ADHD – the four letters that are enough to strike terror into the hearts of most parents. After all, the condition is thought to affect one in ten children, mostly boys, leading to poor academic achievement, social isolation, and unhappy kids. But “fear is a toothless dog” goes the saying, and you only need to take a peek inside the jaw to feel relief. So let’s look inside the jaws of attention deficit and hyperactivity disorder (ADHD), and see if the stigma can be lessened once we have investigated the ins and outs of this misunderstood, routinely overdiagnosed, often mismanaged – and yet treatable – condition.
What is ADHD?
Psychiatrists use their Diagnostic and Statistical Manual (DSM) to help them classify and diagnose mental illnesses and conditions. In the fifth edition of the DSM, ADHD can be diagnosed if children show six of the following symptoms, from either or both the inattention and the hyperactivity and impulsivity criteria, by the time they are 12 years old:
- An abnormally short concentration span.
- A frequent resistance to sustained mental effort, especially with boring or repetitive tasks.
- Easily distracted. Marked forgetfulness. A tendency to lose things easily and frequently.
- Difficulty organising tasks and poor planning.
- Not listening properly to given instructions.
- A tendency to rush work, giving poor attention to detail and making frequent but careless mistakes.
- Often not completing tasks.
- Constantly on the go, as if driven by a motor.
- Runs about or climbs on things excessively.
- Restless, unable to stay seated for even short periods. Fidgets excessively. Excessively talkative. Plays loudly.
- Often interrupts or intrudes on others.
- Cannot wait his turn.
- Blurts out answers before the question is completed.
It is quite normal to display “first-year medical student” syndrome and diagnose your child on the spot as you read this list, especially with vague-sounding symptoms such as these. All children do display these behaviors, age appropriately, from time to time. So bear in mind that these symptoms must cause significant impairment to your child’s daily functioning, and must not be better explained by another mental disorder – which is important when you consider 40 percent of boys with ADHD also have an oppositional defiant disorder (a persistent pattern of rebellious behavior).
Children with ADHD are impaired in their schoolwork as well as in their social functioning and are distressed and demoralized. Still, judging these symptoms is to some extent subjective, acknowledges Johannesburg psychiatrist Dr. Brendan Belsham in his excellent book, What’s The Fuss About ADHD? (2012), which is a must-read if you suspect your child may be affected. A good doctor will seek a thorough assessment from parents, teachers, and other significant adults, as well as from the child himself. Furthermore, a diagnosis needs to be made by a qualified person. This would be a child psychiatrist, a pediatric neurologist, a specialist neurodevelopmental pediatrician, or a GP with an interest in the condition, says Dr Belsham. They should then assess the child using a rating scale where different evaluators can rank the severity of each symptom.
Genetic or environmental?
ADHD is a polygenic condition. So as opposed to something like cystic fibrosis, which is caused by a single gene mutation, ADHD is caused by a complex interplay of several genes – as well as the environment. Scientists know that neurotransmitters in the brain called dopamine, and to a lesser extent noradrenaline, play a role in ADHD. A variant on the dopamine receptor DRD4 (the 7R allele) interferes with the usually smooth process of releasing dopamine, and re-taking up excess dopamine, in synapses in the brain. Ritalin regulates the amount of dopamine transmitted across synapses or taken up again, and that’s why it is effective in alleviating the symptoms of ADHD.
But while close relatives of an ADHD child have been found to have approximately five times increased risk of having it themselves, that’s not the full picture. Genetic makeup contributes 70 to 80 percent to the observed symptoms of ADHD, which means that shared factors in the home environment can account for a fair sized percentage of ADHD diagnoses – but equally, that the right home environment can also mitigate against ADHD developing in a child. That’s the hopeful bit.
The trick is to figure out, once you know you have the propensity towards ADHD, how to minimize the impact of these genes, and how to make them whisper instead of shout. He lists the following as strong risk factors for a child contracting ADHD: smoking and alcohol consumption during pregnancy, maternal stress, prematurity, and oxygen deprivation at birth, epilepsy, brain infections, HIV/AIDS, and certain congenital and genetic conditions. A recent study by Frederica Perera and others in the journal Plos One linked exposure to polycyclic aromatic hydrocarbons (which are air pollutants) to five times higher risk of developing ADHD. Excessive screen time and obesity have even been correlated with ADHD – although whether this is a cause, effect, or merely cooccurrence is debatable. There is a connection between an insecurely attached child and ADHD.
Is ADHD overdiagnosed?
Though it’s been described by doctors since the early 1900s, before 1980, ADHD wasn’t officially recognized by its current name. Right now in the US, around eight percent of children are diagnosed with the condition. The rate of increase seems sharp, but whether we are getting better at recognizing the disorder, or whether the diagnosis is too easily slapped onto a “difficult” child, is debatable. Either way, you should ensure you consult with qualified professionals before labeling your child.
Is ADHD overmedicated?
Ritalin is an amphetamine-like drug. It was marketed for children in 1963 as a “tonic”. An anecdote in Dr. Belsham’s book tells how the drug was named after the wife of the chemist who synthesized the drug – as she used it before playing tennis. Her name was Rita, so the drug became known as Ritalin. Adderall is a similar amphetamine-based drug. Strattera, or atomoxetine, is the first non-stimulant drug used to treat ADHD.
There is evidence that Ritalin is used as an occasional drug or “study aid” by students. Some professionals have indeed voiced concerns that Ritalin is prescribed too freely among children of high-achieving, ambitious, or wealthy parents, or of parents who demand medical interventions rather than first investigating alternative ways to make the ADHD genes express themselves in that whisper.
Orchids and dandelions
Quoting Thom Hartmann’s book The Edison Gene, Dr Belsham argues that many characteristics of ADHD children – “restlessness, risktaking” – may be discouraged by our school system, but are qualities that are necessary to a percentage of human beings so that humanity as a whole can benefit from explorers and pioneers, challengers to the status quo and drivers of societal change.
“Dandelion children” is a term for resilient children who will achieve their potential and cope in most circumstances. In contrast, so-called “orchid children,” are particularly sensitive to their rearing conditions. Given the right environment, they bloom spectacularly, but if neglected they quickly wither and wilt. Whether good or bad, the environment has a pronounced effect on how they turn out.” Orchid children are at higher risk of ADHD, yet if they are nurtured, they are more likely to “bloom spectacularly” into those discoverers and achievers we need and revere.
ADHD need not doom a child to failure. If you suspect your child has it, get the best diagnosis and treatment you can – and watch him soar.