Attention Deficit Hyperactive Disorder – otherwise known as ADHD – is something we increasingly hear about these days, especially where children are concerned. Some get diagnosed, others don’t and many get misdiagnosed. The truth is that like a lot of things in the field of psychology, it isn’t an exact science. While in other medical fields, scans or blood tests could give you a good idea of what’s going on, making a diagnosis in psychology is a very complex process. Or at least it should be – especially since hasty ADHD diagnoses that result in prescribing medication can produce heavy side effects, especially on kids. In recent months I have met quite a few parents whose kids have been rightly or wrongly diagnosed with ADHD and several who have children who are either hyperactive or inattentive. Kids will be kids and I don’t like being overly obssessive when it comes to questioning their behaviors because that can do more harm than good. Still, as I was researching this topic I remember thinking that every parent should know what ADHD is and what it isn’t.
As luck would have it, a friend of mine recommended I meet with Razmin Shah, Senior Psychologist at Kids First Medical Center. Having practiced for many years in the UK and in Dubai for the past 5 years, she is a gold mine of information about the topic. Enjoy the interview!
WM: What is ADHD? What is the difference between ADHD and ADD?
RS: Attention Deficit and Hyperactive Disorder is when someone presents a persistent pattern – persistant meaning which happens all of the time across all situations – of 3 things: inattention and/or hyperactivity and/or impulsivity. You could have only one, two or a combination of all 3. The combined presentation would have all 3 things going on – inattention (day dreamy, dazed, etc), hyperactivity (constant fidgetting and needing to move, tapping foot, hand) and impulsivity (not thinking before doing something, blurting out the answer, not waiting their turn, not resisting the impulse).
ADD – or Attention Deficit Disorder – doesnt exist as a construct anymore. ADD is associated with the inattentive presentation, the “day dreamers”. ADHD is the umbrella term and ADD is a type of ADHD.
The hyperactive form however is the most commonly diagnosed, because it is the most obvious one for parents to see.
WM: So hyperactivity is a sign of ADHD?
RS: Not necessarily, it can also be a symptom of something else. That is why it is important to have a psychologist or psychiatrist that is well qualified and thorough, and who has strong knowledge of the subject. This is key. ADHD is one of those things that in my experience – especially in Dubai – gets overdiagnosed. A lot of ADHD symptoms are symptoms many people can have, but it doesn’t mean they all have ADHD.
WM: So how does one get diagnosed?
RS: It depends on your doctor. We meet the families at least on 2 or 3 occasions. We have an interview with the parents alone to ask questions about early development, how they are at home, etc. Then we discuss with the school, we speak with the teachers and get feedback on the kind of behaviors that happen in the school environment. We then try to have a discussion with someone outside the close family (friends, etc) if they are willing. If possible we also like to have a conversation with the child’s doctor. And of course we speak with the child and observe them either in a home or school environment.
Finally, we give them structured tests to support the information that we have gathered.
It is a comprehensive but necessary process where we really get to know what the child is like: are the behaviors present across all situations? That is really important, otherwise it can be something like sensory processing disorder where someone’s senses are overwhelmed by external stimuli or are not responding to external stimuli. With SPD it depends on the environment, that isn’t the case with ADHD.
We tend not to diagnose under the age of 7 at our clinic. It is a NICE principle (National Institute of Health Care and Excellence) we abide by. The reason is because the frontal lobe of the brain – the area that controls action and hyperactivity and all sorts of thing – doesn’t develop enough until the age of 7. We will acknowledge that they have symptoms and try to equip them but don’t want to encourage that they take medication that young.
WM: How could ADHD be misdiagnosed?
RS: In the last 4 years, I have only given the ADHD diagnosis to a handful of children. If a doctor isn’t super thorough in their interviews and diagnosis process, there could easily be cases of misdiagnosis.
For example, there are times when we get referrals from school, it has to do with the kids’ cognitive abilities, they find the work too difficult, they are not functioning at their full capacity, there are other social and emotional things going on. It is very important to look at their family situation as well and understand what is going on. A lot of children engage in hyperactive and difficult behavior to get away from problems or to get attention from parents, especially here in Dubai where a lot of kids are looked after by their nannies because parents have to work full time. The behavioral attention is sought in many different ways by children. You have to really explore everything and have the in-depth interviews. You also have to keep in mind that kids are kids, and sometimes our society has expectations that are too high for them, like staying in a class seated for 40 minutes.
WM: What are the main criteria that will qualify a child as having ADHD?
RS: We follow a diagnostical statistical manual. In order for a young person to meet the criteria of ADHD, they need to meet 6 out of 12 criteria. They must be present persistently for at least 6 months and has to be affecting their life at home, with friends and school/work. That is when it becomes a clinical problem.
These 12 criteria are symptoms of inattention and hyperactivity and in ADHD kids, at least 6 are present in 2 or more settings:
- Fail to give you give attention to detail and make a lot of mistakes
- They often have difficulty sustaining attention to a task or activity – activities are half done
- They often don’t seem to listen when they are spoken directly to
- They don’t follow instructions
- Often do not finish their work
- Avoid or dislike tasks which require long, sustained effort
- Often lose things – PE kit, pens, bag
- Easily distracted by outside stimuli
- Find it difficult to remember things even if these things reccur daily
- Fidget constantly (get out of their seat and walk around the classroom, running and climbing in inappropriate situations, etc)
- Unable to play in leisure activities easily – always making noises or talking to themselves, always want to be on the go, talk excessively (blurt answers without waiting, etc)
- Often interrupt others
You need 6 of these in at least 2 settings. Depending on the symptoms, it can be a different type of ADHD.
WM: What happens when you have a diagnosis?
RS: We produce a detailed report. ADHD is an umbrella diagnosis, so every child manifests differently. We suggest that parents take a behavioral approach to helping their children.
We conduct a lot of parenting workshops to help parents manage some of the behaviors, and communicate with their child in a way that the kids can understand their instructions. The ADHD child has a different lense from you and I – it is about equipping the parents with how they can read that filter and speak a common language with the child. Giving them activities to engage in where they expend their energy. We provide the parents with strategies to manage a situation rather than having to tell the kid 100 times to do the same thing to no avail. Using eye contact, signs, checklists, games or daily rituals to help them get organized for example.
In classrooms, there are tools that can be used too. Even something as simple as fidget spinners or other fidget toys can help hyperactive children in school – they release that need for movement without distracting the class because they aren’t noisy.
In cases of inattention, we recommend the child sits in front of the classroom and in general, you need to be very clear with instructions: give only one-step instructions like “can you write your name at the top of the paper” rather than “write your name then write two paragraphs about this and that”. It is about breaking things down step by step. Children cannot usually hold more than 4 pieces information at a time, for kids with ADHD it is only 1 piece of information at a time. Also, techniques to help the child focus and concentrate and filter out the external noises and distractions, like always engaging the child with eye contact, can be incredibly useful.
Basically, we give them as many strategies as possible to keep the child in school and functioning to the best of their capacity.
WM: What about medication?
RS: Sometimes it really is necessary, but we only go down the route of medication when we have tried the behavioral approach first. Medication is a family choice.
ADHD medication can have strong side effects, some of them are very addictive. You don’t really know the long term effect of medication on children. Medication, in my opinion, is something that should be used as a last resort.
What are the causes of ADHD?
RS: I think it is important to mention that it is not caused by “bad parenting” – parents should not feel like it is their fault because the main causes are genetic.
Some research indicates differences in brain chemistry and that there is often delayed frontal lobe development which can imply that they don’t have the “hit the brakes” aspect in the brain. Control and focus require certain neurotransmitters like neropenephrine, etc and it is suspected that people with ADHD have circuits that are not as wide, which makes it harder for their brain to use these chemicals effectively. That can be causing some of the issues, but it is very complex.
There are some studies where children with traumatic brain injuries and/or epilepsy can have ADHD-type symptoms. Also external factors such as prenatal exposure to smoking or high levels of lead that can increase the chances of children of having ADHD. But like I said, there is a lot to it and in the end, the best a parent can do is to get a proper diagnosis to treat them correctly.
How does ADHD evolve?
ADHD can affect self-confidence, self-esteem, it can lead to emotional disorders as well because of the isolating factors. Because you don’t make friends easily, because you don’t wait your turn, you don’t listen to others as much, etc, it can lead to bullying – all these things are by-products. Then, ADHD can become more problematic in during secondary school time and college. That is when kids are expected to have a great deal of concentration and attention on quite a wide variety of topics. When you think of the GCSCs, they have over 10 subjects to manage, along with homework and assignments as well as having a social life. Luckily, as they get older and come to a point in their life when they can make choices, their symptoms reduce. Because they are able to choose the things they are good that – hopefully they can choose topics which they enjoy and can really focus on those things because they have a vested interest in them. With age, you can have activities and a job you can choose. In that sense, things get better. Also post-adolescence, the brain changes which also helps.
WM: Are boys or girls more likely to have ADHD?
RS: Boys are twice as more likely to be diagnosed with ADHD. Girls will tend to have the inattention types of ADHD, which have less obvious signs that get overlooked. As soon as kids are hyperactive, teachers and parents start ringing alarm bells but inattentive kids tend to be labelled “day dreamers” or something like that.
WM: What happens if it goes undiagnosed?
RS: These children are smart, they just function differently. If their environment does not realize this, the danger is that the kids will probably miss out academically and not achieve to their full potential because they don’t have access to tools and strategies to help them. It will also have social emotional effects on some of them. Every individual will have a very different manifestation, it depends on their resilience and how easily they can bounce back from being rejected by people, by not doing well at school, etc. Resilience is a key underlying strength that can help people deal with difficulties. Luckily, it can really be helped with good parenting. If you don’t have resilience as a child, life can become very difficult as an adult. Getting a proper diagnosis can really change their life in a big way.
If you would like more information on this topic or if would be interested to speak with Dr. Shah, please contact:
Kids First Medical Center: https://www.kidsfirstmc.com/
Villa #1171A Al Wasl Road
Dubai
Telephone: 04 348 (KIDS) 5437
E-mail:info@kidsFIRSTmc.com
