ADD Fad or Fact?

Attention Deficit Disorders has become a catch phrase in educational circles. When I started my clinic almost 10 years ago, a diagnosis of ADD resulted in puzzled and suspicious looks from parents and teachers alike. However, the pendulum has swung the other way. It has become a substitute for a hyperactive child. Parents and even some professionals make this diagnosis by ticking off a number of symptoms that they may have observed in the child. This has led to misdiagnosis and misuse of medication. In our fast track lives, a quick diagnosis with a quick solution has replaced careful clinical assessment and multimodal interventions.

For the novice reader, ADD stands for Attention Deficit Disorder, a common mental disorder seen in 10 to 20 percent of children. I hesitate to call it a mental disorder because it’s signs and symptoms are not pathological. It is a dimensional not a categorical disorder i.e. many of the symptoms may be seen in the average child or person but in a person with ADD they are severe enough to cause problems in education, behaviour and or social fields.

ADD is a complex disorder not a checklist disorder. It can start insidiously wherein subtle signs are missed in early childhood because they are mainly related to inattention. They may also present with a bang with a hyperactive child. Nonetheless, these children may even present later in life if they are very bright e.g. in high school or even college. ADD can mimic other problems. A child traumatised by a mixture of unrealistic expectations, harsh punishments and inappropriate curriculum can present with inattention and restlessness. Anxiety, especially posttraumatic stress disorder and separation anxiety can also cloud the picture. Other disorders like Juvenile Bipolar disorder or Asperser Syndrome wherein hyperactivity is also a symptom can complicate the diagnosis.

ADD also has a wide spectrum of clinical presentations. From an inattentive, quiet and withdrawn child (Inattentive ADD) to a restless, impatient and impulsive one. In fact Dr. Amen has described 6 types of ADD each having their own brain images on the SPECT machine. No two children with ADD are same. Co-morbid conditions like anxiety and depression can change the clinical picture. Language difficulties, either spoken or written along with Specific Learning difficulties complicates the clinical presentation. Environmental conditions also affect the ADD child. Highly mobile expatriate societies as those seen in Dubai, Hong Kong and Brussels see a higher rate of ADD in their student population. One of the reasons being changing school systems, anxiety with relocation and other environmental factors that aggravate a mild predisposition to ADD to a blatant one.

The other feature that can confuse parents and teachers alike is that ADD is not an absolute deficit. This means that symptoms can fluctuate. A child with ADD can be well focused in a subject he enjoys but can become very restless and difficult in those he doesn’t. Thus an ADD child can sit and work on a computer for hours but cannot sit and read (even if he is good at reading). Some readers may feel that this is true of many people. However, those without ADD can make themselves pay attention to uninteresting topics when they know they have to. Also many ADD children may not be educationally impaired.

Early diagnosis and multimodal intervention is the key.

Research has shown that ADD is a life span disorder that can be seen to follow the ADD child into adulthood. Untreated ADD can lead to many complications. From emotional disorders to psychiatric disorders; from school failure to school dropouts and from behavioural problems to felony, a child with ADD can develop many problems.

I cannot end this article without touching on the crucial factor of medications. Many parents and teachers feel alarmed by use of behaviour changing medications, especially if the child is not very difficult to manage. However, ADD is a neurochemical disorder. That means it is organic in origin and is not caused by bad parenting or poor schooling. (Though they can aggravate it). Medication is necessary to prevent complications and ensure academic and social success. Stimulant medications can improve attention and reduce impulsive and restless behaviour. They can improve academic efficiency and performance and hence avoid complications of low self-esteem. They can improve behaviour and attention and hence improve social acceptance. However, social skills, remedial help for learning difficulties must be given.

To conclude ADD is a complex disorder which impacts the person life long. Diagnosis and therapy must be long term and multimodel.