in activities, not appearing to listen what is being told, failing to follow through instructions, impairment in organising tasks, avoiding or strongly disliking activities requiring sustained mental effort, losing things frequently, and being easily distracted by external stimuli.
Hyperactivity is reflected by the following: Fidgeting often with hands or feet or squirming in the seat, often leaving seat in situations where remaining seated in expected, running about often or climbing in situations which are inappropriate, being unduly noisy, and seeming ‘on the go’.
Impulsivity symptoms include: Blurting out answers before questions have been completed, failing to wait for one’s turn, interrupting or intruding on others, and talking excessively.
More often than not, there is a mixed picture in children, reflecting some parts of all three criteria. Of these core criteria, hyperactivity (because of the distress it causes to the caregiver) is often the quickest to be observed and picked up, and often becomes the reason for psychological referral.
Often when children are referred to mental health services, parents/ teachers describe them as being overly naughty and disobedient. The nature of the symptomatology is such that it is easy to misattribute the ADHD syndrome (especially the hyperactivity and impulsivity type) to plain naughtiness, leading to harsh punishment being meted out to the child for no fault of his own.
On the other hand, at times true ADHD symptoms are overlooked, because it is a common belief that it is normal for children (especially males) to be naughty during their developing years. Though there is a higher prevalence of the condition among males as compared to females (4:1), recent research has suggested that the rates among girls might be highly underrepresented.
This is because of the stereotype of someone with ADHD is a hyperactive little boy, and girls usually don’t fit into that. Their symptoms differ from those of the boys (more of the inattention type, hence less disruptive to the caregivers) which makes it less likely that they will be noticed.
The causes of ADHD are manifold. Most of the research evidence points towards genetic factors and disturbances in brain functioning (which explains why the condition is a neuro-developmental one).
Environmental factors are more important in maintaining the condition rather than causing it. Parents often blame themselves for their child’s condition and wonder what they could have done to prevent it. Knowing that the cause is biological (and hence out of their control) may help in absolving themselves of the blame. Needless to say, parents, teachers and caregivers go through an enormous amount of distress in handling a child with ADHD. Mostly they unsuccessfully resort to physical punishments and other aversive procedures such as extreme criticism, failing to realise the ineffectiveness of the strategies.
With all the negative connotations attached to the diagnostic label of ADHD, one may easily overlook the immense difficulties that children with ADHD have to face each day. Enduring mockery, punishments and criticism from everyone around them brings intense feelings of shame, low self-esteem, sadness, and anger.
Children sometimes deliberately display “bad behaviour” in order to mask the real issues they face. For an accurate and complete diagnosis, it is imperative that the child is assessed by a Psychologist.
Assessments are usually paper-pencil tests completed across multiple settings- at home, at school and at the clinic. Direct observation, standardized tests and subjective reports are combined to arrive at a diagnosis. An early diagnosis leads to early intervention, which prevents the magnitude of difficulties that the child and caregivers would have to otherwise face. Intervention strategies are multi-modal in nature. The parent, the school and the (various) mental health professionals work in collaboration to manage the child’s condition. It is important to recognise that the child spends a lot of his/ her time in school and hence it also becomes the school’s responsibility to provide the appropriate environment for the child.
Children with ADHD often endure a lot of bullying by their peers and are neglected by them. With schools and its teachers holding academic performance as the benchmark of evaluating children, the needs of a child with ADHD are somewhere lost. Parents and teachers need to work closely with the mental health professional in order to gain a better understanding of the child and make an individualistic behavioural management plan for the child keeping in mind his interests, hobbies and personality traits. Cognitive remediation exercises are also taught to the child in order to increase his attention span.
Medication is given in a few cases (especially to children with extreme hyperactivity). There is understandably a considerable amount of parental anxiety regarding the side effects and addictive properties of such medications. Research points to the fact that the side effects seem to be low in comparison to the potential benefits of the medication. Monitoring a careful increase in dosage, appropriate timing and precise watch over any side effects should be done by the caregiver and the treating psychiatrist.
Parents often wonder whether their children will ever get cured of the condition. It is important to know that because ADHD is a neuro-developmental problem, it may be excellently managed but not cured. This means that there needs to be a continuous effort by the parent, child and the school to work in unison with the treating team in order to deal effectively with the problem. The realisation that the issue is the condition and not the child himself will go a long way in managing target symptoms and helping the child lead his life smoothly.