Understated ADHD/ADD in Children

A Story From Field

Observation

During one of my initial school visits, I observed a student, let’s call him Kiran (name changed for privacy), running around the classroom. He was noticeably active, moved constantly between other children and occasionally glancing towards me and my colleague.

It seemed to me as if he was trying to get our attention.

For some reasons I had this thought that Kiran may have chances of  ADD/ADHD. So I asked about him along with few other randomly chosen children. Kiran was a student of class 4 and upon checking his attendance register he appeared to be irregular in class. Further, I analysed his learning profile maintained by his teacher. He had not moved even a single step in his learning ladder. However, to my surprise his notebooks displayed impressively neat handwriting. I inquired what does Kiran do in the classroom and the teacher described that he writes into his notebook, often copying from other books. He doesn’t prefer to copy from the blackboard.

(Students lacking essential foundational Literacy and Numeracy skills receive special classes through Vidyasathi Program of Gram Vikas Trust. I support Vidyasathi teachers in this remedial program by providing resources, teaching strategies etc. to bring program improvements. Among these students is Kiran, from a government school in Vagra Block, Bharuch District, Gujarat)

Intervention

I started researching and learning about ADD/ADHD and after 4 weeks I went back to the same classroom. Kiran was absent on the day, so I decided to discuss with the teacher about him. I started with asking his opinions on Kiran’s behaviour and his learning styles. According to the teacher, Kiran was not at all interested in learning, his interest only lied in playing. Further, I asked what might be the  chances of Kiran having any learning problems – the teacher responded that Kiran might not have MR (Mental Retardation) as he is intelligent and active in doing most activities apart from learning. Previously I had had discussions with all the teachers and I knew the teachers are not educated about learning disorders or any other psychological and neuro-developmental impairments.

I requested the teacher to respond to my questions about Kiran with some examples from their experiences in the classroom. I took the ADHD Assessment questions from ‘NICHQ Vanderbilt Assessment Scale Teacher Informant.’ (Vanderbilt Assessment Scale is a standardized assessment tool developed by American Academy of Pediatrics and National Institute of Children’s Health Quality. This tool helps in the diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD) in children between the ages of 6 and 12.)

The teacher was really surprised with the questions and responded ‘Very Often/Often’ to 6 out of 9 question from ‘Inattentive Subtype’ and to 4 out of 9 questions from ‘Hyperactivity Subtype.’ To diagnose ADHD/ADD in addition to the Teacher Informant, a Parent Informant also need to be assessed. Also these tests needed to executed by a Medical Professional to eliminate other potential reasons for these symptoms. 

Learnings

• Kiran may or may not have ADHD impairment but it is a must to conduct an ADHD assessment for him. The teacher shared with me possibilities of some other students in the Vidyasathi classroom of same school exhibiting similar symptoms. Therefore, I understand ADHD/ADD is an underestimated psychological disability that profoundly impacts a child’s social and educational attainments. Also it is crucial to assess ADD/ADHD for all children who may have chances of this disorder.
• In India, authorities do not consider ADHD/ADD a disability, leading to a lack of assessments for the condition. There exist a medical team including Psychiatrist, Psychologist, physician and special educators working with Block Education office for identifying, assessing and educational interventions. But they are not dealing with any of Attention Deficit Disorders, Emotional Disorders, Conduct Disorders and Pervasive Development disorders.

  

What is ADD/ADHD ?

ADHD was formally recognized only in the 20th century and became one of the most common mental disorders.  This is a developmental disorder, and it may last through adolescence and until later adulthood. ADD, i.e. Attention Deficit Disorder is a group of symptoms related to the difficulties in children’s attention paying abilities. It has three main features:

• Inattention: not being able to stay focused
• Hyperactivity: excess movement that is not appropriate to the setting or excessive fidgeting, tapping, or talking
• Impulsivity: acting hastily without thinking and in a way that may have high potential for harm.

According to American Psychiatric Association, ADHD is considered a chronic and debilitating disorder and is known to impact the individual in many aspects of their life including academic and professional achievements, interpersonal relationships, and daily functioning (Harpin, 2005). ADHD can lead to poor self-esteem and social function in children when not appropriately treated (Harpin et al., 2016). Adults with ADHD may experience poor self-worth, sensitivity towards criticism, and increased self-criticism possibly stemming from higher levels of criticism throughout life (Beaton, et al., 2022).

ADD/ADHD symptoms can vary for each individual; it can range from mostly poor attention to mostly hyperactivity or impulsivity, and can be a combination of both. Also, Undifferentiated Attention Deficit Disorder (ADD) children have a higher likelihood of being undiagnosed or ignored, as hyperactivity or impulsivity are not visible in them. Children with ADHD experience differences in the development of the brain and brain activity. ADHD affects the ‘executive function’ of the brain, and the brains of these children are 3–4% smaller than others. Executive functions help to get things done, such as organizing and regulating, managing emotions and actions, remembering and paying attention, etc. 

Perspective on ADHD Prevalence

According to WHO it affects 5-8 % for children. In United States as per ‘National Institute of Mental Health‘ ADHD affects more than 11 % of children. There is huge gap in ADHD studies in India context compare to the United States, but from various studies it ranges from 1.6 to 14 %. Male children exhibit a higher prevalence compared to female children.. Also prevalence of ADHD is higher in 9-10 year old and in children of lower socioeconomic class. The most common type of ADHD was ‘Inattentive Type’. A recent study reveals that adult diagnosed with ADHD seem to have 2.77 fold times greater risk of having Dementia in future life.

While the exact prevalence of ADHD in India remains understudied, existing research suggests a significant impact on children and adults, highlighting the need for increased awareness, diagnosis, and support systems.

Importance of ADD/ADHD Diagnosis and Intervention

ADHD effects the daily activities like work, academics, hobbies, play, memory etc. and relationships like friendships, relation with parents or teachers etc. It is impossible to bring improvement in learning and management of emotions or relations of an ADHD person without addressing the psychological problems/symptoms first. Without a diagnosis, a child with ADHD may be mislabelled as naughty and irresponsible, facing blame and punishment for their behaviour. Their behaviour can worsen with punishment. If children with ADHD lack care and support, they may drop out of school. Additionally, children with ADHD tend to experience more accidents and injuries of all kinds compared to those without ADHD. Also, during teenage they are likely to engage in impulsive risky behaviour like substance use and unsafe activities.

There is no cure for ADHD but treatment can help to control the symptoms. Especially early interventions can bring the severity of symptoms much lesser and improve the attention and management skills. Therefore, the earlier ADHD is diagnosed, the better treatment can be provided. 

Diagnosis and Treatment

There is no lab test for diagnosing ADHD, observation and understanding from Parents and Teachers is the only way available. The symptoms must be present before 12 year, minimum 6 persistent symptoms of inattention or 6 symptoms of hyperactivity or impulsivity must be present in two or more setting (school/friends and home). Also these symptoms must be present for at least 6 months. Some of the symptoms include, not paying attention to details, difficulty in sustaining attention in plays, tasks, conversations etc., losing focus or getting side-tracked easily, forgetting about daily activities, an inability to play or engage in hobbies quietly, having difficulty to wait in turns, intruding on others while they are conversing, answering before finishing the question etc.

Treatment of ADHD has to be the teamwork between a Psychiatrist, a Psychologist, a Special educator/teacher and the Parent. This includes Medication, Psycho-Therapy, Education and Training, as well as Parent Education. While not all children with ADHD require medication, for many, it is essential. Medications can decrease hyperactivity and impulsivity, enhance the child’s ability to focus, work, and learn, as well as improve their physical coordination. It is not practical to adopt a medication only treatment for ADHD. Psycho-therapy is essential for regaining their emotional and mental strength. Education and training in school and home must be adopted on basis of ‘Accommodations’ (a list of things based on strength and weakness of each child).

Conclusions

Scholastic backwardness in children like Kiran can result from ADHD, making it crucial to do ADHD assessments for effective and early intervention. Educating teachers on various psychological, physiological, and developmental disorders that can impact student learning is necessary. If diagnosed, parents must receive education, and a collaborative treatment plan should commence as early as possible. A proper system needs to be developed by educational department to address diagnosis and treatment of ADHD. There exists a huge gap of more relevant studies on ADHD among the primary school students in India. 

References

1. Joseph, V. V. Know Your Child. ALDI Learning Centre, 2014.
2. Suthar N, Garg N, Verma KK, Singhal A, Singh H, Baniya G. Prevalence of Attention-deficit hyperactivity disorder in primary school children: A cross-sectional study. Journal of Indian Association for Child and Adolescent Mental Health. 2018;14(4):74-88. doi:10.1177/0973134220180405
3. WHO-EM/MNH/214/E
4. ADHD Diagnosis in Adulthood Increases Risk of Dementia in Later Years: Study. India Today, 18 Oct. 2023,
5. https://www.psychiatry.org/patients-families/adhd/what-is-adhd