ADHD: A Disorder We Mistaken for Misbehaviour

ADHD or Attention-Deficit Hyperactivity Disorder is a behaviour disorder, with characteristic clinical features of hyperactivity, impulsiveness, and/or inattention. Symptoms usually manifest before 12 years of age, may be mild to severe, and continue into adolescence.

During the developmental years, young children are most energetic and may at various points in time display hyperactivity, impulsiveness, or inattention, depending on the level of interest. An occasional misdemeanour is expected, but ADHD becomes suspect when such errant behaviour gets disruptive, prevents the child from fulfilling expected tasks, and results in impairment in academic, social, and occupational functioning.

Unlike other developmental conditions which can be diagnosed at an early age, the symptoms and patterns of ADHD are usually observed when there is increased demand in the environment that calls for certain behavioural compliance. An example is attending a school where students are expected to sit, keep quiet, and observe classroom rules. Usually, the authority figures (such as teachers) are the ones who notice and flag up a child’s unusual behaviour in comparison with other students, which may then necessitate further looking.

Types of ADHD 

• Predominantly Hyperactive/Impulsive 

The symptoms of hyperactivity and impulsiveness often overlap. 

The following are features of hyperactivity and impulsiveness: 

• Being unable to remain seated and still; constant fidgeting with hands or feet, squirming 
• Engaging in excessive physical movement – run around or climb in inappropriate situations, always on the go
• Talking excessively
• Interrupting conversations 
• Being unable to wait for their turn 
• Acting without thinking
• Having little or no sense of danger

Usually, the signs of hyperactivity peak at 7 years old, and then start to decline until they are almost unnoticeable by the adolescent years. However, impulsiveness persists throughout life. It may manifest as drug abuse, risky sexual behaviour, and reckless driving. 

• Predominantly Inattentive 

The symptoms of inattentiveness include:

• Appearing not to listen, even when spoken to directly
• Having difficulty following through on instructions
• Making careless mistakes, e.g. in schoolwork
• Appearing forgetful or losing things
• Having a short attention span, and being easily distracted
• Being unable to complete tasks that require focus, are tedious or time-consuming
• Having difficulty organising tasks

Mental sluggishness and reduced speed in cognitive processing are commonly observed with the predominantly inattentive type. The chief complaint is usually about academic problems and is not usually observed until 8 or 9 years of age. Like impulsiveness, inattention persists throughout life and is seen in cognitively demanding roles and tasks. 

• Combined Presentation 

This is a mix of hyperactive/impulsive symptoms and inattentive symptoms.

Causes 

There may be an interplay of various factors:

• Genetic 
  • There is up to 75% risk of developing ADHD if one has first-degree relatives or a twin with ADHD.
• Neuroanatomy (problems with the central nervous system during key moments in development)
  • Neuroimaging studies have shown that brain metabolism in children with ADHD is lower in the areas of the brain that control attention, social judgment, and movement.
• Environmental 
  • Ongoing research has suggested dietary associations e.g. food additives, refined sugar intake, food sensitivity, various fatty acid deficiencies, iron, and zinc deficiency.
  • Other factors include sleep deficiency, prenatal exposure to tobacco smoke, drugs and alcohol, prematurity, and head trauma in young children. 

Diagnosis

Diagnosis of ADHD is based on a formal assessment by a child psychiatrist or a mental health physician. Information is obtained from different sources/authority figures in different settings e.g. parents, and teachers. Certain tests may be done to rule out other conditions, and to test intelligence and specific skill sets.

To be diagnosed with ADHD, your child must have:

• ≥6 symptoms of hyperactivity and impulsiveness, or ≥6 symptoms of inattentiveness
• been displaying symptoms continuously for ≥6 months
• started to show symptoms before the age of 12
• been showing symptoms in at least 2 different settings – e.g. at home and school, to rule out the possibility that misbehaviour is just a reaction to certain teachers or parental control
• symptoms that make their lives considerably more difficult on a social, academic, or occupational level
• symptoms that are not just part of a developmental disorder or difficult phase, and are not better accounted for by another condition

For diagnosis in adults, the criteria are: 

• having ≥5 symptoms of hyperactivity and impulsiveness, or ≥5 symptoms of inattentiveness
• presence of symptoms since childhood, as it is currently thought that ADHD cannot develop for the first time in adults 
• symptoms have a moderate impact on different areas of life, such as:
• underachieving at work or in education
• reckless driving
• difficulty making or keeping friends
• difficulty in relationships with partners

Treatment 

ADHD is best treated with a combination of behaviour therapy and medication. For preschool-aged children, however, behavioural intervention is recommended as the first line of treatment before medication is initiated.

Typical behavioural intervention includes providing rewards and meting out consequences to encourage desired behaviour. Proper training, strong parental involvement and school-based intervention will ensure activities and guidance are developmentally appropriate for ADHD kids. 

Social skills training also helps ADHD kids learn how their behaviour affects others, how to comprehend non-verbal language, self-awareness strategies, and even basic turn-taking or sharing of space and materials. This will better enable them to form friendships and conduct relationships with others appropriately.

In addition, it is essential to adopt a healthy lifestyle:

• Eat a healthy balanced diet including plenty of fruits, vegetables, and whole grains and choose lean protein sources.
• Engage in daily physical activity based on age e.g. in children and adolescents aged 6 to 17 years old, encourage aerobic and muscle/bone strengthening exercises for at least 60 minutes, 3 days a week.
• Limit the amount of daily screen time from TVs, computers, phones, and other electronics. Studies suggest that instantaneous feedback and rapid turnover of information from excessive digital media will further hamper the normal development of sustained attention and impulse control.
• Get the recommended amount of sleep each night based on age e.g. 9 to 12 hours daily for school-going children aged 6 to 12 years old

Before starting pharmacotherapy, a comprehensive cardiovascular workup and history should be completed to examine potential cardiac risks and their association with stimulant medications. These medicines cannot cure ADHD but may help sufferers concentrate better, be less impulsive, feel calmer, learn, and practise new skills. Medications are only suggested in children at least 6 years old. It is also important to establish the baseline of vital signs, height, and weight. Side effects of medications such as weight loss, insomnia, and tics should be discussed. 

For ADHD adolescents and adults, if there is a history of substance use in the patient or in the household, drugs with less potential for abuse should be considered instead.

Conclusion

Children with ADHD may struggle with poor performance in school, troubled relationships and low self-esteem. Symptoms sometimes abate with age, but some people never completely outgrow their condition. While treatment is not curative, it can make symptoms more manageable. Learning coping strategies with the behavioural intervention will render ADHD sufferers better able to comply with societal norms and assimilate better into the community. Thus, early diagnosis and treatment are imperative.