To ADHD or not to ADHD, Part 1

In the light of our ADHD campaign this month, we decided to look at some of the basic information around ADHD; ADHD in South Africa; assessments/tools used to diagnose and treat ADHD; and arguments for and against ADHD; in a four-part series.

• Part 2: ADHD in the South African context

• Part 3: Assessments and tools used to diagnose and treat ADHD

• Part 4: Does ADHD exist?

What is ADHD?

Previously, the Diagnostic and Statistical Manual of Mental Disorders (DSM) classified ADHD as a behavioural disorder, however in the 5th edition it has been reclassified as a neurodevelopmental disorder that typically starts in childhood. One of the diagnostic criteria in the DSM-5™ is that symptoms need to start before the age of 12. Inattention in children with ADHD typically means that they wander off-task, act without thinking, they are always on-the-go, and struggle to focus on tasks. This means that even though they understand what is expected of them, they struggle to function because they find it difficult to sit still, pay attention, and focus on detail. Most younger children at some stage display these behaviours, but for ADHD to be diagnosed, the behaviour needs to be present for a prolonged period of time, at least 6 months in different settings. This means that the behaviour must negatively impact the child’s functioning at home, and/or in school/academically, and/or socially. Diagnostic criteria as set out by the DSM-5 are used when making an ADHD diagnosis. ADHD can be diagnosed with, or without, the hyperactivity/impulsivity component, and a distinction is made between mild, moderate and severe cases. The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Inattention manifests behaviourally as wandering off-task, finding it difficult to focus and persist with a task, and being disorganised. The hyperactivity component is described as excessive motor activity such as excessive fidgeting, tapping or talking. Impulsivity is the last component and is described as making hasty decisions without taking the consequences into consideration, especially when the individual could cause harm to themselves.

What causes ADHD?

The cause is still unknown; however, a genetic component is strongly suspected. The following risk factors are thought to influence the development of ADHD:

• The child’s temperament: reduced behavioural inhibition, negative emotionality, and effortful control

• The child’s environment: low birth weight, smoking during pregnancy, alcohol exposure in utero, neurotoxin exposure, history of child abuse/neglect, and diet

• The child’s genetic and physiological make-up: children of parents with ADHD have a much higher chance of developing ADHD themselves, visual and hearing impairment, sleep disorders, and nutrition and metabolic abnormalities may all contribute to ADHD symptoms.

It should be noted that different cultures use different methods of assessing for ADHD and some behaviours are also more acceptable in different cultures.

How often does ADHD occur?

According to the DSM-5 it occurs in about 5% of children and 2.5% of adults. Overall 10% of school-age children are affected by ADHD. The disorder manifests differently in childhood and adolescents and adulthood. It occurs more often in boys than in girls, although it is not yet understood why. Which other difficulties occur in conjunction with ADHD? It is thought that delays in motor, language, and social development co-occur in children with ADHD. These children may also have low frustration tolerance, irritability and mood lability. As adults, they may have a higher suicide rate and impaired functioning at work. Other disorders such as Oppositional Defiant Disorder, Autism Spectrum Disorder and Anxiety Disorders often have symptoms that mimic ADHD. ADHD can also co-occur with other disorders such as Oppositional Defiant Disorder and Conduct Disorder. In adults, antisocial and other personality disorders may co-occur with ADHD. In light of the above and other information describing the complexity of ADHD, it cannot, and should not be an easy or a quick task to diagnose a child with ADHD. A comprehensive assessment process should be followed, which includes, but is not limited to: consultations with the parent/s, the child, and the teacher where possible, the use of a battery of psychometric assessments, and carefully applying DSM-5 diagnostic criteria. The labelling of a child with ADHD should not be done flippantly. How is ADHD diagnosed? It is important that the psychologist consults with all parties involved – the parents, child and teacher - to obtain a holistic view of the child‘s behaviour in different settings. There are many assessment methods, both objective and subjective, used to assess for ADHD. In South Africa, diagnostic psychometric assessments, such as the Conners 3™ or ASEBA® ranges, can be used by a Clinical, Counselling, or Educational Psychologist to aid them with an ADHD diagnosis. These tests also obtain information from various parties to further understand the child’s behaviour. Typically, the child’s parents, the child (from 11 years and older), and the class teacher will complete a checklist of behaviours, rating the frequency of the inappropriate behaviour. Psychometric assessment is only a small part of the process needed to diagnose ADHD. The psychologist will make a diagnosis based on all the information gathered. If ADHD is the appropriate diagnosis, the psychologist will refer the client to a specialist like a paediatrician or a psychiatrist. Psychologists cannot prescribe medication. The specialist may investigate the diagnosis further before prescribing any medication. An important part of ADHD treatment that is often overlooked, is behavioural therapy. In addition to any medication that may be prescribed, therapy is required to further assist with behavioural modification for the child and for the parents. ADHD is a challenging disorder, both for the child and their families. It often persists into adulthood and sufferers struggle on a daily basis to manage their behaviour effectively.

A note on language:

While nothing much about the diagnosis and treatment of ADHD has changed in the medical community, there is a big societal shift to move away from using language such as diagnosis, disorder, and treatment when describing this complex condition. The relatively recent movement started in 1998, when the term Neurodiversity was coined by Australian sociologist Judy Singer. The movement’s focus is to shift our thinking about the neurodiverse population, which includes people who have been diagnosed with neurodevelopmental conditions such as Autism Spectrum Disorder (ASD), Attention Deficit/Hyperactivity Disorder (ADHD/ADD), Dyslexia, Dysgraphia, Developmental Coordination Disorder (DCD), Dyscalculia, and Tourette syndrome (Doyle, 2020). References

American Psychiatric Association. (2013). The diagnostic and statistical manual of mental disorders - DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association What is ADHD? Retrieved from /en/parents/adhd.html