Identifying & Managing ADHD

Published in "Panorama"


Identifying and Managing Children with Attention Deficit Hyperactivity Disorder



10 year old Rohit spotted his dad park the car across the road. He abruptly stopped playing with his friends; looking neither left nor right, he dashed across the street to greet his father. There was a sharp screeching of tyres as Ahmed applied the brakes. Rohit narrowly missed getting knocked down by the car; he’d indeed received a new lease of life!

Rehaan’s parents dreaded going for his ‘Open House’. The complaints would be the same, they were confident. “Rehaan is very smart, good at his work, but he is highly distracted. It’s very difficult to get him stay put in his place while the class is going one!”

Vinay’s mother was in a perpetual state of tension. He was too ‘naughty’ for a five year old, constantly jumping onto anything and everything – sofas, beds, window sills. That guests were present didn’t make any difference to him. He’d even take generous helpings of savouries from their plates and continue with his ‘monkey tricks’.

Well, all these youngsters may be more than just naughty or mischievous, says Dr.Philip John, Specialist in Learning and Behaviour Disorder, Indian Specialist Medical Centre, Dubai. “These children may be suffering from Attention Deficit Hyperactivity Disorder (ADHD). This is the most common psychiatric disorder in children, comprising almost 5-6% of all psychiatric cases. The number of children who suffer from it and are not recognized as such, are phenomenally high. However, the light at the end of the tunnel is that, this is also the best understood disorder today in terms of its neuro-biological implications, in terms of the neuro-imaging results that we have been able to obtain in the brain scans and in understanding of its genetics.”

More males than females are affected by ADHD, the ratio of incidence being roughly 3:1 between them. Should teachers be observant, they can more easily identify ADHD children from the rest of the class. Left untreated, children with ADHD go on in later life to have oppositional behaviour because many of them have poor self-esteem. Despite being very intelligent, they are unable to show their output which creates frustration which in turn gets reflected in aggression, socially undesirable activities and delinquency. However, Medication is only part of a comprehensive strategy in managing and treating the problem, says Dr.Philip.

So, what is ADHD? Who is at risk of the problem and what is the age of onset of the problem? Dr.Philip explains, “It is a syndrome which has basically three rubrics of deficits or problems; children display a triad of features: age-inappropriate over-activity, inattention and impulsivity. A child can be born with ADHD, the problem being genetically inheritable. If you look at a new born with ADHD, it will show all these three features, or may be only attention deficit disorder (ADD); the other two features may not be there.”

The unfortunate thing about ADHD is that it is very difficult to make a diagnosis of it since it’s a spectrum and you don’t know where the cutoff occurs, from normal to abnormal, rues Dr.Philip. “Because all children these days are hyperactive, where do you draw the line? Also, there are a lot of mentally challenged and autistic children with ADHD. Children who have suffered brain injury, damage or trauma during delivery can also have ADHD. Chronic epileptics whose treatment of the condition is inadequate, making the epilepsy uncontrolled even with medication, may go on to suffer from ADHD. These then become the triggering forces for ADHD apart from the genetic factors which cause it.”

Is it possible that children born with the condition, may outgrow the problem in later life? Dr.Philip replies, “Yes, it can happen. These children go on into adulthood with ADD. Somewhere along the line, they stop the hyperactivity and the impulsivity.”

What are the symptoms of ADHD and how early do they get manifested? “Right from the early years they can get manifested, as early as when a child starts movements,” explains Dr.Philip. “The problem, however, is most understood when we expect the child to be quiet, to hold its attention to an ongoing task for an adequate period of time.”

Most young children are playful and fidgety, so how do we identify the ones that have the disorder? “I have a thumb rule,” opines Dr.Philip. “When these ADHD significantly impairs or comes in the way of academic achievement or social skills or interpersonal relationships, then we call it a disorder.”

WHO (World Health Organisation), says Dr.Philip, has identified a set of symptoms which will make it easy for parents to identify children with ADHD.
1. These children can’t give attention to details, especially in the exams where the pattern is structured.
2. These children are unstructured and disorganized.
3. They make careless mistakes in schoolwork and during exams.
4. Their attention cannot be sustained for an adequate period of time to an ongoing task.
5. Though they may be good at sports, even here they do not come out successful and on top because they fail to complete what they take up and can’t concentrate for a sufficient period of time.
6. Whatever be the nature of work they do, they don’t complete them.
7. They are poor at managing time.
8. Younger kids have a tendency to lose their belongings and may be forgetful.
9. These children are generally intelligent with above-normal intelligence and are very quick on the uptake.
10. They are fidgety, squirmy and restless; their hands and feet can’t sit quiet.
11. These children cannot sit in one place for long.
12. At home, some of the younger kids run out, climb up windows and other things in situations where it is not appropriate. They are always on the go, as if driven by a motor!
13. Their impulsivity becomes very embarrassing; in the classroom context, they shout out answers out of turn.
14. They have difficulty awaiting their turn in a queue.
15. They often interrupt and intrude upon conversations.
16. They have a difficulty in evaluating risk.

Because of their distractive, disruptive and bullying nature, these children are most often loners, says Dr.Philip. “Most parents become aware that all may not be right with their child, when the child enters the higher classes and is unable to perform well in academics. Parents are frustrated because they feel the child’s lack of concentration is because he does not will to remain focused. But this is not really true. His concentration cerebrum mechanism don’t function and hence he cannot keep his attention on, long!”

But being hyperactive, will not these children bring more physical injury to themselves? “Yes, that’s absolutely true,” says Dr.Philip. “This is something about which we warn parents. They dash across streets without looking in either direction for oncoming vehicles, climb up heights without realizing the dangers of climbing on to something which will not support them. These kids are very much prone to physical injuries.”

Is it always true that children with ADHD always have above normal intelligence or are very intelligent? “No, this is not always true because there are other disorders which may appear along with and overlapping with ADHD. If there is one developmental disorder, always look for another disorder which will mostly co-exist, because this is so common. Very often learning disorders are associated with ADHD. In Cochin where we did a statistical survey of 4300 children with ADHD, 32%, almost a third of them, had associated learning disorders, which is a phenomenal number!”

So how does one tackle the problem of ADHD and to what extent is treatment effective? Dr.Philip beams as he says, “This is the joy of seeing a child with only ADHD. Research has been able to identify the disturbances in the biochemistry which produces ADHD. Therefore there are medicines that have been evolved which give incontrovertible benefits, as much as 60-70% benefit across the table. It is short term, but it is what is used for the treatment of ADHD. These medications improve the function of the two chemicals in the brain which are responsible for the cerebral controls. As a result, attention improves, hyperactivity reduces and the child’s goal setting becomes better. This turns on a good cycle of events. For that period of time when the child is able to hold his attention, he takes in all the information and does well. This improves his self-esteem, thus reducing the behaviour problems; he becomes more quiet and socially more successful in his interactions. The overall output of learning improves.”

Dr.Philip is absolutely emphatic: “Medication is only part of a comprehensive strategy. It has to be combined with other tools. Usually teachers and parents see the initial improvement and they forget about the rest of the strategies. For the long run success of treatment, the Evaluation, Management and Treatment of ADHD should be multidisciplinary, requiring a team of psychiatrist, psychologist, educational specialist and if necessary, a speech and language pathologist to work together.

Dr.Philip delineates the other necessary measures along with medication.
1. These children do very well when taught one-to-one. In a classroom situation the child may be placed in the front best so as to be close to the teacher.
2. Many of them do well when they are read out to first and then made to read, themselves.
3. Academic strategy involves good amount of limit setting; the child should be made to manage his time and to be organized.
4. Emotional support strategies involve, both the family and the school. Many of these children are given a lot of freedom and pampered. Freedom once given cannot be taken away. So we need to set limits and teach these children control systems.
5. With respect to parenting, thumb rule is consistency. Even normal children whose parents have double-bind and are inconsistent in their behaviour and rule setting, fare badly in the long run; the situation is worse in the case of children with ADHD. Similarly, parental-undercutting should be avoided. For instance, one parent should not allow the child to act in contradiction to the regulations set by the other parent. When the disciplining mechanism goes out of control, it is difficult to remedy ADHD in the child.
6. There is an element of discipline that is majorly involved in the management of children with ADHD. This does not imply negative re-inforcements alone, but also positive ones to build the self-esteem and respect of the child.

E N D