How young is too young to diagnose a child with ADHD (Attention Deficit Hyperactivity Disorder)? For Prof. Hemamali Perera, a Consultant Child and Adolescent Psychiatrist, there’s a clear line. “If a three- year-old was diagnosed with ADHD, I would tend to strongly disagree,” she says firmly, adding, “while there is always a possibility that he or she will turn out to be a child with ADHD - because it shows up very early – it’s not right to diagnose at that age.” Prof. Perera agrees that we’re seeing more cases of ADHD these days, but that doesn’t necessarily mean the incidence of the disorder has gone up. Instead, it could be just that more cases are being brought to the attention of medical professionals, she contends.
A diagnosis of ADHD should not be given lightly. A thorough assessment and medical history are required to judge first if the child has the disorder and if yes, how intense it is. “Children with ADHD symptoms are all loosely put into this one basket of ADHD, children might have attentional problems and hyperactivity for a variety of reasons, so all of them don’t fall into this category,” cautions Prof. Perera.
ADHD, with its focus on attention, activity and impulsivity, is a broad diagnosis and can manifest very differently in different patients. We must be particularly wary of an overhasty diagnosis with very young children – their ability to concentrate is still developing even up to age five. “Children at the age of 3 are busybodies anyway,” she says. “I think the child has to be in school proper, not preschool, before they can be diagnosed.”
For some parents, the diagnosis of ADHD may actually come as a relief (especially if they have been criticised for how they’ve chosen to raise their child). Overwhelmed with concern, they might have watched their child struggle and fail to cope with the schoolwork or found themselves unable to discipline their child at home. Depending on the intensity of the disorder, children with ADHD have trouble concentrating on their tasks, are easy to distract and are disorganised. They’re so full of energy, they’re bouncing off the walls – sitting down holds no appeal.
They may talk a mile a minute and fail to govern impulsive behaviour. Over-excitable and easily frustrated, they find it hard to fit in with their more docile peers. Sometimes such children may become a real danger to themselves, acting reckless enough to risk serious injury or leaving their parents totally overcome and unable to exert authority.
Unsurprisingly, ADHD has been linked with serious learning disabilities in children. Though these children might have a normal IQ, they don’t perform well at school. Work being left incomplete or an assignment ending in lines of gibberish are not unusual. “Because academic performance is judged on the basis of marks, it will look like they have difficulty learning,” says Prof. Perera. “Pure ADHD is unusual,” she adds. Aside from learning disability, ADHD has also been linked to Oppositional defiant disorder (ODD), anxiety and depression as well as smoking, drug abuse and risk taking behaviours.
If left unchecked, in the long term ADHD can take a heavy toll as the children grow into adulthood – they might find themselves unable to meet the requirements of higher studies or to hold down jobs. They are more likely to procrastinate a lot or be disorganised and on a social level, they might have trouble maintaining healthy, personal relationships. Interestingly, a percentage of adult victims only receive their diagnosis when their child is diagnosed with ADHD, says Prof. Perera, explaining that “there is a genetic cause, so it can be inherited. Especially, when it comes to boys, the father may have had ADHD and could still have it as an adult.”
It’s also worth noting that there are subtle differences between the genders: researchers have found that girls with ADHD might not be as hyperactive as the boys; instead they have more trouble paying attention. “For this reason, girls with ADHD often go unnoticed,” says Prof. Perera. Growing up, those with untreated ADHD are more vulnerable to having problems with self-esteem, depression and anxiety. Mothers too can pass on ADHD to their children.
While genetics are believed to play a crucial role, the causes of ADHD are still being understood. Environmental factors, brain injuries, nutrition, and the social environment have been identified as possible culprits. Children exposed to pollutants, particularly lead, have been found to be adversely affected but even in the womb children are vulnerable to toxins. Mothers who smoked or consumed alcohol while pregnant place their children at increased risk for ADHD.
Once a child is born, however, what they eat can be equally influential. A diet rich in oily junk food, processed foods packed with chemical preservatives and flavours as well as fizzy drinks can cause significant harm to any developing child, particularly one with ADHD. Even foods that look simple and healthy, such as the imported grapes and oranges may not be so, having been doused in chemicals to keep them looking appealing. Children should be eating wholesome foods such as locally sourced fish, vegetables and fruit instead, emphasises Prof. Perera.
Socially, children need some amount of structure and routine. Chaos and disorganization in the family environment can worsen ADHD in children, says Prof. Perera. Rectifying such problems is key to helping a child. Some drugs have been proven to help patients improve their concentration and reduce the impulsiveness and hyperactivity associated with ADHD.
This is true particularly for those with intense symptoms but while the medication may be very helpful, they won’t do the trick alone. In some cases, a child might not even need a dose of pills.
“All children with ADHD don’t need to be given drug treatment,” she says. Children with milder forms of ADHD could benefit from activities to improve attention span alone. “Teachers have to know how to help the child and the parents have to know too,” says Prof. Perera, adding that they have to identify and work on any particular learning problems a child might have such as poor reading or writing skills. “We have to be careful that we don’t overprescribe,” she says, cautioning both against unnecessary medication and depleting important medicine stocks.
There’s been much controversy in the media surrounding the use of drugs like Ritalin, but Prof. Perera emphasises that the drug therapy has been consistently used to good effect. “Doctors go by lots of research and very hard, documented evidence that something is useful,” she says, explaining that people’s concern often rises from their own conflicting feelings about using medications.
Medication helps but it’s difficult to predict how long a child might need to be on it. Doctors must consider all the different factors at play, such as the intensity of the condition and how successfully parents and teachers have been in addressing the surrounding issues. “At least some of them will go into adulthood still needing medication,” she says. If taken off treatment and therapy prematurely, some patients might actually relapse.
However, as patients grow older they can become practised at managing their symptoms, learning how to thwart the condition. The first step really lies in a correct diagnosis.