The teachers complain, "He is so naughty. Never attentive. Always talking." The parents complain, "He never sits still in one place. Always on the move." The peers complain, "He is very aggressive. Just doesn't fit into the team." When you start healing these complaints from all quarters, it is very likely that the child at the centre of the controversy is an unfortunate victim of a condition called 'Attention Deficit Hyperactivity Disorder’ or ADHD!
Not all hyperactive children suffer from ADHD. Anxiety, depression, anticonvulsant and anti-psychotic medicines and conditions like Tourette Syndrome can also cause hyperactivity. Similarly inattentiveness can be a manifestation of some sensory impairment like a healing deficit or of the petit mal epilepsy, conduct disorder or learning disability. There is also a variant of ADHD without the hyperactivity element, called ADDmH (Attention Deficit Disorder minus Hyperactivity). But here I will be limiting my discussion to the bewildering medical entity called ADHD. Definition: Three I's - Increased motor activity, Inattention and Impulsiveness define the ADHD when they are together and are inappropriate for the developmental level. Previously this illness was also termed as Hyperkinesis and some even called it Minimal Brain dysfunction (MBD). To add more confusion some called it ADDH -just by changing the order of the words! This is one the most common behavioural problems of childhood and adolescence. No less than 3-5 per cent of school age children suffer from this disorder. Boys are six times more likely to be victims and half of them start showing symptoms before the age of four. Causes:
No one knows the exact cause of this illness. Obviously it has got something to do with the imbalance of various neurotransmitter chemicals in the brain. The frontal region of the brain that controls the motor activity and the pre-frontal region which affects the mood and attention are the likely problem areas. The genetic link is thought to be a major factor, a quarter of such children have parents suffering from the same condition and many of their first-degree relatives also show presence of illnesses like ADHD, developmental disorders, adult alcoholism and anti-social disorders. ADHD patients often have associated learning and language disorders, impaired co-ordination and other behavioural problems. Diagnosis:To make a diagnosis, the American Psychiatric Association has devised 14 criteria. Out of these, if the patient displays eight or more characteristics for six months or more before the age of seven then he is said to have ADHD. Following is the list of these criteria: - Fidgets, squirms or seems restless.
- Has difficulty remaining seated.
- Is easily distracted.
- Has difficulty awaiting his turn.
- Blurts out answers.
- Has difficulty following instructions.
- Has difficulty sustaining attention.
- Shifts from one uncompleted task to another.
- Has difficulty playing quietly.
- Talks excessively.
- Interrupts or intrudes on others.
- Doesn’t seem to listen.
- Often loses things necessary for tasks.
- Frequently engages in dangerous actions.
Difficulties in diagnosis:
Aren't all these things too familiar in very young children to be called abnormal? But unfortunately this test doesn't take into consideration the age of the patient. Actually clinicians often cite the lack of age-related criteria as a limiting factor for this diagnostic tool. This often results in over-diagnosis in younger children and under-diagnosis in the older children and adolescents. That’s why some authorities say that to diagnose ADHD in an age-group of 3-5 years as many as 10 factors should be positive and in children older than 11, as less as six. Furthermore the diagnosis can be seldom made in a one-time clinic setting. Almost 80 per cent of such patients can behave completely normally when in the clinic for evaluation. Repeated observations at home and school, in structured and non-structured settings, in small and large groups and in differing complexity of situations are necessary to reach the proper diagnosis. Management:Managing such a child is a much more complex issue. Awareness, anticipation and acceptance; behaviour modification; cognitive therapy and control of diet and drugs form the ABCD of the management. It needs a team approach involving parents, teachers and medical personnel like a paediatrician, a child psychologist and a psychiatrist. The affected child should be made involved and made to feel responsible in the management process from day one. Behaviour modification:Behavioural changes are to be brought about both at home as well as at school. Fostering positive feelings between the child and the parents and the teachers by setting aside special time which could be as little as half an hour is the first and foremost step. Making the child realise that he is loved will make him try and change his behaviour to please the people who love him. Short attention and retention in these children make it mandatory that they receive frequent feedback from the caregivers. Setting few, simple, short-term goals (like playing quietly for half an hour] and prompt rewards -not in cash or kind, rather by praise and affection is needed for such children. But it should be seen that the rewards outnumber the punishments to make the programme a success! A set routine for the day, avoidance of over-stimulation and excessive fatigue (which specifically includes avoiding long automobile journeys and shopping sprees!) and a quiet time before bed without TV and without rough and tumble games are some of the general measures which are helpful. Valuable, breakable and dangerous items should be kept away from these children. These children often do well in individualised activities and games rather than the team activities where they often find difficulty to adjust. Sometimes allowing them to interact with younger children improves their social behaviour. Cognitive therapy (Positive self-talk) and encouraging them to participate in the social activities like scouting are excellent ways of improving their self-esteem. Diet:
A controlled diet avoiding sugar and allowing only selected items like chicken, lamb meat, rice, potatoes, apples, bananas, cauliflower, cabbage, cucumbers, carrots, celery, broccoli, salt and pepper along with a supplement of vitamins and minerals has been found to be beneficial in some studies. But many authorities are still sceptical about this approach. Drugs:
Stimulant medicines like Methylphenidate, Dextro-amphetamine and Magnesium pemoline and some others like Clonidine, Guanfacine and tricyclic anti-depressants have been found to be beneficial in about 70 per cent of the patients. All of them require a period of at least 2-3 weeks for evaluation and titration of the dosage. Though they all have significant short-term benefits in reducing hyperactivity and improving the attention, their long-term benefits have not yet been proved. Due to their side-effects like anorexia, abdominal pain, increased nervousness, jitteriness and growth suppression, drug-free holidays for at least 2-3 weeks per year are recommended. Final word:
Though hyperactivity is likely to subside considerably with age and treatment, other symptoms are likely to persist even in adulthood often leading to complications like adult alcoholism, anti-social behaviour and hysteria. Considerate and compassionate multi-disciplinary treatment is the only way to manage this common disorder with such far reaching, socially devastating complications and to turn around and transform a potentially unpleasant, unproductive and unpopular life!
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ADHD - My child can not sit still!
