I frequently got referrals from teachers or parents with a lively 5-year-old, who runs around a classroom in kindergarten, "has this child got ADHD or ADD?"
Well, ADHD can not be diagnosed through phone call or a glance at the child? It is a neuro-developmental disorder, and I do need to go through the usual clinical approach: taking a good history, physical examination, in some children, I may have to do detailed developmental and psychometric assessment, plus investigations, e.g. blood tests and radiology imaging.
It is estimated that ADHD/ ADD affect 5-10% of school-going children depending in areas, therefore its burden can not be ignored. The main symptoms of ADHD/ADD are poor attention, hyperactivity and impulsivity. However, it is a neuro-
developmental disorder, therefore it is difficult for clinician to determine until the child is 5-6 years old. Why? Because attention and impulse control is a also milestone, as you will not expect a 6-month-old baby to walk till 9-18 months of age, you can not expect a child to learn to sustain his/ her attention more than 5 minitues till 4-6 years of age. It is the way our brain mature and develop.
The main symptoms of ADHD/ ADD include:
- Poor attention span
- Hyperactivity
- Impulsitivity
Not all children have all the symptoms. Some can just have problems with poor attention (in my experience, girls seem to more attention problem than boys), while others are mainly hyperactive.
- Children with poor attention span can appear forgetful, distracted, not seem to listen, disorganised, take ages to start doing things and then when they do, they rarely finish it. Parents often describe them unable to pay attention while being given instruction, and unable to tasks.
- Children with hyperactivity seem restless, fidgety, and "always on the go". These children always give teachers grief as they are unable to sit still in the class, and want to move around but without any purpose, which is different from naughty children who move with plan/ trick in mind.
- Children with symptoms of impulsivity do things without thinking. They have difficulty waiting for their turn in games, or in a queue, and interrupt people in conversation.
Children with ADHD have the symptoms in all the settings, i.e. they continue to be hyperactive anywhere- in all the classes and at home. But naughty children will behave when being disciplined properly.
As in all clinical setting, Paediatricians will take a detailed history first. We do know certain risk factors, such as early birth problem (birth asphyxia/ prematurity), maternal smoking/ illness, family history and others may contribute to ADHD. Of course, like clinicians, I do not want to miss common childhood problem, like iron deficiency anaemia which may have explained the poor attention, or brain tumour that contribute to headache and poor attention, or even epilepsy that explains the day-dreaming. There is a long list of checklist in my head when I take history, but we encourage parents to elaborate the story in their time. Then come the usual physical examination to exclude the possibility of any organic illness that may explain the behavioural problems.
Currently, there is no specific blood test or imaging that can confirm or exclude ADHD. Functional brain imaging has demonstrated the deficit in frontal lobe of ADHD brain, but those are mainly used for research purpose. However, clinicians may go on and do investigate if they think there may be underlying organic causes. Some children with ADHD/ ADD may have other problems such as reading disorder, autism, conduct disorder, tics, etc. These have to addressed carefully as well.
For highly suspected case of ADHD/ ADD, we will usually do a detailed developmental assessment, using tools like Griffith assessment, and questionnaires with scores, e.g.
NICHQ Vanderbilt Questionnaire and
Conner 3. If the assessment results and scores are highly suggestive of ADHD/ ADD. We will counsel for medication treatment and behavioural therapy.
Medication:
The mainstay of medication is methylphenidate, which is a stimulant that has been used in Western countries for many years. There are newer generations of medication developed since, but in Malaysia, only methylphenidate and slow released methylphenidate are available. There are other second-line treatment we can consider if methylphenidate fail to work, such as atomoxetine. Hopefully this will change in the next few years.
The common side affects of methylphenidate and medications in the same class are decreased appetite, and insomnia. Therefore I usually advise parents to give methylphenidate after meals, and not to give the medication after 3pm. The normal methylphenidate effect will wear off after 6-8 hours, and the long-acting should wear off after 12-14 hours. A very rare side effect is stupor, which we will stop the medication immediately. It is a controlled medicine, and so its use must be under strict clinician's supervision.
The medication is only licensed for use in children above 6 years of age.
Behavioral therapy
I usually refer the children with ADHD/ ADD to clinical psychologist for behavioral therapy. I always emphasize that we need to teach children how to organise their own scattered mind and behaviour once the medication action kicks in. The other purpose is for family to learn to approach this in a more structural way. Clinicians are usually not very well versed in these, so we ask our psychologist colleague to help.
There are many other ways a family, school and even society can change to help the child with ADHD/ ADD:
- Give simple and short instructions. Stand near them, look at them in the eys, and tell them slowly what you want them to do.
- Praise the child immediately when he/ she has done what is required, no matter how small it is.
- Checklist helps. Tasks can written as a list, and put it somewhere when it can be seen clearly.
- Daily routine and timetable
- Break long and complex tasks into small parts. For example, home work can be split into small time spans of 15-20 minutes, with break in-between.
- Healthy and balanced diet. Avoid additives and processed food. Some food additives and food colouring are known to make children hyperactive, such as sunset yellow (E110), quinolone yellow (E104), carnoisine (E122), allura red (E129), tartrazine (E102) and ponceaus 4R (E124). If parents do notice certain food worsen the symptoms, they should discuss these with doctors or specialist dietician, and avoid the food.
- Make exercise a daily routine. Starting 2-year-old, children are recommended to have 30-60 minutes of moderate physical activities daily. This will improve blood supply to brain, and help to improve concentration. Recommended activities include swimming, badminton, etc.
- Limit multimedia and TV screen time to <2 hours a day. Research has showed prolonged usage of screen time is associated with obesity, poor school performance, and poor sleep. Do limit screen time to <2 hours a day, and control what children do on screen time. For example, select TV program, and watch with them.
The suggestions on website and support-groups are endless. Do one thing at a time. Be patient, and love the child. They will blossom, many of my patients with ADHD/ ADD continue to surprise me with their behaviour and school performance. Many have failed all the subjects in school exam, with medications/ therapy/ efforts from family, they succeeded to gain A/A+ in SPM/ STPM, and went onto further education.
