Rupa Malik couldn't believe her ears when her seven-year-old son, Rohit, started spouting abuses at the drop of a hat. "My husband and I had always taught Rohit the right kind of values -" to respect elders, to be gentle with his peers, to speak softly etc. So when he started exhibiting signs of aggression, I was extremely worried," she rues. Notes also started pouring in from school about his lack of focus in studies. "Teachers complained that he was unnecessarily picking up fights with kids," says Rupa, a homemaker who lives in Delhi's bustling Lajpat Nagar neighbourhood.
Apart from displaying aggression, Rohit also had difficulty concentrating on any single task. He would hold a toy for a few seconds and move on to another one. Rupa and her husband took it as normal behaviour exhibited by children at that age. "He was our first baby and was pampered by the entire family. But when he started abusing and retorting back on being scolded, I knew there was reason to worry," she explains. Driven to frustration, Rupa and her husband didn't know whom to turn to. That's when her father-in-law reminded her of another such case in the family and asked her to visit a specialist. It took time for them to accept that their child needed professional medical help and it was after several months that they headed to Delhi's Vidyasagar Institute for Mental Health, Neuro and Allied Services (VIMHANS). "After several sessions, the psychiatrist told us that he had a condition called attention deficit hyperactivity disorder, or ADHD," says Rupa.
It took a while for Rupa to assimilate the facts thrown at her by the doctor. She had not even known the existence of such a condition, let alone the causes and symptoms. Majority of people across the country share Rupa's ignorance about this neurodevelopmental disorder. "Firstly, we should stop calling it a disease. It's a behavioural disorder that can be treated when diagnosed correctly," says Shivani Aggarwal, consulting psychiatrist, VIMHANS, who has been treating Rohit since October 2012.
Quite often hyperactivity is confused with overactivity. However, experts maintain that there is a fine line between the two. "Hyperactivity affects the overall functionality of the child. For instance, an overactive child will follow instruction. But a hyperactive child will not register the instruction and exhibit disruptive behaviour like breaking toys, fighting with peers, so on and so forth," explains Mumbai-based Anjana Thadani, consulting developmental pediatrician, Learning Disability Clinic, KEM Hospital. Hyperactivity affects the child's play as well as studies as his attention shifts from one incomplete activity to another. "One should refrain from labelling all kinds of 'overactivity' as ADHD," warns K John Vijay Sagar, associate professor with the Department of Child and Adolescent Psychiatry at Bangalore's NIMHANS (National Institute of Mental Health and Neurosciences). So, parents shouldn't jump to the conclusion that their child is afflicted with ADHD just because he or she is noisy, energetic or boisterous.
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"ADHD is a neurodevelopmental disorder with clinical features related to three key areas of inattention, hyperactivity and impulsivity. It is linked to deficits in the functioning of several brain areas, including the prefrontal cortex, the basal ganglia, cerebellum, temporal and parietal cortex. These areas are important to activities that may be impaired in ADHD, such as response inhibition, memory, planning and organisation, motivation, processing speed and attention," explains Vijay Sagar. Furthermore, history of the disorder in parents and siblings is known to increase the risk of ADHD. "Researchers have identified several candidate genes said to be involved in ADHD. However unlike certain genetic disorders, ADHD is not caused due to defect in a particular gene. There are no genetic tests available to predict the exact risk of the disorder," he adds.
Parents and teachers should thus look out for hyperactivity, inattention and impulsivity. If a child is forgetful, loses things too often, spends time daydreaming and doesn't follow instruction, then these are classic symptoms of inattention. Hyperactivity symptoms include restlessness, fidgeting with hands and disruptive behaviour. And if he can't wait for his turn and is extremely impatient, then the child is showing signs of impulsivity. According to the guidelines issued by the American Academy of Pediatrics (AAP), children should have at least six inattention symptoms or six hyperactivity/impulsivity symptoms for a psychiatrist to be able to diagnose ADHD. "And there should be impairment of social activity in at least two settings, be it the school, home or relationship with peers. Children who are generally naughty and overactive may be noisy at home but calm in school due to the presence of an organised structure. But a hyperactive child will be disruptive in every setting," says Aggarwal who maintains that around four per cent of all school-going children in India have ADHD.
According to a press note by AAP, emerging evidence has now made it possible to diagnose and manage ADHD in children from 4 to 18 (the previous guidelines, from 2000 and 2001, only covered children ages 6 to 12). "Treating children at a young age is important, because when we can identify them earlier and provide appropriate treatment, we can increase their chances of succeeding in school," the note quotes the lead author of the report, Mark Wolraich. Indian psychiatrists too believe that treating ADHD as early as possible paves the way for a better future for the child. According to Thadani, the disorder is at its peak when a child turns nine. "These are the peak years of learning as well. So, if the child has low grades at this time due to ADHD, then it's detrimental for his or her future," she says.
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Gautam, 33, found this out the hard way. In spite of being an intelligent child, he just couldn't notch up top grades in school, much to the frustration of his parents and tutors. Having failed twice, he finally decided to drop out of school. It was only when he was 28 did he realise that he could be suffering from a disorder. "I browsed the net and somehow chanced upon information about ADHD. On reading the first-hand accounts, I realised that I too had been exhibiting those symptoms all my life," he says. It was in 2010, at the age of 30, that he decided to go to Aggarwal for treatment. And now his life is much better for that. It is more difficult to diagnose ADHD in adults as one needs to get the past history and school records from parents and teachers. "Although ADHD can't set in adulthood, 50 per cent of the kids who have ADHD symptoms continue to be afflicted with the same even as adults. That's because the symptoms have been missed or not diagnosed during childhood," says Aggarwal. However, the upside is that the disorder can be treated using a mix of medication and behavioral counseling so that patients can lead a normal life. "Children usually do much better when on medication; however, it has to be monitored carefully," says Thadani.
It is important to note that ADHD often coexists with various other conditions such as autism, social anxiety, depression and bipolar affective disorder. This coexistence of disorders is called co-morbidity. "It is a good clinical practice to always evaluate for the presence of one or more of these co-morbid disorders in order to appropriately choose the treatment strategy," explains Vijay Sagar. Behavioral counseling is suggested not only for those suffering from the disorder but for their parents and teachers as well. "During the counseling we were told that parents shouldn't fight in front of the child. One should have reasonable expectations from the child. Punishment is a no no as it leads to resentment and anger. Today because of this counseling and medication, Rohit is already 60 to 70 per cent better. He is more respectful and focused,' says Rupa with a smile.
Some names have been changed on request
COMMON MYTHS ABOUT ADHD
> Children suffering from ADHD don't require treatment as it is just a passing phase of life.
> Poor parenting and bad family structure lead to this disorder.
> Use of medication for ADHD can damage a child's brain.
> ADHD doesn't affect girls.
> The disorder can be controlled with harsh punishment.
> Children with ADHD are being difficult on purpose and can behave better if they want to.
> Children with ADHD can't do well in life.
