A significant number of children and adults suffer from a disorder characterised by features such as hyperactivity, inability to sit still, easy distractibility, and inattentiveness known as attention deficit hyperactivity disorder (ADHD).

It is our responsibility as clinicians and mental health professionals to sensitise the population to the perils of this disorder going untreated in the vulnerable childhood population. ADHD is among the top most commonly diagnosed childhood psychiatric disorder in child guidance clinics across Jamaica.

SYMPTOMS

ADHD is a cluster of symptoms from two categories, namely inattentive type and hyperactive type. A combined type is also recognised with features of both present.

INATTENTIVE SYMPTOMS

This must include at least six of the following symptoms of inattention that must have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities;

• Often has difficulty sustaining attention in tasks or play activities;

• Often does not seem to listen to what is being said;

• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions);

• Often has difficulties organising tasks and activities;

• Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort;

• Often loses things necessary for tasks or activities (school assignments, pencils, books, tools, or toys);

• Often is easily distracted by extraneous stimuli;

• Often forgetful in daily activities.

HYPERACTIVE SYMPTOMS

This must include at least six of the following symptoms of hyperactivity-impulsivity that must have persisted for at least six months to a degree that is maladaptive and inconsistent with developmental level:

• Fidgeting with or tapping hands or feet, squirming in seat;

• Leaving seat in classroom or in other situations in which remaining seated is expected;

• Running about or climbing excessively in situations where this behaviour is inappropriate (in adolescents or adults, this may be limited to subjective feelings of restlessness);

• Difficulty playing or engaging in leisure activities quietly;

• Unable to be or uncomfortable being still for extended periods of time (may be experienced by others as “on the go” or difficult to keep up with);

• Excessive talking;

• Blurting out answers to questions before the questions have been completed;

• Difficulty waiting in lines or awaiting turn in games or group situations;

• Interrupting or intruding on others (for adolescents and adults, one may intrude into or take over what others are doing).

CAUSE

ADHD has been linked to significant genetic predisposition and heritability along with imbalance in key neurotransmitters in the brain such as dopamine. Anatomical changes in the brain have also been implicated based on brain imaging studies.

There is currently no evidence to suggest that a high sugar diet causes or exacerbates ADHD.

INVESTIGATIONS AND MANAGEMENT

Early detection and treatment is critical in the prevention of long-term economic and social costs associated with the disorder. ADHD is highly comorbid with other psychiatric pathologies, such as conduct disorder, major depression and substance use.

All children with symptoms suggestive of ADHD must receive a comprehensive physical examination, blood and radiological investigations to rule out associated medical conditions. A baseline ECG is required to rule out cardiac pathology due to risks involved with using psychostimulants in the treatment of this disorder.

TREATMENT

Treatment primarily involves a multidisciplinary approach involving the child, family and teachers. A combined treatment protocol involving pharmacotherapy and psychotherapeutic techniques is recommended.

Regarding medication for ADHD, stimulants are the first-line therapy and probably the most effective treatment. Targeted symptoms include impulsivity, distractibility, poor task adherence, hyperactivity, and lack of attention.

Care should be taken to not dose too close to bedtime because stimulants may cause significant insomnia.

Other common adverse effects include appetite suppression and weight loss, headaches, and mood effects (depression, irritability).

Atomoxetine (Strattera) has become a second-line and, in some cases, first-line treatment in children and adults with ADHD because of its efficacy and classification as a non-stimulant.

There is currently lack of sufficient evidence to recommend tricyclic antidepressants, clonidine and guanfacine as first-line treatment in the management of this disorder.

Methylphenidate is currently covered under the National Health Fund and is available in pharmacies islandwide.

NON-PHARMACOLOGICAL MANAGEMENT

Various combinations of behaviour training and cognitive behaviour therapy has shown efficacy in managing ADHD. This approach primarily involves rewarding positive behaviour and ignoring unwanted behaviour in the child.

Classroom Tips for teaching children with ADHD

Seat the student with ADHD away from windows and the door, right in front of your desk unless that would be a distraction for the student.

Seats in rows, with focus on the teacher, usually work better than having students seated around tables or facing one another in other arrangements.

Give instructions one at a time and repeat as necessary. If possible, work on the most difficult material early in the day.

Use visuals: charts, pictures, colour coding. Create outlines for note-taking that organise the information as you deliver it.

Create a quiet area free of distractions for test-taking and quiet study.

Reduce the number of timed tests. Test the student with ADHD in the way he or she does best, such as orally or filling in blanks; give frequent short quizzes rather than long tests.

Divide long-term projects into segments and assign a completion goal for each segment. Create worksheets and tests with fewer items.

Accept late work and give partial credit for partial work.

Dr Ashish Sarangi MBBS is a resident in psychiatry at the University Hospital of the West Indies. He may be contacted via email at aks_sarangi@hotmail.com.