Attention Deficit Hyperactivity Disorder is a Spectrum of Conditions – Q & A session with an expert.
(Focus - Australia)
We present our discussion on ADHD with Dr. Soumya Basu, a renowned Child and Adolescent Psychiatrist from Melbourne.
People with ADHD (Attention Deficit Hyperactivity Disorder) often get distracted, sometimes with severe consequences. ADHD prompts them to take unwarranted risks; for e.g., they can climb up on a tree, fall, and break their legs. They also get distracted while crossing the road, which could result in accidents - says Dr. Basu
Dr. Soumya Basu is an Associate Professor, Child, and Adolescent Psychiatrist, currently serving at Dept. of Psychiatry, Monash University, and ELMHS, Monash Health, Melbourne, Victoria, Australia.
If there is a childhood trauma where they have experienced significant abuse, patients can feel more anxious and agitated without necessarily having ADHD. If there are other neurodevelopmental disorders like autism spectrum disorder or other problems that can look like ADHD, it is not just ADHD. Emotional neglect, early childhood trauma can impact brain development and simulate the symptoms of ADHD.
Good evening, Dr. Basu; thank you so much for joining me today. Doctor, I understand that ADHD is a chronic condition that affects millions of children, and many parents are unaware of this condition. How can parents/teachers recognize that a child has ADHD?
Dr. Soumya: ADHD affects not only children but adults as well. It is a lifelong neurodevelopmental condition. There is an increasing awareness of how it affects older people and how it manifests differently.
Unfortunately, it is a big spectrum of conditions, including hyperactivity and impulsivity, which are considered the two important symptoms that can be easily picked up at school. And the other problems that are not picked up are executive functions which include planning, organization, time management, attention issues, and distractibility.
ADHD can be of two varieties.
One is ADHD combined variety, which is ADHD with hyperactivity, impulsivity, and inattentiveness.
The other is ADHD inattentive and distractible variety. Hyperactivity and impulsivity are usually picked up, as compared to the inattentive characteristic in a classroom setup.
Doctor, I have heard many parents complain that their child is hyperactive, and they have impulsive behavior, but not all the time; the child might develop or have ADHD, right? So, are there any symptoms that are often mistaken for ADHD?
Dr. Soumya: Yes, that is an excellent question. If there is a childhood trauma where they have experienced significant abuse, patients can feel more anxious and agitated without necessarily having ADHD. If there are other neurodevelopmental disorders like autism spectrum disorder or other problems that can look like ADHD, it is not just ADHD. Emotional neglect, early childhood trauma can impact brain development and simulate the symptoms of ADHD.
Can you please brief us on how you diagnose and conclude that a person has ADHD?
Dr. Soumya: It is a clinical diagnosis where you take an entire developmental history and full psychiatric assessment. Then you go through all the psychiatric symptoms that can co-occur. If you suspect someone might have ADHD, we use standardized rating scales and questionnaires for the child, the parents, and the teachers. So, when we see these difficulties in school and at home, we are much more convinced that the child may have ADHD. Still, it is not necessary that it can be the case because sometimes children can somehow manage to focus and remain quiet at school, and at home, they can at times mask their symptoms and become symptomatic where they feel safer. So, essentially, it is a clinical diagnosis often aided by rating scales, which can give us confirmation on ADHD symptoms as it is associated with many comorbid conditions. Clinical diagnosis can provide a good idea about the entire presentation.
ADHD is a spectrum of conditions. So, we have severe ADHD and milder forms of ADHD at one end. Because of these significant problems with executive functioning, planning, organization, time management, and self-motivation, people may be under constant stress. From early childhood, they can be criticized by their teachers and parents, may be corrected, may underperform in multiple areas, and likely to develop chronic self-doubt. So, the psychological pressures in various areas result in secondary problems, and obesity is secondary to self-gratification through food, which is lacking in daily life.
Talking about the risk factors, can you elaborate on the genetic and environmental risk factors of ADHD?
Dr. Soumya: ADHD is a genetic condition. So, if there is suspicion of ADHD, there would likely be a family history of patients with this condition. And this is even more common for girls with ADHD. It is a condition often picked up more in boys than girls because boys often suffer from the combined variety, a combination of hyperactivity, impulsivity, and inattentiveness, but girls with ADHD often suffer more from inattentiveness, which is often not picked up. When diagnosing and assessing ADHD, we must take a family history. Then there may be first-degree and second-degree family members with ADHD and other neurodevelopmental disorders like learning disability, autism, etc., often associated with ADHD.
If we talk more about the risk factors, are there any events during pregnancy or birth that might lead to the likelihood of developing ADHD in offspring? Like exposure to drugs, premature birth, low birth weight, hypertensive disorders in mothers, etc.?
Dr. Soumya - Low birth weight and premature birth are associated with ADHD. Parental substance use, especially alcohol use, is also a factor. I do not know about the incidence of alcohol use in Indian families, but it is quite significant here in Australia. So, fetal alcohol syndrome can have several neurodevelopmental disorders, including ADHD. Sometimes smoking can be associated with low birth weight and also ADHD. It is quite interesting how much pre-existing genetics and parental substance use are associated with ADHD. It seems that the genetic predispositions may interact with the environmental factors leading to clinical manifestation.
Doctor, some studies have found prenatal exposure to maternal smoking is associated with a greater than 50% increase in the incidence of ADHD. Do you see any similar cases in your clinical practice? 
Dr. Soumya: Yes, it is quite common. Cigarette smoking is also associated with low birth weight, and nicotine can impact the developing brain. People, who continue to smoke despite knowing that they are pregnant, whether they have disorders related to impulse control as well has to be thought through.
A Swedish national register study of over 2.5 million people found ADHD patients had a threefold greater risk of obesity than their non-ADHD siblings and cousins. So, what are your thoughts on it, doctor?
Dr. Soumya: It is correct. Because for ADHD patients, one of the core problems is impulsivity and self-regulatory behavior. Often ADHD symptoms are associated with significant lifelong stressors, like poor academic performance, chronic sleep, and poor sense of self. And you must understand that ADHD also can be conceptualized as a hypo dopaminergic state in the brain that constantly seek reward. Food can be the most primitive among all these rewards; being impulsive in eating can cause obesity; impulsivity around sexual behavior can lead to teenage pregnancies, and impulsive behavior can also lead to risk taking while driving leading to car accidents.
So, are there any other medical problems commonly associated with ADHD?
Dr. Soumya: ADHD is a spectrum of conditions. So, we have severe ADHD and milder forms of ADHD at one end. Because of these significant problems with executive functioning, planning, organization, time management, and self-motivation, people may be under constant stress. From early childhood, they can be criticized by their teachers and parents, may be corrected, may underperform in multiple areas, and likely to develop chronic self-doubt. So, the psychological pressures in various areas result in secondary problems, and obesity is secondary to self-gratification through food, which is lacking in daily life. For an average child, the gratifying experience can be doing good in studies or having good friendships and close relationships. But for a child with ADHD, all those things are lacking, and food is the only reward. So, they can develop secondary problems related to food.
Similarly, because of their inattentiveness, they can get into all sorts of problems. They are much more accident-prone and more prone to head injuries. Because of ADHD, they may take significant risks, climb up on a tree and fall and break their legs, get distracted while crossing the road, and get into accidents as a result. In this modern life, for existence, you need to have much more organizational ability, and in this world, we have so much distractibility. But a child with ADHD is almost hardwired to distraction, so they are at a risk of having more accidents, which can give rise to many problems. They are prone to develop anxiety and depression; secondary to that; there will be problems like suicide, a high risk of pregnancy, substance use, and other related issues. So, a multitude of problems can be associated with ADHD.
There is a tremendous source of enthusiasm in the clinical community; the parents, the ADHD advocates, and psychiatrists to gain the government's attention as much as possible. But Australia is a welfare state. It is the only country in the world where we have a National Disability Insurance Scheme (NDIS), which is a mind-boggling initiative that is not there in any part of the world. So, ADHD has not met the cut yet into the NDIS system, but conditions that are often associated with ADHD, like people with autism, can get a massive amount of package, which can be helpful.
Now talking about the treatments, could you comment on the pharmacological and non-pharmacological treatments available for ADHD?
Dr. Soumya: First, understanding the nature of the condition, providing psychoeducation to the child and the family, and understanding where the difficulties can be of great help. Then having an infrastructure where the educationalists, the teachers, and students are aware of this condition and understand how severe and complex this problem is can create a more validating environment.
Most of the research has been on medications, and excellent medications can help treat ADHD. So, from a medication perspective, we have two varieties of medicine.
The first varieties are called stimulants. And among them are methylphenidate (MPH) and dexamphetamine (DEX). These two stimulants have robust evidence for almost a life-changing impact on people with ADHD. It is a highly treatable condition, but some people cannot tolerate stimulants, which can have side effects. The treatment causes loss of appetite, significant weight loss, and sometimes growth retardation. So, that is one of the significant side effects of the medication. So, both obesity and significant growth retardation are seen in individuals with ADHD.
Some people cannot tolerate stimulants, so they must use non-stimulants. In non-stimulants, we have three medications: Atomoxetine, which is available in India. Among the other two, one is available in India, and the other one I do not think is available. One is guanfacine, and the other is clonidine. Often people with ADHD can be impulsive, their emotions can be sudden, and they can become angry quite quickly. So, sometimes these medications can help to regulate their emotions better.
From a non-medication perspective, there is massive research on the non-psychotherapeutic approaches. There is an emerging evidence base for cognitive behavioral therapy, which can help with the secondary conditions often associated with ADHD, like depression and anxiety. And now, there is a considerable impetus for meditation, and mindfulness, yoga, in managing the distraction. Indian psychotherapeutic mindfulness and meditation methods are now well researched in this domain in managing distractibility and mind wondering, the results are exciting.
People with ADHD do well in a structured environment with predictability. Time management is a problem, so if you can manage the time, activity scheduling, children can do very well. They do well with rewards because they have a brain that always seeks rewards. So, if the tasks are shortened with a reward, that can be much more helpful. Parental psychoeducation is very important to understand and educate the parents on how to deal with these children without getting exasperated and then radically accepting this condition.
An Indian movie called "Taare Zameen Par" discusses inattentiveness and learning disabilities and how to embrace this. Sometimes people with ADHD have extraordinary talents, and their problem-solving ability can be hardwired in different ways; they can see things from different angles. So, conventional education and conventional life might be challenging for them; the parents must accept what is going on, understand that they have a condition, and, often, acknowledge to celebrate their uniqueness. Some of them can be brilliantly talented musicians and actors and have talents in different areas that need to be understood and nurtured. And often, these children will need parental help for support as they have an executive functioning problem, so the negative criticism and the use of harsh language can be more damaging to these children and demotivate them. So, that needs to be understood. The child and the parents would also need 'child-focused parent's therapies' to help the parents negotiate this difficulty in raising a child with ADHD, which is more challenging.
Thank you for the detailed explanation, Dr. Basu. While preparing for this interview, I went through the ADHD cases in Australia and found that around 1 in every 20 Australians has ADHD. 
Dr. Soumya – That is a conservative estimate. The real figures may be higher.
First, early detection, diagnosis, and understanding of the condition can be critical. We have got best treatments for people with ADHD.
So, are there any initiatives by the government to address the social stigma and raise awareness of ADHD in Australia?
Dr. Soumya: There is a tremendous source of enthusiasm in the clinical community; the parents, the ADHD advocates, and psychiatrists to gain the government's attention as much as possible. But Australia is a welfare state. It is the only country in the world where we have a National Disability Insurance Scheme (NDIS), which is a mind-boggling initiative that is not there in any part of the world. So, ADHD has not met the cut yet into the NDIS system, but conditions that are often associated with ADHD, like people with autism, can get a massive amount of package, which can be helpful. In universities and schools, children with ADHD get more time to finish their tasks. If we can explain, they can get extensions to complete their work. Also, there can be discrimination; for example, kids with ADHD are often more prone to car accidents, so they need a psychiatrist's report to get a driving license.
There is a push to recognize ADHD in the NDIS system. The condition is getting a lot of media attention as the consumers and people with lived experience are gradually raising their voice.
Doctor, you mentioned that ADHD patients and their parents are constantly stressed. So, what is your key takeaway message for ADHD patients and their families?
Dr. Soumya: First, early detection, diagnosis, and understanding of the condition can be critical. We have got best treatments for people with ADHD. I have seen ADHD in every profession, including surgeons, bankers, and football players. Michael Phelps, the greatest of all sportsmen in the history of the Olympics, has ADHD. So, it is not all doom and gloom; compassionate understanding of the problem and realizing that coercive techniques, ruthless criticisms, and cruel words, sometimes used by the parents, can stick with these kids forever. These people can be brilliant because they solve the problem not by conventional methods but from a different angle altogether. Because they have this innate capacity for out-of-the-box thinking, they must be understood and celebrated in many ways.
We have these two conditions, autism and ADHD.
Autism is the most well-advocated child psychiatric condition in the world.
But in ADHD, there has been a lot of controversy and mis-understandings which has caused a lot of disadvantage to children and adults with the condition which is very treatable.
So, that would be my take-home message for parents. And the parents also need to understand that radical acceptance is essential. Some excellent books have come up; there is a book called "12 principles of raising a child with ADHD" by Professor Russell Barkley, which can be very helpful for parents. And then there is a new book I recommend to many parents called "ADHD 2.0" by Edward M. Hallowell, a psychiatrist with ADHD. So, it is written in a way that has this whole brain approach towards ADHD, the role of exercise, the part of time management, understanding the condition, and pre-empting where the mistakes can happen can be helpful. Thank you, Dr. Basu, for your time. It was an insightful discussion.