By Bernadine Rodrigo
“Don’t play with her, she’s hyperactive.”
“He has a problem, he’s hyper.”
“Those children are violent, they’ll hurt you.”
“They’re not normal.”
“Something’s wrong with them.”
These are some of the overwhelmingly hurtful phrases that have been said in reference to children who are just like other children, bar a slight neurobiological difference that alters their behaviour into being more energetic than the rest – Attention Deficit Hyperactivity Disorder, aka. ADHD.
Although ADHD is researched on in many other countries such as the US where a population of more than six million children are reported to have it, in Sri Lanka, where a population of 5.1% is believed to have the disorder, according to a study published in the Journal of Burn Care and Research in 2008, for the most part, only mental health professionals are aware of it.
Firstly, when it comes to Sri Lanka, people are unsure of what the disorder really is. Children with the condition are often simply referred to as being “hyper”, which is a word that rings with a great deal of stigma and negativity, and, unfortunately, is used out of ignorance.
When we asked the public what they thought about ADHD, apart from a few students of psychology, all we got were blank stares and a few comments referring to it as a “mental health disorder”. In addition, when we asked those persons about hyperactivity, strangely, they said: “Those who are hyperactive cannot bear to have emotions – they feel things in extremes and that makes them unable to handle it.” This simply goes to show just how unaware of the disorder the people in Sri Lanka are, or that if they have heard of it, they are unaware of the details.
Of course, one cannot be expected to know something just out of the blue; their lack of knowledge could be attributed to the lack of focus on this subject in the education system. However, if we are to try to pinpoint who and what is to blame for the lack of knowledge among the public, nothing will get resolved. As such, all that can be done right now is for the more knowledgeable to enlighten the less knowledgeable on the subject. This is indeed appropriate for the month of October as it is officially ADHD Awareness Month.
University of Jayewardenepura Faculty of Medical Sciences Department of Psychiatry senior lecturer and Colombo South Teaching Hospital Kalubowila honorary consultant psychiatrist Dr. Dulshika Waas backs up our point on the public’s unawareness. She said: “People like to view it more as an issue with behaviour rather than make a psychiatric diagnosis.”
Locally practicing psychologist Dushika Soundararaj too, further confirmed it as she said: “People sometimes bring their patients to me; parents bring their children to me hoping I could provide them with a ‘cure’ for what they believe is a mental disorder causing their child to behave more actively than other children but in truth, it is the neurobiological disorder of ADHD.”
What causes ADHD?
An exact cause of ADHD has not been pinpointed as yet and many biological, hereditary, environmental, and medical, including psychological, reasons have been provided by various psychiatrists, medical doctors, and other experts since the discovery of the disorder.
ADHD is believed to have a strong genetic predisposition, as it is seen being passed from generation to generation and at the same time, it has also been discovered that it is more likely to occur in children who have suffered significant traumatic experiences.
Earlier, scientists thought that low levels of a neurotransmitter named dopamine caused ADHD. Dopamine is a neurotransmitter implicated in many psychiatric problems. Among other things, dopamine impacts movement, mood, motivation, and attention.
More recent evidence suggests that the relationship between dopamine and ADHD is a bit more complicated.
Individuals with ADHD seem to have an excessively efficient dopamine removal system. They have a higher concentration of dopamine transporters called reuptake inhibitors. When dopamine is removed too quickly, it doesn’t have sufficient time to exert its effect. Researchers believe that this overly efficient transporter process may help to explain some ADHD symptoms.
Further, they now believe that it could be caused by the reduction of two other neurotransmitters: norepinephrine and serotonin. These neurotransmitters influence brain function in the cerebellum. Hormones are messengers that communicate with both the brain and the rest of the body, via the blood stream.
In contrast, neurotransmitters communicate within the brain. Some chemicals operate as both neurotransmitters and hormones. When norepinephrine functions as a stress hormone, it affects attention.
Serotonin is another neurotransmitter implicated in ADHD. It influences mood, social behaviour, sleep, and memory. Low levels of serotonin may impair these important functions. As previously mentioned, some studies seem to indicate that there are different levels of neurotransmitters in the brain between the three subtypes of ADHD:
predominantly inattentive, predominantly impulsive/hyperactive, and combined.
Also, some neurotransmitters affect the release of certain hormones and hence, it is important to know that there are many credible, scientific explanations for the involvement of neurotransmitters and hormones in a disorder such as ADHD.
How is it diagnosed?
As ADHD has three subtypes, its diagnosis goes as a deferential diagnosis according to Soundararaj. “Some people dominantly show attention issues and some people show hyperactive issues. For it to be ADHD, both have to be present,” she said.
If the issues are only to do with attention, it is more likely that the disorder is ADD (Attention Deficit Disorder) which contains no hyperactive element. There is a further issue on the matter of diagnosis according to Soundararaj.
She said: “Sometimes, there is confusion that ADHD can only occur in children. It is most often viewed as a disorder that only children get as adults are believed to be entitled to their own behaviour, sometimes regardless of how irregular it is.
“However, adults get it too. It most certainly is not just a children’s issue. Sometimes, adults show it differently.
Children would have more conduct and behaviour issues while adults would have more social issues when it comes to paying attention to authorities and such.
“These qualities would most certainly affect their occupational life due to their short attention spans. For a child of course, it would affect their education and other activities they are involved in. An adult with ADHD is believed to be someone who is above the age of 17 showing symptoms of the disorder.”
When it comes to how they are diagnosed, in both children and adults, the diagnosis criteria depends on whether you have the symptoms and whether it has lasted for at least six months.
How is ADHD dealt with in today’s Sri Lankan society?
Children and adults with ADHD, or any disorder or mental illness for that matter, are often not associated with by those who believe themselves to be “normal” – this is so in the case of children too.
This is an issue that arises very largely in countries such as Sri Lanka where knowledge on the matter is very minimal.
As Janice Anthony, the head of a special needs unit in a popular school in Colombo, said: “There is still a lot of stigma around these things, especially when it comes to children, as for them, when someone is different, they feel they are outsiders.”
In her institution, they always aim to get these children to interact with the others, unless it’s exceedingly difficult to guide the child.
A child is isolated only if a class is too large and the teacher finds it difficult to keep an eye on every student. On certain occasions, the special unit’s teachers need to give direct instructions to the children on how to behave in certain situations. “Sometimes, they make mistakes just because they do not know what the right thing to do is,” Anthony said. “If they are given guidance and instructed accurately on how to behave, they happily comply because they know what to do.”
Sometimes, they are given small breaks so they can engage in an activity such as going on a walk, if they focus and work hard for a short period such as 20 minutes.
Further, instead of labelling these children as troublemakers, they try to give the children extra responsibilities so that they may channel their excess energy into doing important things that make them feel special and also make them less likely to act impulsively.
Such activities include making the child a monitor in class so he/she would feel responsible and also feel the need to adhere to the school rules as he/she is now the one setting the example, and sending the children on little errands for the teachers.
Anthony hugely recommends sports for kids with ADHD as it is one of the best ways to release all their pent up energy. Another technique they use is positive reinforcement, where they reward the child with a treat of sorts that they like whenever they properly follow instructions. In this case, their good behaviour is being reinforced and therefore, would be displayed more often by the child if continued.
However, they must be cautious when giving things such as treats as according to both Anthony and Soundararaj, items which are too sugary or energy-inducing will only make them more active. We must not aid these children in being more active but rather simply maintain their activity at a level that is beneficial for them.
Soundararaj also spoke of a clinical method that patients with ADHD who do not receive treatment from school – sometimes due to the fact that their schools do not provide treatment – can adopt in managing the disorder.
The method is a currently popular method known as CBT (Cognitive Behavioural Therapy), developed by Dr. Aaron Beck in the 60s. The procedure goes on the lines of explaining every tiny detail of the disorder to the patient and teaching them to be mindful of their behaviour and its consequences. This would make them more aware of how they act, thereby encouraging them to act in a more controlled manner and also involves rewarding them when they do so.
It is of course a sad fact that most local schools do not provide facilities such as this to its students, leading to such children being somewhat shunned by the other children who are simply unaware of the problem and therefore would only see the child as a troublemaker who is not be associated with.
This would consequently negatively affect the ADHD-affected children, stunting their personality growth.
According to Anthony, however, there is much hope in this field as she herself has worked in many schools, albeit just in the private sector, which provide great opportunities for children with special needs such as ADHD to engage with other children and obtain treatment.
An advantage of obtaining treatment from school is that it usually comes free of charge, not making the child a financial burden to his/her parents. Although an unfortunate occurrence, many parents are forced to pay great amounts for their child’s treatment which, as Soundararaj confirmed, is rather expensive.
Further, if a solution cannot be obtained through therapy, medical professionals, i.e. psychiatrists, must be consulted to provide medical aid – in a nutshell, the prescribing of pills. These are given to regulate the chemical imbalances in the patient which can sometimes lead to side effects that affect children more severely than adults. Some of the side effects include depressive feelings which, of course, are harmful to the patient.
Another issue when it comes to parents in Sri Lanka, as both Anthony and Soundararaj said, is that they refuse to accept the fact that their child has a disorder. Parents’ expectations of children are unbelievably high in this country and children, almost from the day they are born, are expected to work towards unattainable goals.
It all ultimately comes down to the lack of knowledge of the public on issues regarding children. As Anthony elaborated, they constantly try their best to not abruptly call the parents of the child to tell them their child has a problem. They always try to meet them personally, accompanied with the relevant persons, and inform them as gently as possible of the entire situation.
Sometimes, parents simply do not take the news well. According to Soundararaj, she had to provide food for a girl once, because her parents refused to care for her at all and just simply neglected even her most basic need.
Sadly, issues such as these sometimes lead to these children and also adults developing other disorders – mostly mental illness such as anxiety or depression which can lead to the dangers of self-harm. However, there is some hope that with the fast-developing world, the bubble of unawareness Sri Lankans are in will pop, and they will gain more knowledge in the field of mental health.
*the names of some individuals have been changed to protect their privacy
Photo Lavi Perchik on Unsplash