Attention Deficit/Hyperactivity Disorder (ADHD) affects 1 in 20 children, and an estimated 1-million South African adults, yet it is a condition often misdiagnosed, and plagued by myths and misunderstandings, particularly with regard to treatment.
When undiagnosed or not effectively treated, ADHD often sees children being unfairly labelled as naughty, delinquent, unteachable, and adults as lazy, lacking focus or incompetent.
Dr Renata Schoeman, co-convenor of the ADHD Special Interest Group of the South African Society of Psychiatrists (SASOP) says it’s important to shed light on this condition which hampers sufferers’ educational performance, self-esteem, relationships and work productivity, and leads to increased risk of other psychiatric disorders, reduced social functioning, delinquency, and substance abuse.
“The negative impact of ADHD on a person’s overall quality of life can be substantially improved with the correct diagnosis and effective, multi-modal treatment which includes medication, behavioural therapy and social and educational support.”
According to Dr Schoeman, registered and approved medication for ADHD in combination with psychotherapy, remains the mainstay of treatment.
“Psychotherapy, whether individual, family or group, and particularly cognitive behavioural therapy (CBT) has the most definitive evidence for its benefit to ADHD patients.
“Therapy provides support to the patient and their family, assists in developing acceptance of the disorder and coping skills, and helps in treating other (co-morbid) conditions that can accompany ADHD such as anxiety, depression, learning disabilities and substance abuse, and benefits organisational and social skills.”
A healthy diet and regular exercise have many benefits for physical, mental and emotional health, and there is some evidence that physical activity benefits ADHD symptoms, she said.
While a multi-modal approach (the combination of pharmacological and psycho-social intervention) is the most widely proven and accepted treatment for ADHD, there are also a host of other treatments including diet and supplements, complementary and alternative medicine (CAM), exercise, and “brain training” methods such as neurofeedback.
But Dr Schoeman warns that many of these require more research to scientifically prove their effectiveness and safety.
She said a systematic review and meta-analysis of more than 50 controlled trials of dietary and behavioural interventions had shown that some alternative treatments did hold promise, but required more scientific evidence before they could be recommended as part of, or stand-alone, ADHD treatment.
These included some promise for omega-3 fatty acid (fish oil) supplements and elimination diets (cutting out artificial colourings, flavourants and preservatives), but the research on both had shortcomings and needed more thorough investigation, she said.
“Randomized controlled trials of CAM products such as herbal medicines and dietary supplements are lacking and it cannot be recommended as treatment for ADHD, although it may be of benefit in some individuals with mild symptoms. People are often unaware that in many of these products, the side-effects outweighed any potential benefits.”
Dr Schoeman also emphasizes the importance of accurately diagnosing ADHD in order to arrive at the most effective treatment for managing the condition, with each patient presenting a unique set of circumstances and requiring an individualised treatment programme.
“A comprehensive clinical assessment should be conducted by a qualified healthcare professional such as a pediatrician, child psychiatrist or psychologist, in line with internationally accepted diagnostic criteria. Rating scales provide useful screening measures, and for monitoring the response to treatment, but cannot be relied on for a diagnosis on their own.”
“In a process sometimes referred to as one of “skillful exclusion”, it is important to identify other possible physical, psychiatric or emotional causes of the typical ADHD symptoms of hyperactivity, inattention and impulsiveness, as well as any accompanying (co-morbid) conditions.”
“Further testing for associated issues such as developmental, learning, speech, sight or hearing problems may also be needed, as well as input from teachers and other educational professionals or therapists.”
ADHD is characterised by a persistent pattern of the “core triad” of symptoms of inattention, hyperactivity and impulsivity that impair development and functioning, and are often coupled with behavioural, cognitive and social problems that can lead to difficulties in interpersonal relationships and in school and work performance.
Signs of inattention include difficulty in staying focused, wandering off tasks, lacking persistence, being disorganized, poor time management and procrastination.
Hyperactivity refers to excessive, inappropriate activity such as constantly fidgeting, talking or leaving their seat in class, is often “on the go” and has difficulty playing quietly; while impulsivity shows in poor self-control such as a short temper, social intrusiveness, making spur-of-the-moment decisions without considering the consequences, and addictive behaviours.
Dr Schoeman said although some children appear to “outgrow” ADHD, the condition does continue into adolescence in most cases and it more a case of some becoming more skilled in managing the symptoms and, as adults, compensating for their ADHD-related impairment through lifestyle and career choices.
“ADHD can continue to have a severe impact, with many adults with ADHD going untreated for most of their lives while being at increased risk of other psychiatric conditions, substance abuse and work-related problems caused by their poor time management and organisational skills.”
With a view to ensuring that those suffering from the condition are correctly diagnosed and receive effective treatment and support, she co-authored the first South African guidelines on the assessment and treatment of adult ADHD, published in the South African Journal of Psychiatry in 2017.
What to look out for?
A persistent pattern combining:
- Inattentiveness – easily distracted or forgetful, failing to follow instructions or finish tasks, wanders off task or topic, lack of attention to detail or careless mistakes, disorganised, procrastination, reluctant to engage in tasks requiring sustained mental effort.
- Hyperactivity – fidgeting, tapping, talkativeness, especially in inappropriate situations such as during class; seems to be “driven by a motor”; has difficulty playing quietly.
Impulsivity – has difficulty waiting their turn, eg to answer questions in class; often intrudes on others or butts into conversations; short temper or low tolerance for frustration; making snap decisions without considering consequences; addictive behaviour.
It’s important to note that none of these behaviours or symptoms in isolation constitutes ADHD. The pattern needs to have persisted for at least six months, be inappropriate for age or developmental level, and/or impact negatively on the person’s social functioning and work or school activities.
Where to get help?
- The child’s school, a clinic doctor or general practitioner should be able to assist with referral to specialist help.
- Assessment and diagnosis needs to be done by a qualified healthcare professional such as a pediatrician, child psychiatrist or child or clinical psychologist.
What treatments have been proven effective?
- For children under 5 years, and those with mild ADHD symptoms, the initial focus is likely to be on psycho-social interventions such as educating the parents, individual and group therapy and training in social skills and areas such as improving memory and concentration.
- With moderate and severe ADHD, medication (stimulants and non-stimulants) go hand-in-hand with psychotherapy, behaviour training and social and educational support.
- A healthy diet and regular physical activity are recommended in addition to medication and psycho-social interventions.