The teacher reports that your child is underachieving in the classroom, and suggests an assessment. It may have been a series of phone calls, possibly from several teachers over the years, and you are feeling increasingly hounded. Where do you turn?
If ADHD (Attention Deficit Hyperactivity Disorder) is suspected, then one of three types of medical specialists could be consulted, namely a child and adolescent psychiatrist, a neurodevelopmental paediatrician or a paediatric neurologist. The symptoms of ADHD are divided into three clusters, inattentiveness, hyperactivity and impulsivity. In order to qualify for the diagnosis, a child should display at least six symptoms from the inattentive cluster (such as distractibility, forgetfulness and disorganisation), or six of the hyperactive/impulsive symptoms (such as excessive talkativeness, blurting out without waiting his turn and restlessness).
In assessing these symptoms, apart from the interview, the doctor will engage the child in structured tasks (drawing, puzzle-building, etc) in order to make direct observations. But feedback from the school teacher is also crucial in ascertaining how the child is functioning in the classroom. Now, it is one thing to have these symptoms – even six of them – but quite another to be significantly impaired by them. This is where the concept of functional impairment comes in. In ADHD, there are three important domains of functioning to think about.
Firstly, ADHD is likely to affect a child’s learning. This is especially important in the early grades, when foundational skills are being learnt. For example, a preschool child learns to identify certain sounds, or phonics which is crucial for the development of reading and spelling. If her concentration is impaired, gaps can emerge in this area, which can be much harder to address later on. ADHD can affect the brightest children, the slowest, and anyone in between. But whatever the child’s intelligence, it will cause her to underachieve relative to her potential.
Secondly, this condition often affects the social functioning of the child. This is usually the result of hyperactivity and impulsiveness, affecting how he interacts with his friends, his siblings and authority figures. He often irritates his peers and becomes ostracised as a result. Family relationships are similarly affected.
And thirdly, as a consequence of the above, these children are often distressed and demoralized. Many have developed a negative attitude to school and learning. We now know that ADHD does not resolve in adolescence or even adulthood. In as many as two thirds of cases, the disorder persists into adulthood. And as one gets older, other conditions are likely to complicate the picture, including anxiety disorders, depression and substance abuse. Even suicide is statistically higher in those with ADHD than without. The stakes are high!
Many parents raise concerns about ‘labeling’ their child with ADHD. In practice, I have encountered many children with undiagnosed ADHD symptoms who have been branded as ‘lazy,’ ‘disobedient,’ ‘a bully’ or worse, with far-reaching implications for their developing self-concept. What these children really need is an appropriate diagnosis; not an excuse but an explanation. Used appropriately, the diagnosis becomes a springboard for a holistic management plan, which ushers in relief, hope and ultimately dignity for the affected child.
Dr Brendan Belsham is a child psychiatrist and author of What’s the fuss about ADHD?