ADHD: Some children just can’t stay still

Across the table in my consulting room at the hospital is a bright-eyed little boy, flanked by frustrated parents. He moves a lot in his chair, randomly picks up things from the table, or keeps fiddling with his fingers. He looks curiously around the room, his eyes darting from object to object, indifferent to his parents’ list of his misdeeds.

Their son is a Problem. Being disobedient and disruptive is a habit, and punishments don’t deter him; if anything, they make him more determined in his efforts to irritate them.

A child with Attention Deficit Hyperactivity Disorder, three times more likely to be a boy than a girl, is typically brought to the hospital with some of these complaints.

• Does not sit still, fidgety, especially when required to do his homework; makes frequent excuses to leave the study table
• Inattentive when he is supposed to be studying; easily distracted, does not complete work, or very slow; can watch television for hours at a time, however
• Disorganised, does not pay attention to detail and fails to notice and correct mistakes
• Runs, jumps or climbs in places where he shouldn’t, even in the classroom
• Impulsive, for example in a hurry to answer, doesn’t bother to hear the question through; has trouble awaiting his turn
• Doesn’t listen; interrupts often

A child may have one of three subtypes: hyperactive-impulsive, inattentive or combined, ie he may not exhibit all of the above behaviours.

What causes ADHD?
ADHD and its diagnosis and treatment have been controversial for decades. Doctors, teachers, parents, media and policymakers have been unable to agree on what constitutes ADHD. While some wonder whether it is a mental disorder at all, others believe that there are genetic and physiological bases for the condition. Psychiatrists accept that it is a genuine disorder.

What happens to the brain in ADHD?
There is no clear answer to that as there are several hypotheses, none of them conclusively proven. A significant percentage of cases seem to be genetically inherited.  Other suggested reasons are damage to the developing fetal brain by maternal stress, exposure to certain infections, pesticides or medicines.

How does ADHD affect a child’s life?
In junior school: A child with ADHD might forget to bring books, pencils and other things to school. He is likely to turn in incomplete or messy work. If his teacher does not recognise the signs of ADHD, she may call him careless and lazy, and upbraid him often.

Other children could pick on him for being ‘dumb’ and make him feel inferior by their put-downs.

Being in the teacher’s bad books, he may not have the courage to approach her and report kids who harass him.

The teacher might complain about his poor school work to his parents and they may punish him. If he is hyperactive, there may be complaints about his unruly behaviour in class as well. The child is too young to think beyond the fact that he is “a bad boy”; he may suffer silently or throw tantrums out of sheer frustration, attracting further punishment.

In high school: A third of the children who were diagnosed with ADHD will no longer have symptoms. Those who continue to be hyperactive and impulsive but have never been diagnosed and treated, may by then be convinced that they are bad and useless people, having been criticised all their young lives. They are at risk for other problems, most notably academic failure with consequent dropping out of school, which may lead to delinquent behaviour; joining a gang of other kids with problems may give them a sense of acceptance and self-worth.

What should adults do?
Firstly, as we realise that the child’s behaviour is unintentional, we need to level with him gently, giving him a wider berth than we would a child indulging in dangerous pranks or being willfully defiant. It is necessary for parents, teachers, psychiatrists and psychologists to work as a team to help the child reach his potential.

Secondly, we need to tone down his hyperactivity and improve his concentration, if he is to learn anything at all.

Medical management of ADHD
Children with mild symptoms often settle down as they grow older.
Pharmacological treatment: Those with more troublesome symptoms are prescribed a medicine by a psychiatrist, usually starting after the age of 6 years. The dose is based on parents’ observations regarding response, as well as feedback from the class teacher. The latter is important because the medicine is given before school and has maximum effect during school hours, its effect reducing towards evening, when the parents get to see the child.

Psychological treatment: Target behaviours are clearly specified and monitored by a psychologist.

The child is made to understand the consequences of his actions; a reward and punishment scheme is established and applied consistently. This is called ‘Behaviour Modification’.

Conclusion
The choice to medicate the child is the parents’. As psychiatrists we suggest medication based on our collective experience with children who have been treated with medicines, shown marked improvement, gone on to college and become independent adults.

Used judiciously, medicines are an ADHD-affected child’s best bet to get ahead and avoid problems that come with an unfinished education.

— Dr Shyamala Vatsa is a consultant psychiatrist