Symptoms of ADHD  | Diagnosing ADHD/ADD

Attention Deficit Disorders has become a catch phrase in educational circles. When I started my clinic more than 10 years ago, a diagnosis of ADD resulted in puzzled and suspicious looks from parents and teachers alike. However, the pendulum has swung the other way. It has become a substitute for any hyperactive child. Parents and even some professionals make this diagnosis by ticking off a number of symptoms that they may have observed in the child. This has led to misdiagnosis and misuse of medication. In our fast track lives, a quick diagnosis with a quick solution has replaced careful clinical assessment and multimodal interventions.

For the novice reader, ADD stands for Attention Deficit Disorder, a common mental disorder seen in 6 to 20 percent of children in different countries. I hesitate to call it a mental disorder because it’s signs and symptoms are not pathological. It is a dimensional not a categorical disorder i.e. many of the symptoms may be seen in the average child or person but in a person with ADD they are severe enough to cause problems in education, behaviour and or social fields.  Whilst diagnosing ADD, this has to be kept in mind.

It must be remembered whilst diagnosing ADD/ADHD that it is a complex disorder not a checklist disorder. It can start insidiously wherein subtle signs are missed in early childhood because they are mainly related to inattention. They may also present with a bang in a hyperactive child. However, as the child matures the hyperactivity may be replaced by some fidgetiness and the student presents only with inattention. In many cases these children may even present later in life if they are very bright and have coped till higher education e.g. in high school or even college.

 ADD/ADHD can mimic other problems. A child traumatised by a mixture of unrealistic expectations, harsh punishments and inappropriate curriculum can present with inattention and restlessness. Anxiety, especially posttraumatic stress disorder and separation anxiety can also cloud the picture. Other disorders like Juvenile Bipolar disorder or Asperser Syndrome wherein hyperactivity is also a symptom can complicate the diagnosis.  Language Disorders not only occur commonly with ADD but can also masquerade as ADD. English as a second language is a common situation for many bilingual and trilingual children. Inattention and fidgeting can be seen in these children as they struggle to understand English instructions in the classroom. Hence whilst diagnosing ADDS other similar conditions must be kept in mind.

ADD also has a wide spectrum of clinical presentations – from an inattentive, quiet and withdrawn child (Inattentive ADD) to a restless, impatient and impulsive one. In fact Dr. Amen has described 6 types of ADD each having their own brain images on the SPECT machine. No two children with ADD are same. Co-morbid conditions like anxiety and depression can change the clinical picture. Language difficulties, either spoken or written along with Specific Learning difficulties complicates the clinical presentation.  Environmental conditions also affect the ADD child. Highly mobile expatriate societies as those seen in Dubai, Hong Kong and Brussels see a higher rate of ADD in their student population. One of the reasons being changing school systems, anxiety with relocation and other environmental factors that aggravate a mild predisposition to ADD to a blatant one.

The other feature that can confuse parents and teachers alike is that ADD/ADHD is not an absolute deficit. This means that symptoms can fluctuate. A child with ADD can be well focused in a subject he enjoys but can become very restless and difficult in those he doesn’t. Thus an ADD child can sit and work on a computer for hours but cannot sit and read (even if he is good at reading). Some readers may feel that this is true of many people. However, those without ADD can make themselves pay attention to uninteresting topics when they know they have to.  Whilst making a diagnosis of ADD this very important fact should be remembered. Also many ADD children may not be educationally impaired and present only with behavioural problems, especially in the primary grades.

Early diagnosis of ADD and multimodal intervention is the key. Research has shown that ADD/ADHD is a life span disorder that can be seen to follow the ADD child into adulthood.  Untreated ADD can lead to many complications. From emotional disorders to psychiatric disorders, from school failure to school dropouts and from behavioural problems to felony, a child with ADD can develop many problems.

Diagnosing ADD requires of gathering information about the child from the teachers, parents and from the child as well. Again this is a process that requires sensitivity, time and patience. Asking questions without understanding and compassion can result in defensiveness and thus incorrect information. Use of behaviour charts are necessary but should be done in the second session.

An educational and psychiatric evaluation forms an important part of the diagnostic process to rule out similar conditions and to evaluate co-morbid conditions.

To conclude ADD is a complex disorder which impacts the person life long. Diagnosis of ADD requires time and use of standardised tests. Input from parent, teachers and student is essential. Understanding the nature of ADD is crucial and that it can mimic or be mimicked is necessary know before making a diagnosis of ADD.

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