When you can’t pay attention

ADHD is increasingly being diagnosed among schoolchildren, but do parents know what it really means? Dr. Sudharshi Seneviratne explains:

by Carol Aloysius

Attention Deficit Hyperactive Disorder (ADHD),is a neurological condition that is increasingly seen among school going children and teenagers, but which many people including parents still don’t fully understand.

Here eminent psychiatrist in this field, Senior Lecturer, Dept. of Psychological Medicine, Faculty of Medicine, Colombo, and Honorary Consultant Child & Adolescent Psychiatrist, Lady Ridgeway Hospital, Dr. Sudharshi Seneviratne, sheds some insight into the disorder, explaining its impact, how it is treated, and the role of parents and teachers in helping such children.

Excerpts

Q: What is ADHD?

A: ADHD (Attention Deficit Hyperactivity Disorder) is a neuro developmental disorder, so called due to a delay in the development of certain areas of the brain giving rise to a group of symptoms. The disease starts from birth.

Q: Which age groups are most at risk?

A: Children. Some children show increased vulnerability to this condition e.g. low birth weight babies, premature babies, certain syndromes, autism, children with epilepsy.

The symptoms begin early and some settle, while some continue to show symptoms even in adulthood. Usually the hyperactivity symptoms settle early but the inattentive symptoms can persist.

Q: What are the reasons?

A: It is mainly due to a delay in the maturation in a part of the brain, which is called the prefrontal cortex.

This is an important area which controls higher order functions such as prioritizing, time management, shifting tasks.

Q: Is it on the rise in Sri Lanka?

A: A higher number of children have been diagnosed with the condition for many reasons. For e.g. children who have had an eventful delivery with brain damage survive. These children will show symptoms of hyperactivity. These reasons may lead to a rise in the incidence.

Q: Is it curable? Treatable?

A: The symptoms can be controlled successfully with both behavioural treatment and pharmacological treatments. The cornerstone of treatment is medications. When the child grows up some amount of development will occur in the before mentioned areas of the brain leading the symptoms to subside.

Q: What are the symptoms? How do you detect them?

A: Symptoms can be broadly divided into two groups. The first group is the hyperactive/impulsive symptoms. Here the child would display inability to be in one place, always on the move, fidgety, cannot wait for his turn, disinhibited, disturbing others in class, climbing heights, injury prone. They are also very impulsive and this will lead them to do things without considering the consequences.

The other set of symptoms consist of the inattentive component. Here the child will have a poor attention span, easily distractible, incomplete work, forgets his belongings, does not bring messages home.

The detection is mainly done on the symptom profile the parents describe. Also valuable information is provided by the teachers.

We can also check the school books and get an idea on to the level of performance and their attention span. Children can have symptoms of hyperactivity for many reasons. So we have to be careful when we make a diagnosis and also look into the impact the symptoms cause.

Q: What is the treatment?

A: Most children will not require hospitalization, as they can be managed as outpatients. Sometimes they may have to be admitted for observation and diagnosis. The treatment has to include strategies for home and school. Drugs are the cornerstone of treatment. There are a limited number of these medications in Sri Lanka and the treatment is very effective.

Q: Which is more important – medication, therapy or education?

A: I think the pharmacotherapy or medicine will have huge benefits but needs to go hand in hand with the education input and behaviour strategies for home.

Q: What about alternative treatment?

A: There are some alternative medications used in other countries but the evidence is not strong enough to make them reliable.

Q: How can parents help such children?

A: By observing symptoms. If there is concern, they should seek advice from a professional. Once diagnosed it is important for them to manage the child’s behaviour with behavioural therapy with patience as the benefits are immense in the long term. Parents need to share all information about the child with the school teachers and authorities, so that the school can cater to the child’s need.

It is also important for parents to monitor their children’s medication and its side effects.

Q: What kind of problems do most parents face?

A: Sometimes it is very difficult to manage the child’s behaviour. As a result some parents tend to punish their children and also make very negative comments about them, which causes emotional trauma and lowers their self esteem. They must also be encouraged to see the positive aspects of the child so that his self esteem can be maintained.

Q: What are the health impacts of ADHD?

A: Physically the child can be prone to injuries and this can be damaging. Other than this there are no main physical complications due to the illness. Emotionally, there can be many effects. Hyperactivity and inattention can have significant effect on the child’s education resulting in poor school performance. Also these children can have difficulties with being in a group, inclusion to group activities, bullied or called names which can impact emotionally and mentally.

Q: Some people believe that ADHD is often the result of a lack of discipline by parents. Your comments?

A: Commonly children with ADHD can have co-morbidity with ODD (Oppositional Defiant Disorder.) This means children tend to do the opposite of what parents request.

These children can be very well treated with medication and the behavioural therapy.

But parents are often reluctant to use medication fearing it could become addictive. This is incorrect. Medication can be stopped at any time when the child has improved.

The benefits of hundred percent commitments by parents with behaviour therapies are immense.

Q: A new study has suggested that pesticides are linked to ADHD. Your comments?

A. There are some new studies showing an association of pesticide exposure and the onset of hyperactivity and inattentive symptoms. Still, they have not shown to have a causative effect but the association was clear mainly in male children.

Q: What are the risks involved in delayed detection?

A: Some amount of symptoms can settle in children who have mild symptoms. But those with severe symptoms are at a disadvantage in their education and achievements. There are also problems with impulsivity and sometimes with substance use disorders. Poor academic achievement can aggravate the problems.

Q: Common myths attached to ADHD?

A: Most parents wrongly believe that because boys are by nature more naughty, they display this trait more than girls. Another myth is that they will grow out of the condition, as they mature. Some delay treatment because they are afraid it could lead to addiction.

Q: What are the gaps in this field?

A: An urgent need is providing parents with clear information, especially with regard to the symptoms and early identification features. For this, the medical team that deals with them needs to be equipped with skills and knowledge to recognize the features early and the need to refer for a specialist opinion.

The medical officer of health, midwives and even GP can make a tentative diagnosis as they may have the opportunity to observe the child’s behaviour over some time or a couple of occasions.

Q: Is it a lifetime condition?

A: Once treated the symptoms can be controlled and at times that treatment can be discontinued. On the other hand some may continue to have symptoms till adulthood where a diagnosis of Adult ADHD can be given. It is mainly the inattentive symptoms, which are resistant to treatment and usually the hyperactivity settles with time.

Q: What do you see as the biggest gaps in treating these children in our state hospitals?

A: Being in a tertiary clinic and being trained in the field of Child and Adolescent psychiatry, I’m fortunate to be in a hospital where there is the most amount of resources.

We also have other allied health staff who can work as a team, e.g. occupation therapist, speech therapist, teachers are very vital in providing services.

We also have an input from the trainee psychologist for the behavioural interventions.

But we lack services from an educational psychologist who is the person best placed to manage the academic needs of these children.

Q: Role of teachers?

A: Teachers have shown skills at detecting these symptoms. They have also generated referrals on their own to the treating team. We have also seen instances where teachers initiate the referrals and ask parents to seek medical advice. Hence we should not under-estimate their capabilities.

Q: Your advice to parents and teachers of children with ADHD?

A: To parents I say, start treatment early and have a regular follow up. You need to work closely with the treating team and use correct behavioural methods to help your child.

To teachers I say, don’t neglect these children and label them as lazy or naughty, as they have difficulties and they need your help.

Parents and teachers need to be firm with setting limits, have schedules to work on, and also employ a reward system for positive or negative punishments, employing the same reward system when a child completes his homework or withholding it if he fails to complete his homework.