I was at a friend’s place when I bumped into his child who was restlessly running around. He could hardly wait for his turn. He was constantly in motion as if driven by a motor. I was told that he was disrupting class, interrupting others, and, in general, was unable to focus on things. The child’s behaviour was termed unruly. My friend was at his wits’ end.
I had a long chat with my friend. I asked him if his son had seen a psychiatrist. As expected, there was a hint of surprise on my friend’s face. I had to explain that this could possibly represent an ongoing pattern of inattention or hyperactivity-impulsivity, which was interfering with his son’s functioning and development. This was attention deficit hyperactivity disorder, or ADHD as known in medical parlance.
Clinical manifestations
People with ADHD experience an ongoing pattern of inattention, hyperactivity, and impulsivity, with consequent disruption in the spheres of social, interpersonal and occupational life. The individual will have trouble staying on a task as a result of poor focus and disorganisation. This does not signify defiance or lack of comprehension, but is the result of a complex brain disorder. A hyperactive individual constantly moves about even in situations where it is deemed inappropriate. Alternately, he or she could fidget, tap or talk excessively. An impulsive individual may act without thinking or may have difficulty in exercising self-control. This may manifest as a need for immediate reward or as a difficulty in delayed gratification. An impulsive person interrupts others, or makes major decisions without considering long-term consequences.
People with ADHD may often miss or overlook details. They make seemingly careless mistakes at work, have difficulty in sustaining attention, find it hard to follow through instructions, start tasks but lose focus and get easily side-tracked. They seem distracted when spoken to, avoid tasks that need sustained mental effort, lose things, and, in general, are forgetful about daily chores or keeping appointments. All these are various ways in which a core symptom of ADHD may manifest clinically.
People with hyperactivity-impulsivity may fidget and squirm while being seated, abruptly leave their seats in situations where they are expected to be seated, are unable to engage in hobbies quietly, talk excessively, answer questions fast, finish other people’s sentences, have difficulty waiting for one’s turn, and interrupt others in conversations, games or activities.
ADHD symptoms can appear as early as between the ages three and six years, and can continue through adolescence and adulthood. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before age 12. ADHD symptoms can be mistaken for emotional or disciplinary problems as had happened with my friend’s son. Worse, the diagnosis may be entirely missed in children who primarily have only symptoms reflecting inattention. Adults with undiagnosed ADHD may perform poorly academically, have problems at work, and in interpersonal relationships.
Risk factors
ADHD predominantly affects males, with a male to female ratio of 3-4:1. Multiple lines of evidence point to strong genetic influence in ADHD. Environmental stressors may change the brain structure and function, and can interact with inherent genetic vulnerability to cause differential effects. Low birthweight, prematurity, obstetric complications, utero exposure to maternal stress, tobacco, alcohol, illicit drugs are associated with ADHD, but may not have a causal effect. Maternal smoking during pregnancy remains an important risk factor.
Parent training
These are educational interventions disseminating information on ADHD to carers, and is typically delivered in groups. Parents are educated about strategies to target and monitor problematic behaviours, encouraged to liaise with teachers, use positive reinforcement, and plan ahead to anticipate problems.
Cognitive behavioural therapy
Persons are encouraged to identify dysfunctional patterns of thinking and behaving. They are then equipped with skills to improve self-esteem, and to deal better with emotional and social difficulties.
Cognitive training
This modality targets specific domains such as attention, working memory, inhibitory control, and aims to improve the functionality of these domains. Studies show that although this improves working memory, it has little effect on the core symptoms of ADHD.
Medication
Strong evidence supports the efficacy of drugs for ADHD in reducing the core symptoms over a period of one year. The most common type of medication used is called a ‘stimulant.’ Stimulants increase the brain chemicals, dopamine and norepinephrine, which are thought to be dysfunctional in ADHD, and thereby allow better thinking and focus. Amphetamine and methylphenidate are the most effective stimulant drugs for ADHD with a response rate of 70 per cent. Amphetamine is a controlled substance as a result of the United Nations decree in 1971. Many countries class it alongside drugs like heroin, and thus it needs specialist advice and prescription.
ADHD is a heterogenous condition and can persist well into adulthood. Sixty per cent of affected children have significant ADHD-related impairments as adults. ADHD drugs, especially in the short-term, represent some of the more effective drugs in psychiatry, and, perhaps, in general medicine with a good safety profile. Given these considerations, there should not be any stigma to opt for drug treatment for a condition that can very much be controlled.
―The author is senior consultant psychiatrist at Manas Institute of Mental Health in Hubli, Karnataka.