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All That Bounces Is Not ADHD!
Let’s look at three things about Attention-Deficit Hyperactivity Disorder or ADHD.
(1) Let’s get it right. Everything that bounces, acts out or runs around is not necessarily ADHD. In medicine and child psychiatry we call this “differential diagnosis.”
(2) Let’s make it right. We need to know “what works for whom.” Health care professionals call this “evidence-based medicine.”
(3) Let’s have the right expectations. We need to think about both pills and skills. Not everything is fixable with a pill. While 85% of children do respond well to stimulant medications, it often takes better skills, on the part of the child, the teacher and the parent to make a real difference. For children with moderate or severe ADHD, both skills and pills are usually needed.
We should aim for a better personal experience for children so that they do not feel frustrated and conclude that they cannot learn or perform like other children in their class or in their circle of friends. Another goal is to achieve a difference that can be observed in behaviour and performance at home, in school and in the community. ADHD is not just a problem in the classroom. The goal should not just be change, but a significant change in symptoms. Is it a difference that makes a difference in the life of the child?
However, not all children with ADHD will achieve the results that the child, the parents or the teachers wish for and we need to really understand and accept the child’s capacities and limits.
Let me take two extremes. The first is a child with great difficulty completing tasks at the same level and rate as other children her age. First, we have to make sure we understand why. If it is due to major learning problems or mental retardation, we have to address those issues. An important part of that is to accept the child we have, not the child we imagined or wished for. A medication may increase the child’s attention span and improve school performance to some extent, but is it worth it? Will it make a significant difference?
At the other end is a bright child who performs rather well in school and with more effort could be in an enriched class and with sustained effort, could get into a competitive program ―at school, in college or university and enter a profession. But if that level of performance is beyond the person’s reach with a reasonable amount of effort and discipline, or even a great deal of effort, and medications can make the individual perform better, is it worth it? These are not only clinical or educational questions, but personal questions that reflect personal, family and social values and priorities.
So, to sum up so far, when it comes to attentional or behavioural problems in youth, let’s get it right, let’s make it right, and let’s have the right expectations.
“Yours, Mine and Ours” ―Understanding and Working with ADHD Is a Shared Responsibility
From the clinician’s point of view, the key is to screen children for ADHD early by recognizing its symptoms and recommend appropriate interventions at home, at school and in the community. In the follow-through care of children with ADHD, it is important to achieve an optimal balance between medication and other interventions ―“pills and skills”― for the best possible daily experience and outcome.
What parents, teachers and clinicians need to know is how to recognize ADHD and to identify other conditions that may alter the attention of a child. Each cardinal symptom of ADHD ― attention-deficit, impulsivity, and hyperactivity― has what we call “false friends.”
Now, let’s put these questions in context.
Children’s Mental Health – A Public Health Crisis
Around the world, one in five children has an identifiable mental health problem at any given time. The major Quebec study done here on children’s mental health showed that it is 15% across the province for children between 6 and 14 years of age but considerably higher in underprivileged neighbourhoods ―up to 4 times higher! In the USA, 80% of children suffering with a mental problem are not identified or treated. And in 2001, the U.S. Surgeon General’s Report on Children’s Mental Health indicated that the mental health of youth (children and adolescents) was a public health crisis!
Attention-Deficit Hyperactivity Disorder (ADHD) has been described and studied in the majority of cultures around the world. According to the recently released 5th edition of Diagnostic and Statistical Manual (“DSM 5,” released in 2013) of the American Psychiatric Association, ADHD affects around 5% of children and 2.5% of adults in the general population. That means although the symptom profile may change, ADHD can persist for a long time and at least half of affected children will enter adult life with some of the symptoms and deficits of ADHD.
The diagnosis of ADHD based on the DSM 5 places it in the category of Neurodevelopmental Disorders whose shared characteristics are that they begins during the developmental (growth) period of life and that the development or growth is impacted in a negative way.
ADHD has three cardinal symptoms –the attention deficit is the main symptom and the two closely allied symptoms are hyperactivity or agitation and impulsivity. The key to understanding attention deficit is lack of concentration and focus on a task and easy distractibility. Hyperactivity means that the child is much more active than other children his or her age to the point of being agitated and disruptive. Impulsivity is best understood as acting before thinking of the consequences.
These three symptoms may be expressed in different proportions or degrees of severity in different children, leading clinicians to distinguish different subtypes. This means that in the most common group, the mixed type, we see a mixture of all three symptoms, while in some children, the attention deficit is the key feature, and in others, the least common, a combination of hyperactivity-impulsivity is what parents and teachers mostly observe.
Other Mental Health Problems Associated with ADHD
In medicine, when people have more than one diagnosis or disorder at a time, we call it co-morbidity — from the Latin for “diseases” and “together.” That may be a consideration AFTER the diagnosis of ADHD. But BEFORE considering ADHD, we need to think about other possibilities that could explain the child’s problem. The medical term for this is “differential diagnosis” –simply meaning that different explanations are explored before confirming the best one.
Some of the conditions that may be associated with ADHD include:
- Anxiety and mood disorders
- Disruptive behavior problems including opposition and defiance or more serious conduct problems
- Specific learning disorders, such as dyslexia
- “Nervous tics” –either motor and/or vocal tics
- Problems related to autism
- Problems related to substance abuse
We may consider children to have ADHD when the hyperactivity, attention-deficit and impulsivity create problems for children to function according to their age in several different environments –for example at home, in school and in the community.
So we have to dispel the myths around ADHD and demystify the diagnosis.
- All that bounces is not hyperactive.
- All that is distracted is not attention-deficit.
- All that is spontaneous is not impulsive.
The most important symptom, attention-deficit, is marked by a difficulty for the child to focus and give their attention to a task and to stay attentive as long as the situation usually demands.
False Friends of Attention-deficit are:
- Hearing and visual problems
- Specific learning disorders
- Mental retardation
- Anxiety and depression
- Psychotic disorders
- Substance abuse
- Side-effects of medications prescribed for other conditions
- Disruptive behavior, including oppositional defiant disorder and intermittent explosive disorder
- Tourette Disorder (Gilles de la Tourette)
- Attachment problems
- Problems related to the child’s temperament and character
- Substance abuse
- Side-effects of medications
- Tics and movement disorders
- Mental retardation
- Attachment problems
- Temperament and character
- Substance abuse
- Side-effects of medications
Collaborative Care and Partnerships
To conclude, I want to highlight three points:
1. Dispel Myths. We all need to dispel myths about ADHD, starting with “All that bounces is not ADHD.”
2. Demystify Diagnosis. Health care professionals need to demystify diagnosis. The proper diagnosis of ADHD is not about parenting style or the child’s ability or motivation, although a child with ADHD can be a real challenge to live with and to teach and may appear unwilling or unable to learn. I refer to the child because the problem always starts early (even if it is not recognized) but it often continues throughout adolescence and into adult life.
3. Conduct Collaborative Care. Physicians, both general practitioners and specialists, need to collaborate with other clinicians, social services, schools and communities and invite children and their families as partners in care.
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