The challenges of recognising ADHD

Attention deficit/hyperactivity disorder (ADHD) is frequently under-reported, says Dr Serena In, Clinical Psychologist and Senior Lecturer at the IMU University. The prevalence of ADHD in Malaysia has been estimated at 1.6-4.6 percent by the Ministry of Health. [Sahril N, Ahmad NA, Idris IB, et al. Mental health problems of children. National Health and Morbidity Survey 2015. Kuala Lumpur: Ministry of Health Malaysia; 2015:190-205, Asian J Psychiatr 2011;4:41-44] The wide range shows the fact that ADHD is seldom recognised and under-diagnosed, she said.

A study showed that boys are three to four times more likely to have ADHD compared to girls. [Asian J Psychiatr 2011;4:41-44] Serena said the figures may not be precise because girls have the ability to adjust their behaviour according to social standards and thus, may not be diagnosed. “I don’t think we will ever have true numbers as it depends on the entire healthcare system to systematically address this area of concern,” she said.

ADHD, a neurodevelopmental disorder that begins in early childhood, influences brain development and affects the way a child functions, but it is not a behavioural problem, Serena emphasised. She described three types of ADHD: the predominantly hyperactive-impulsive type, the predominantly inattentive type or a combination of both. While the hyperactive-impulsive types have impaired concentration, are restless and lack self-control, inattentive types have recurrent memory lapses.

Although ADHD is an inherited condition, other possible causative factors include exposure to hazardous medication in foetal stage and environmental toxins in early childhood. Also, experts have been cautioning parents to postpone screen time in children as much as possible because the increasing speed of movies, constant advertisements and notifications can lead to sensory overload, addictive behaviours and shorter attention spans. Serena noted that more longitudinal studies need to be conducted to further gauge the impact of overusing devices.

Diagnosing ADHD
The first step to diagnosing a child with ADHD begins with the observations of parents and caregivers in multiple settings including home, school, babysitter’s home, and recreational activities. When the observations indicate the child’s behaviours across these settings form a pattern, the child is usually referred to a clinical psychologist based on best practices in other countries.

Comprehensive assessment will take a minimum of three sessions. During the sessions, the clinical psychologist uses a combination of assessment tools, behaviour observations, cognitive assessments as well as other adaptive functioning screening to rule out other disorders. Besides deriving a diagnosis, the clinical psychologist will also identify the child's strengths e.g., memory abilities, creativity or the ability to hyperfocus on areas of interest, by doing a thorough assessment. Essentially, a diagnosis leads to specific and practical recommendations, as well as a treatment plan that is tailored for the child.

A treatment plan could be based on therapy, or medicine or a combination of both and is a useful guide for the parents or caregivers. Serena noted that if medication is recommended, the child will be referred to a psychiatrist for the necessary prescription. She highlighted that attempting to diagnose with online tests can lead to misdiagnosis or over-diagnosis. Parents can be referred to both private or public health clinics depending on levels of affordability and urgency of the case.