The dilemma of diagnosing ADHD

Parents tend to underreport the problem in their children, while teachers may over-report it. Right diagnosis is important.

Vinay, an eight-year-old, is a sparkly child with an impish grin. Though his class teacher recognizes that he has a keen intellect, she’s often overwhelmed by his behaviour. He gets into fights with other kids, refuses to stand in line or wait for his turn on the playground, blurts out answers in class and doesn’t complete written work. His handwriting is also barely legible.

At home, his parents do not really notice anything untoward except that he tends to be dreamy and careless about his belongings. They assume he’ll outgrow such behaviours in time. However, as his teacher continues to complain about his lack of focus and impulsivity, his parents visit a psychologist who diagnoses the child with attention deficit hyperactive disorder (ADHD).

Reports say that ADHD affects 5 to 8% of children in India. How do clinicians diagnose this condition? How long do they observe the child? Do they get detailed information on how the child behaves in multiple contexts? If parents and teachers provide varying portrayals of the child, how do they make sense of these conflicting accounts? Should they give more weight to a teacher with experience working with multiple children? Or do parents know their kids best? To what extent do contextual factors play a role in the manifestation of ADHD? Many such questions remain unanswered.

Dr Akila Sadasivan, Director of Samvidh Psych Services, observes that parents often don’t perceive their child’s behaviour as problematic. Though they may describe ‘symptoms’ of ADHD when the clinician is taking down the child’s history, parents tend to rate their child favourably on standardised rating scales. ADHD symptoms often surface only in certain contexts, like a classroom. Also, some children are inattentive only in group situations but can focus one-on-one. Whereas parents tend to underreport the problem in their children, teachers may exhibit the opposite tendency.

Complexity of diagnosis

In an interview in The Harvard Gazette, two professors at Harvard Medical School, Anupam Jena and Christopher Worsham, discuss the complexity of diagnosing ADHD. In any class where children are supposedly of the same age, there can potentially be a 12-month difference between the youngest and oldest child. Younger children in a class are more likely to be diagnosed with ADHD than their slightly older peers. Especially when children are young, a 12-month age gap can spell quite a difference in developing faculties.

However, teachers tend to treat all children in a class as having the same age and developmental levels. This could be a reason why teachers tend to over-report the problem.

As neither the parents' nor the teachers' perspective may be entirely accurate, an astute clinician must make sense of these contradictions. Sadasivan points out that ADHD may manifest only in selective contexts, like certain academic periods in school. The clinician has to factor in these incongruities along with the fluctuating nature of ADHD when making a diagnosis.

In addition to getting feedback from the parent and teacher, Sadasivan and her team also establish rapport and get to know the child before conducting academic and cognitive assessments. These assessments aim to gauge whether the child lacks focus, makes impulsive errors and lacks behavioural inhibition and mental flexibility.

Rather than just looking at scores, they deconstruct the process to see how the child approaches tasks involving visuomotor perception, arithmetic reasoning and problem-solving. If they cannot observe a child over multiple days, they give the child breaks and assess them over two or three sittings that may last about thirty minutes.

The diagnosis of ADHD cannot be done in a cursory or hasty manner. Instead, a discerning clinician needs to understand the factors impeding a child’s behaviour before making a diagnosis. Given this disorder's subjective and contextual nature, educators may consider tweaking pedagogic practices before referring children for a formal assessment. Being cognizant of a child’s age relative to peers within the same class would be one place to begin.

Further, teachers may find ‘hooks’ for each topic that draw all children in. The hooks could range from children’s hobbies, personal experiences, sports, food and memes from popular culture. Providing a choice of activities for students to express their learning can help mitigate symptoms of ADHD in at least a subset of children.