Joe is eight and he constantly feels the need to fidget and jump up during class, in a movie, as he eats his meals, or tries to read a book. He tries to wait his turn but can’t stop himself from blurting out answers during lessons and interrupting his friends. No matter how hard he tries he can’t remember where he left his favourite dinosaur toy, or his pencil, or his schoolbag, or his half-eaten sausage bun. He’s been told over and over again that he’s so naughty and frustrating. They keep telling him he’s not trying hard enough. But he does. He struggles every day to be like his friends but every day he seems to fail.
Joe is a typical case of a child with attention deficit/hyperactivity disorder (ADHD) and while symptoms and specific challenges may vary from one person to the next, the helplessness and the feeling of being misunderstood are a shared struggle for those diagnosed with the disorder.
In Malaysia, the Ministry of Health in 2020 estimated that 1.6 % to 4.6% of the country’s population was diagnosed with ADHD. The wide range reflects the fact that ADHD is not always recognised and diagnosed. “Like many other disorders, it tends to be under-reported,” says Dr Serena In, Clinical Psychologist and Senior Lecturer at the IMU University.
The available statistics show that it is more prevalent in boys who are three to four times more likely to have ADHD compared to girls. However, Dr Serena again acknowledges that these figures may not be entirely accurate as girls tend to adapt their behaviours in socially desirable ways thus leading to fewer diagnoses. “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 says.
What is ADHD?
ADHD is a neuro-developmental disorder that starts in early childhood. It affects how our brain develops and how it processes things. “It is not a behavioural problem. What happens in the brain affects the way a child functions,” stresses Dr Serena.
She explains that there are three types of ADHD – the predominantly hyperactive-impulsive type, the predominantly inattentive type or a combination of both.
The hyperactive-impulsive types have difficulty staying on a task, are always on the go and are fidgety. They can’t sit still through a class lesson, or even a movie. They may also display a lack of self-control. For example, a typical child would be able to learn behaviours such as lining up and taking turns, but a hyperactive-impulsive type will find it very difficult to do so.
On the other hand, the inattentive types tend to forget things or lose things, are easily distracted and find it difficult to concentrate. Students may frequently say they forgot their homework or appointments that they have made. They don’t seem to be listening well and lose interest, appear bored or seem like they are daydreaming.
Whichever type of ADHD a child has, they are still often dismissed as children with behavioural and discipline issues, and unfortunately, they can go through their lives labelled as being rude, uncontrollable and naughty.
What causes ADHD?
Many different factors play a part in how our brains develop. According to Dr Serena, genetics play a role, with children having a predisposition to it if it runs in the family. She adds that with identical twins, if one twin has it, it is very likely the other has it too.
There are also environmental factors such as toxins that we may be exposed to as children; as well as maternal prenatal factors such as medication consumed by a pregnant mother that can expose a foetus to potential hazards.
According to Dr Serena expert groups have also advised parents to delay screen time in children for as long as possible. The increasing speed of movies, constant advertisements and notifications can be very overwhelming and over-stimulating especially for young malleable brains that are still developing. These also can increase addictive behaviours and shorten attention spans.
“Excessive screen time also means less exercise, less quality sleep, less time for homework which ultimately affects a child’s ability to be at their best,” says Dr Serena adding that more longitudinal studies need to be done to really understand the impact of over-using devices.
How to get a diagnosis
For children, it starts with the observations of parents and caregivers in the child’s many multiple settings – from home to school, at the babysitter’s, during recreational activities and so on. “Observations need to come from more than one person and from different settings. When you see that the behaviours across these settings form a pattern, then there could be cause for concern,” explains Dr Serena. She notes that parents who bring their children for assessment have often been asked to do so by teachers. “Teachers play an important role in recognising when a child needs help,” she says.
Who would you see? In Malaysia, there isn’t a standard procedure, but best practices in other countries stipulate that you would see a clinical psychologist. Comprehensive assessment will take a minimum of three sessions. During the sessions, a clinical psychologist will use a combination of assessment tools, behaviour observations, cognitive assessments as well as other adaptive functioning screening to rule out other disorders.
Dr Serena stresses that trying to self-diagnose with online tests is a sure way to misdiagnose or over-diagnose. “Always see a registered professional as they are adequately trained to diagnose accurately,” she says.
Parents can go to both private or public health clinics depending on levels of affordability and urgency of the case. The private sector will be able to see a child quite immediately while those seeking help at government hospitals will have to wait to get an appointment. You also need to get a referral letter from a clinic or a GP if you want to get an appointment at a government facility.
During the sessions, a clinical psychologist will also identify the child’s strengths. “We don’t confirm a diagnosis and leave you with just a label,” explains Dr Serena. Through a thorough assessment, psychologists will highlight the child’s strengths for example memory abilities, creativity or the ability to hyperfocus on areas of interest. Essentially, a diagnosis leads to specific and practical recommendations, as well as a treatment plan that is tailored for the child. That is why a psychological assessment by a mental health professional is so beneficial.
A treatment plan could rely on therapy, or medicine or a combination of both and helps to guide the parents or caregivers on what to do. Dr Serena notes that if medication is recommended, the child will also need to see a psychiatrist for the necessary prescription.
Setting up for success
To help children with ADHD handle school routines better, doctors can write reference letters to advocate for certain needs accommodations such as longer exam times, to be allowed sit where he or she can get up and move during class without disrupting others, or to be allowed to use fidget toys in class. “We need to learn to manage and support these children effectively instead of just scolding or disciplining every time,” says Dr Serena.
Outside of school, psychological therapy is also essential for addressing related issues like depression or anxiety. Therapy often involves teaching children coping mechanisms, such as expressing their emotion constructively, as well as manage their behaviours by using timers and reminders which can help a child stay focused.
At home, parents can relook at how they organise family life and set up routines and habits such as structured meal times. Ensuring the house is clean, neat and orderly also helps. “These are little routines and structures that help everyone, but they are especially beneficial for individuals with ADHD,” says Dr Serena.
Next steps
According to Dr Serena, our society has come a long way in awareness and understanding of the disorder. “It has definitely progressed in the last decade,” she says, but we still have a lot to do. Awareness has to be embedded into the school system and the success of a child also depends a lot on the dedication of parents and caregivers to advocate for their children. Her message to parents is that there is no harm in coming for an assessment. Clinical psychologists are very careful not to over-diagnose and understanding your child’s struggles will help both child and parent to come up with constructive ways to not just cope on a daily basis but also to thrive in life.
She reminds us that from the outside, we may think that our child is coping. But for children like Joe, they could be struggling in silence every day. Imagine if instead of just trying to survive and cope, every child like Joe is supported so that they can flourish.
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Common perceptions about ADHD
Dr Serena sheds some light on some common perceptions of ADHD.
My child is just lazy, naughty and difficult.
If their behaviour doesn’t change despite everyone’s best efforts, the child should be assessed so that they can get the targeted support that they need. What we see as a behavioural problem may really be a medical condition. Their brains are just wired in a different way. The right support will help them to do better in class, at home and anywhere else they are. There are different ways to help them so that they can cope, but it starts with an accurate diagnosis.
My child will grow out of it.
They do not grow out of it – if you don’t get help, it gets worse. Undiagnosed, ADHD can lead to more problems. For example, when a child cannot cope in school, they get in trouble, which could lead to discipline problems. They get punished a lot; they can go into depression and might even drop out of school. Their potential is cut because they do not get the right support. On the other hand, you can actually manage well and succeed with the right treatment plan.
ADHD only affects boys.
ADHD can look different in boys and girls. Generally, girls tend to find ways to cope, for example spending extra hours to finish up homework. A girl who spends more hours studying will look like she’s coping, but she’s actually struggling. Inside they may be questioning themselves: “I study so much but I still can’t get it. I feel stupid. Why am I not as good as others?” This mask means that girls often don’t get diagnosed and this can lead to anxiety and depression.
All children with ADHD are hyperactive.
It depends on the type of ADHD that you have – the hyperactive-impulsive type, the inattentive type or a combination of both. The symptoms associated with the types present differently.
These are just usual things people need to cope with.
There is a scale of mild, moderate and severe cases. If you are in the mild range, you may be able to cope with your difficulties. However, there are those who struggle in many areas, or have other co-morbidities that they need help with. Even with mild cases, an assessment will help you understand how to work with your challenges rather than wonder why you don’t function like others do.
People have survived without a diagnosis all these years. Why the fuss now?
The people who go through their whole childhood, teenage years and adulthood without a diagnosis may function but are they in a lot of distress? It can affect your career choices, your earning potential and relationships. If they had answers earlier, it would have made a big difference, and they could have lived to their ultimate potential.
