Pediatrician and our ADHD expert, Dr. Billy Levin, discusses the importance of properly understanding ADHD in children.

Children with special learning disabilities exhibit a disorder in one or more of the basic psychological processes involved in understanding or in using spoken or written language. These may be manifested in disorders of listening, thinking, reading, writing, spelling or mathematics. They include conditions, which have been referred to as perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia, development aphasia, hyperactivity etc. They do not include learning problems which are due primarily to visual, hearing, or motor handicaps, to mental retardation, emotional disturbance, or to environment disadvantage (Clements, 1966)".

The out-dated term, Minimal Brain Dysfunction (MBD) is no better or worse a name than the other 40 odd names suggested for this condition but it has severe shortcomings. For instance, the word "minimal" refers to the degree of cerebral damage or probably more accurately, dysfunction, which is minimal, compared to cerebral palsy or retardation, but the condition M.B.D. or the ramifications of the condition are certainly not minimal. More recently Attention Deficit Hyperactivity Disorder (A.D.H.D.) and in the teenager Residual Attentional Deficit (R.A.D.) has become acceptable.

It is the most common and largest single problem seen by psychologists and doctors working in this field. The age at which it presents itself stretches from infancy to senescence. Presentation being from Minimal Brain Dysfunction (M.B.D.) in the child to Adult Brain Dysfunction (A.B.D.), Attentional Deficit Disorder (A.D.D.) to Residual Attentional Deficit (R.A.D.) in the adolescent. As the condition becomes better known to more practitioners, more adults are going to be recognised as needing treatment.

The incidence of A.D.H.D. is about 10% of all school children and is found very much more in boys than in girls. The reason is because boys have a higher incidence of right brain dominance than girls do. The male hormone Testosterone boosts the right hemisphere and Estrogen, the female hormone, boosts the left hemisphere. It presents as either a learning problem (left brain immaturity) or behavior problem (right brain excess), or both. If seen by someone familiar with the condition it is easily diagnosed even before the child goes to school. Far too many children are only being diagnosed late, when major problems have already developed. The incidence does appear to be increasing simply because the population is increasing but also because the diagnosis is being made more frequently. This is encouraging but still not enough. A.D.H.D is still a very much under-diagnosed condition.

Diagnosis of ADD

Despite the high incidence, the devastating effects on the individual, and his family, and the prolonged morbidity of the condition, even after school going age, it is frequently misdiagnosed by unenlightened medical and paramedical personnel, or when diagnosed, poorly treated. It should be added that, even when the correct diagnosis is made and the treatment suggested facilities are too often inadequate, lacking entirely or stifled by negativism.

There is probably only one real cause, and that is a biochemical neurotransmitter deficiency in the brain, that is genetic and maturational in its nature. This predisposes the brain to an above normal susceptibility to any stress, be it physical (temperature or trauma) emotional, oxygen deficiency, nutritional depravation or bacterial invasion. Prematurity of the nervous system especially the left hemisphere of the brain also plays a part as premature infants and twins are more susceptible. The maturity lags of these children form an integral and prominent part of the diagnosis.

There are clearly psychological factors, but these are invariably secondary in nature, certainly part of the syndrome, but never the cause. With adequate treatment, most secondary emotional problems fade rapidly.

Being a syndrome all the symptoms are not required to be present to make a diagnosis. It is acceptable to confirm a diagnosis if some of the traits are present, and at that, in variable degrees from mild to severe. It needs to be understood that the milder forms should be recognised if only to receive more understanding and not necessary medication.

In infancy, colic, insomnia, excessive vomiting, feeding problems, toilet problems, restlessness and excessive crying are common. The restless baby becomes an overactive, frustrated and difficult child at nursery school. At school the learning and concentration problems develop resulting in underachievement and poor self-esteem. At first the reading problem manifests (auditory imperception) but not early maths. Later when story sums are done the maths takes a down turn. These students cope better with Geography than with History. Better at Geometry than Algebra and usually love Art and Music and especially action shows on television. All these are due to right hemisphere talent and or left hemisphere immaturity. Gradually the activity level slows down at puberty or later, but the fidgety and restless nature remains and sometimes the impulsiveness as well. The last to fade and usually the most troublesome are the frustrations and the inability to concentrate on a task for very long. Yet in certain instances they can focus their attention more easily, provided they are involved in a right brain activity such as chess.

Problems of co-ordination in the early years manifest as lags in ability to cope with the expected age related tasks but later the child is often clumsy and either poor at ball games or has an untidy handwriting or both. Yet some are highly skilled at ball games? Inco-ordination as a maturity lag and lack of inhibitory function sometimes results in enuresis (bed wetting) and encopresis (soiling pants), and is more prevalent during periods of stress but is not caused by stress.

These children have severe problems with auditory perception and verbal concentration. The inability to concentrate for any length of time on a given task, and the ability to be so easily visually distracted, makes learning a major problem. Yet learning on a computer, which is visual/mechanical is a pleasure.

With the passing of time, their developmental disability, especially in language, is now coupled with a slowly developing educational lag, to a point where they are unable to cope with the work expected of them in school. At this point, the daydreaming problem starts to show itself. (These children cease to daydream when tasks are set at their level of ability, and they can enjoy the success). The vicious cycle soon establishes itself where poor achievement leads to unfair criticism to poor self-esteem, demotivation, frustration and failure.

The aforementioned negativity is very poorly tolerated by the A.D.H.D. child who becomes supersensitive to criticism and often very aggressive and antagonistic to any form of discipline. In the teenage years depression often develops. He has constant excuses to explain inability. His impulsive nature often allows him to get into trouble before he realises what is happening to him. He will either act impulsively first, and then think about the situation afterwards. Or having erred, will explain with an untruth. Although he might even regret it, he will be too proud to admit it. These children clearly first act and then think and this often accounts for their accident proness, or getting into hot water at school or with the police. They also struggle to sequence events and organize themselves, and in so doing create even more problems for themselves.