Driven to distraction: recognizing and coping
with ADHD in children
by Dr Joel D. Lazaro, MD, DPPS, FPSDBP
There was a time when children who behaved badly or couldn't seem to pay attention
in school were not considered to have a medical problem. Their difficulties were
blamed on poor parenting, poor teaching or inherent flaws of character and intelligence.
Today, many parents and educators have heard a great deal about ATTENTION DEFICIT
/ HYPERCACTIVITY DISORDER(ADHD) and they are likely to turn to health care professionals
for help with a problem child.
What is AD / HD?
AD / HD (American Psychiatric Association, 1994) is a name given to a cluster of
behavior manifesting as persistent inattention and/or hyperactivity and impulsivity
that is more frequent and severe than typically observed in children at a comparable
level of development. AD / HD is not a unitary disorder as it is now divided into
three subtypes:
• AD / HD, predominantly Inattentive type
• AD / HD, predominantly Hyperactive-Impulsive type
• AD / HD, combined type
These subtypes take into account that some children with AD / HD have little or
no trouble sitting still or inhibiting behavior, but may be predominantly inattentive
and, as a result, have great difficulty getting or staying focused on a task or
activity. Others with AD / HD may be able to pay attention to a task but lose focus
because they may be predominantly hyperactive-impulsive and, thus, have trouble
controlling impulse and activity. Majority, however, will have significant symptoms
of all three characteristics.
What are the characteristics of a child with
AD / HD?
We professionals who diagnose AD / HD use the diagnostic criteria set forth by the
American Psychiatric Association (1994) in the DSM IV. As what was mentioned in
the definition, features associated with the disability are inattention, hyperactivity,
and impulsivity.
Inattention
A child with AD / HD is usually described of having a short attention span. In fact,
it is the cardinal feature of AD / HD. The process of paying attention to a task
involves getting tuned into a task and remaining focused on it until the goal is
achieved. How much attention a child pays to a task depends upon the developmental
level of the child as well as the nature of the task. The normal attention span
for a task is roughly around 3-5 minutes per year of age. A typical preschooler
for example would be able to concentrate on a task for about 25-30 minutes. More
often than not, children will effortlessly pay attention to a task if it is pleasing.
AD / HD children would in fact be able to focus on TV / video games because they
derive instant pleasure and gratification from them. (process called reinforcement).
These activities also tend to flood the senses with so much input that other distractions
cannot enter the brain. The litmus test of AD / HD is the inability to focus on
a task that does not reward the children immediately e.g. homework.
Hyperactivity
Although generally considered to be the most salient and visible feature of AD /
HD because of its obtrusiveness, this symptom is not present in all AD / HD cases.
Hyperactivity may take different forms and presents in the following patterns: a
macro form, in which children are agitated, restless and move constantly as if driven
by a motor; a micro form, in which children squirm and fidget in their seats; and
a motor mouth type, in which children are garrulous, talking excessively, often
interrupting others (Gupta, 2000). Children at some point in their lives may exhibit
hyperactive behavior but the essential difference in AD / HD children is the inability
of the child to control the hyperactive behavior and its irrelevant and non-productive
nature.
Impulsivity
Children with AD / HD also acts impulsively signifying deficiencies in self-control,
monitoring and reflection. The tendency to act impulsively rather than reflectively
is due to poor working memory, resulting in poor processing of incoming information.
The working memory cannot simultaneously hold information about prior experience
with an action and its likely consequence. Simply stated, forethought or afterthought
are absent. The AD / HD child fails to delay gratification and wait for his turn.
How does a normally active, exuberant child differ
from an AD / HD child?
It is difficult to draw a clear-cut line between normal and abnormal child behavior.
All children are different and behave along a spectrum that ranges from normal to
abnormal. Some children are noisy, some calm, some brash and others polite, some
are dynamic while some are passive.
Diagnosis of behavioural disorders does not depend upon telltale signs that can
be seen, touched, or heard. It is inferential based on upon constellation of observed
behaviours. The following questions maybe used to validate the presence of AD /
HD:
• Are the symptoms of inattention and/or hyperactivity-impulsivity present with
onset less than seven years of age and for more than six months duration?
• Are the symptoms of inattention and/or hyperactivity-impulsivity discrepant with
the developmental level of the child?
• Are the behavior problems significant in two or more places? (e.g. home, school,
daycare)
• Are the behavior symptoms significant enough to cause dysfunction in the life
of the child? (e.g. academic performance, social relationships)
• Does the child have other mental health disorders to account for the behavior
symptoms exhibited? (e.g. mental retardation, autism or schizophrenia)
If the answer to questions 1 to 4 is YES and number 5 is NO, then a diagnosis of
AD / HD is probable. Referral for more extensive evaluation by a competent professional
should then be made to ascertain the diagnosis.
What is the epidemiologic profile of AD / HD?
AD / HD is a common disorder in children, with an estimated frequency of 5% (range
2-9%) (Barkley, 1990) Males are diagnosed three to seven times more often than females,
depending on whether they present to a specialty clinic or primary care clinic.
There is familiar pattern of occurrence, with 30% of first degree relative of children
with AD / HD also being affected (Goldstein, 1990). Siblings are at particularly
increased risk, three-fold higher for sisters and five-fold higher for brothers.
AD / HD occurs in persons of all races and socio-economic classes.
What are the academic implications of having AD / HD?
Many children with AD / HD experience the greatest difficulty in school where demands
for attention and impulse/motor control are virtual requirements for success. AD
/ HD does not interfere with the ability to learn, however, it does wreak havoc
on performance. AD / HD therefore is an educational performance problem. Generally,
AD / HD will affect the student in one or more of the following performance areas
(Fowler, 1994):
• starting a task
• staying on task
• completing tasks
• making transitions
• interacting with others
• following through on directions
• producing adequate and quality work consistently
• organizing multi-step tasks
When little or nothing is done to help the AD / HD child improve his performance,
over time he will experience academic underachievement. The academic underachievement
is caused by the cumulative effects of missing important blocks of information and
skill development that build up from lesson to lesson and from one school year to
the next.
What is the social impact of AD / HD?
Most children with AD / HD have problems understanding social context and mood and
are unable to match their behavior accordingly. This in a way make them socially
inept. These children may appear intrusive, aggressive, defiant, tactless, and lacking
in social grace. These behaviours cause conflicts with their siblings, playmates
and classmates making them unpopular, and lead to social isolation and rejection.
How is AD / HD treated?
No cure or 'quick fix' exists to treat AD / HD. The symptoms, however, can be managed
through a combination of efforts. This is called multi-modal management approach.
This approach consists of combined interventions like behavior modification, family
education/training and counselling, use of medication as well as appropriate education.
What is the effect of DHA in the brain and its
potential role in the treatment of AD / HD?
Docosahexaenoic acid or DHA, is the primary structural fatty acid found in the brain
and retina. It is a long chain polyunsaturated fatty acid (Omega-3 acid), one of
the two principal type of unsaturated fats found in the diet. DHA is obtained from
fish, egg yolks and marine algae. DHA is critical for brain development during pregnancy
and early childhood. It is essential for the structural or anatomical development
of the brain as it is incorporated in the phospholipid of nerve cell membranes as
well as source of neurotransmitters like dopamine. These structures are ultimately
responsible for rapid and efficient transmission of nerve impulses.
Interest in the relationship between fatty acids and AD / HD dates back the time
of Hippocrates 2,500 years ago. For a condition similar to AD / HD, Hippocrates
prescribed prescribed barley (glutten-free) rather than wheat bread, fish (rich
source of fatty acids like DHA) rather than meat, watery drinks and many natural
and diverse physical activities (Baumgaertel, 1999). Mitchell (1987) in a study
comparing the clinical and biochemical differences of AD / HD children and controls
found lower levels of Omega-3 DHA, Omega-6 DGLA and arachidonic acid. Stevens et
al (1996) found that boys with lower Omega-3 fatty acids had more health, behavior
and learning problems compared to those with high Omega-3 fatty acids. In a carefully
conducted study, Stevens (1995) subsequently found lower levels of omega-3 DHA in
boys with Attention deficit/hyperactivity disorder. Currently, a randomised, double
blind, controlled study on long chain polyunsaturated in children with AD / HD is
ongoing led by Burgess et al (2000).
What is a physician's role in improving the quality
of life of the AD / HD child?
AD / HD is a common and difficult problem for affected children and their families.
Indeed it is a life problem, not just a school problem. The primary care physician
should therefore exercise patience and thoroughness during the initial evaluation
of a child suspect for AD / HD. Appropriate referrals to specialist maybe needed
to confirm the diagnosis and to carefully plan treatment and/or management. Finally,
helping the child and parents to understand and cope are just as important to provide
an effective solution to the problem.
Advise to parents of children with AD / HD
• Become proactive. Learn and understand the condition
• Seek competent professional advise and help
• Appreciate the positive qualities of the child
• Learn appropriate discipline strategies to deal with difficult behaviours
• Join support groups
• Take time for alone for yourself or with your spouse
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References:
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 4th ed., Washington, DC, 1994; 78-85.
• Gupta, V.A Closer Look at ADD/ADHD. Exceptional Parent, Vol. 30, August 2000,
74-81.
• Barkley, R. Attention Deficit/Hyperactivity Disorder: A Handbook for diagnosis
and treatment. New York: Guilford Press, 1990; 61-2, 95-105.
• Goldstein, S. Managing Attention Disorders in Children; a guide for practitioners.
New York: Wiley; 1990; 37.
• Fowler, M. Attention Deficit/Hyperactivity Disorder. NICHCY Briefing Paper October
1994.
• Baumgaertel, A. Attention deficit and Hyperactivity Disorder. Pediatric Clinics
of North America. 1999. Vol. 46; 977-992.
• Mitchell, E. Clinical Characteristics and serum Essential Fatty Acid levels in
Hyperactive children. Clinical Pediatrics, 1987, Vol. 26; 406-411.
• Stevens, L.; Zentall, M. Omega-3 Fatty acids in Boys with Behavior, Learning and
Health problems. Physiol Behav, 1996, Vol. 59; 915-920.
• Stevens, L. Essential Fatty Acid metabolism in Boys with ADHD. American Journal
of Clinical Nutrition, 1995, Vol. 62 No. 4; 761-768.
• Burgess, J. Long Chain polyunsaturated Fatty Acids in Children with AD/HD. American
Journal of Clinical Nutrition, 2000, Vol. 71 (suppl) 327-330.