ADHD in Children: FAQ Part 2

- How is it diagnosed in children?

The diagnosis of ADHD is made with careful clinical assessment by a trained specialist, usually a psychiatrist. A detailed history from the parents and teachers is taken to assess for ADHD symptoms and during the interviews, the child is observed for ADHD behaviour. Clinical scales may be used to determine the severity of ADHD and to assess improvement in subsequent follow-ups after treatment.

- In your opinion, do you think ADHD is over- or under-diagnosed in Singapore ? Why?

ADHD continues to be under-diagnosed in Singapore. Even though, parents and teachers are more likely to pick up the symptoms of ADHD and know that their kids have difficulties, many continue not to to bring their children to psychiatrists for formal diagnosis and  treatment. Parents are fearful that their children will be stigmatised and they have misconceptions about the illness and medication. They are unaware that without treatment, the consequences of ADHD is debilitating and affects the child negatively in the long term.  

- Why is it easy for ADHD (especially the milder cases) to go unnoticed? How common is it for parents/ teachers to think that the child is simply "naughty"? How to tell when the child's "naughtiness" could be ADHD?

Parents and teachers often think that children with milder forms of ADHD as being naughty and lazy. This is especially so when the symptoms are predominantly in the attention deficit domain. As these children do not display hyperactive behaviour and are often well behaved in school, adults may not realised that they are having problems concentrating in class and are not fulfilling their potential academically.

It is very common for ADHD symptoms to be misconstrued as "bad" or "naughty" behaviour by parents and teachers alike. Even after diagnosis, parents and teachers often require plenty of education and convincing before realising that the symptoms are not wilful or deliberate in nature. It is normal for kids to have naughty behaviour here and there. However, ADHD symptoms are pervasive, meaning that the child is constantly inattentive, hyperactive and impulsive in most situations. Unlike in naughty behaviour, these symptoms lead to long term difficulties academically in school and in other aspects of the child's life.

- How is ADHD treated? How safe is it for children to take medication for ADHD long-term?

ADHD can be treated with medications. Currently, two main types of medications are available, stimulants and norepinephrine uptake inhibitors. They help ADHD by  increasing the level of neurotransmitters (chemical messengers) in the brain called dopamine and norepinephrine. Behavioural modifications and therapy are also useful treatments and are always given alongside medications.

Latest studies showed that medications are safe and effective for long term ADHD treatment when taken under the supervision of a psychiatrist and earlier fear of untoward heart problems are unfounded. However when under treatment, the psychiatrist will continue to monitor for any possible side effects that may occur and will make the necessary adjustments when needed.

- How can parents of ADHD children cope and what can they do to help their child?

First and foremost, parents will need to be educated about that ADHD  is not unlike any other medical problems and ADHD children are not lazy, naughty or being wilful. As such, what parents need to do is not be punitive but to approach the symptoms with patience and compassion and to assist the child with managing his or her symptoms. Parents should consult their child's psychiatrist in learning about the specific approaches they can adopt. These will usually include setting up firm and consistent boundaries and routines for the child, rewarding and encouraging positive behaviour and meting out the appropriate consequences for bad behaviour. Adjustment to communication styles are important. Parents need to catch their child's attention before speaking to them rather than just yelling at them. Use as little words as possible as the ADHD child has poor attentional span and will not be able to follow long instructions.

ADHD in Children: FAQ Part 1

These are some questions about ADHD readers posted to me. Hope they are of help to both parents and children with ADHD.

- Typically at what age does ADHD surfaces?

Parents will notice ADHD symptoms in their children before the age of 7. Typically, the symptoms become more pronounced once the children go to preschool where they are required to sit through lessons especially when compared to other kids.

- In Singapore, what age is ADHD diagnosed?

In Singapore, ADHD is only diagnosed when the children are at least 6 years of age. Typically most children with ADHD are picked up in lower primary school from  7 years old to 9 years old.

- How do ADHD children behave and what is it about this disorder that causes them to behave in this way?

ADHD children have two main types of symptoms and behaviour, i.e. the inattentive and hyperactive-impulsive types. Most have both types of symptoms.

When kids have Inattentive type symptoms, they have difficulty in paying attention, they make careless mistakes in school,  have inability to stay in or to complete tasks and activities,  appear not listening to and not follow instructions, they are disorganised and lose things like toys and stationaries easily and are distractible and forgetful. 

Hyperactive-impulsive type symptoms include being fidgety, restless and have difficulty staying seated, excessive running and climbing, being always on the "go" and inability to play quietly, talking excessively and blurting out answers before hearing full questions and tendency to disrupt or interrupt activities like classes and will cut queues.

It is however pertinent to note that ADHD children can concentrate if they find something interesting but their symptoms are particularly pronounced when they are bored.

The causes of ADHD are not fully understood. We know that ADHD is hereditary and environmental toxins have also been implicated. In children with ADHD, executive functions which are the processes involving planning, working planning, memory and inhibition and initiation and monitoring of actions are affected.

- When a child has ADHD, what aspects of the child and his/her parents' life is affected ?

ADHD has far reaching consequences for the children and their parents. It impacts not only the child, but also parents and siblings, causing disturbances to family and marital functioning of the parents.

When untreated, ADHD children are found to perform much worse than their peers in school academically. They are seen as different by their classmates and have difficulties making friends and are not invited to social events like parties. Parents are stressed up coping with their behaviour and this often leads to tension between parents. As much more attention is needed for the ADHD child, their siblings are neglected. As a result, family relationships may be severely strained, and in some cases break down, bringing additional social and financial difficulties.

Postpartum Depression

In a study published in March this year in  JAMA Psychiatry,  1,396 of 10,000 mothers screened positively for postpartum depression on the Edinburgh Postnatal Depression Scale (EPDS). This study sponsored by the publicly funded National Institute of Mental Health in the US shows that depression after childbirth is a significant problem. Unfortunately, postpartum depression remains underidentified and undertreated. Some of the following are common myths about Postpartum Depression.

Postpartum Depression (PPD) is the same as baby blues.

Unlike baby blues that goes away after a few days, postpartum depression lasts for weeks to months. The symptoms of PPD is the same as for a Major Depressive Episode. 

PDD is normal and ok to be sad after having a baby.

Whilst changes in mood may be normal after birth, if they are prolonged or are affecting your ability to care for your child, you should seek medical attention. If left treated, PDD can lead to:

1) Inconsistent and poor childcare
2) Avoidant or venting type of coping strategies with child
3) Insecure attachment between mother and child (may result in anxiety and depression of the child in later life)
4) Risk and danger if mother becomes agitated or suicidal with depression

PDD occurs right after birth.

It can occur right after birth or even up to a year later. Most of the time it occurs within three months.

Treatment for PDD will prevent me from breastfeeding and harm my baby.

Effective treatment is available for PDD. Antidepressants safe for pregnancy can be used to treat PDD after the risks and benefits have been discussed. Psychological therapy with techniques such as CBT is also useful.

It is unfortunate that PDD often goes unrecognised leading to tragedies such as these. Seek help today as PDD  can be treated!

The Myths About Antidepressants

Antidepressants are the mainstay of treatment for clinical depression and anxiety disorders.  These medications are effective and safe for the general population. However, many remain skeptical about antidepressant treatment and many myths remains.

1. I will become reliant on antidepressants and be addicted.

This is one of the main concern that my patients have when they have to be started on an antidepressant medication. It is important to realise that unlike sleeping pills, it is not possible to be addicted to antidepressants. Antidepressants do not cause tolerance or cravings like street drugs do. The fact that there are no street values with antidepressants attest to the fact that they are not addictive. However, if a patient is on high doses of antidepressants for a long time, it is best for him or her to seek the advice of the psychiatrist and not stop medication abruptly as this can cause "discontinuation syndrome". Discontinuation syndrome can lead to physical discomfort and can be completely avoided by weaning off the medication slowly in a few weeks.

2. My condition will become worse that when it started if I stop the medications.

Your condition will not worsen or rebound simply because you stop your medication. Antidepressants treats your depression or anxiety and also protects you from future episodes. If you stop the medication, it is like you taking off your armour. You will be vulnerable to depression or anxiety again.

3. Antidepressants have terrible side effects.

Newer classes of antidepressants like SSRIs are currently the mainstay of treatment. Unlike older antidepressants, these newer medications are well tolerated. At times, side effects can still occur to the minority of people. Known side effects include weight gain, sedation and rarely sexual dysfunction. These side effects are reversible and if any these side effects arises, you must inform your doctor who will switch you to another medication.

4. My brain will be affected by the medications!

Sometimes patients worry that they will be "changed" by the medications and their brain will become different. Antidepressants normalises the neurotransmitters in your brain  and this in turn makes your mood normal again. Antidepressants are not "happy"pills. They help by making you cope better so that you can solve the problems you have in life and it is up to you to find new meaning and happiness.

5. I'll have to take medications forever!

Many patients are afraid that once they are on medications, they cannot come off it. Majority of patients will become better once they have been treated and will come off medications. Some patients who have multiple episodes of mood or anxiety problems and may decide to stay on the medications long term. Your doctor will discuss with you the pros and cons of taking medications and how long you will require them. Ultimately, you have the choice of whether to take medications and the choice to stop them.

ADHD Increases Risk of Mental Illness in Adulthood

A 20 year long study conducted by Mayo Clinic published recently showed that not only did symptoms of ADHD persist into adulthood, children with ADHD were also much more likely to be diagnosed with other psychiatric illnesses as adults.

In this study, the researchers followed a cohort of 5718 children born between 1976 and 1982. Within the cohort, 367 were diagnosed with ADHD and 75% received treatment for ADHD as children. 29.3% of the children with ADHD were later found to still have the disorder in adulthood and within this group of children, 81% had at least one other psychiatric condition. The concomitant conditions they had included major depression, generalized anxiety, hypomanic episodes, substance abuse and antisocial personality disorder. Also 57% of all children with ADHD had another psychiatric disorder as adults compared to 35% in the control group. The study also showed that suicide rate amongst ADHD children was five times higher than those without the disorder.

These data are no doubt disturbing and brings to the table stronger evidence to what doctors and psychiatrists have long suspected and observed anecdotally about ADHD. The evidences indicate that ADHD is an illness with serious consequences, morbidity and mortality. Starting treatment young will help the children cope with the hyperactive, inattentive and impulsive symptoms, preventing the eventual pathways leading to other serious mental illnesses, personality disorders and suicide. Treatment into adulthood is often necessary and doctors must be vigilant in assessing and picking up co-morbid psychiatric illnesses.

ADHD is by far the most common neuro-developmental condition in children. It should not be trivialised and ignored as it progresses into long term difficulties for the individual. Seek help today!

The Top Five Regrets of the Dying

Bronnie Ware is a palliative nurse who has been seeing dying patients. From her experience, she observed five common themes that often resurfaced with regards to the regrets of people who were dying.

1. I wish I'd had the courage to live a life true to myself, not the life others expected of me.
2. I wish I didn't work so hard.
3. I wish I'd had the courage to express my feelings.
4. I wish I had stayed in touch with my friends.
5. I wish that I had let myself be happier.

In essence, the dying often wished that they have lead a more meaningful and fulfilling life. That they have been more true to themselves and in touch of their feelings. They wished they had spent more time with family, friends and with the things they like to do instead of just their work. Such reflections are not new. Kubler Ross in her work about the grief of dying had often alluded to these.

Sadly, our society continues to overemphasize academic and occupational achievements. Family and other social aspects of life are often neglected.

If your time is ending, will you have any regrets?

How to Prevent a Relapse of Bipolar Disorder

Read my article on how to prevent a Bipolar Disorder relapse. Click here.

You can read about symptoms of Bipolar Disorder by following this link.