Diagnosing a Child with ADHD

The principal characteristics of ADHD are inattention, hyperactivity, and impulsivity. These symptoms appear early in a child’s life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the child receive a thorough examination and appropriate diagnosis by a well-qualified professional.

Symptoms of ADHD will appear over the course of many months, often with the symptoms of impulsiveness and hyperactivity preceding those of inattention, which may not emerge for a year or more. Different symptoms may appear in different settings, depending on the demands the situation may pose for the child’s self-control. A child who “can’t sit still” or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a “discipline problem,” while the child who is passive or sluggish may be viewed as merely unmotivated. Yet both may have different types of ADHD. All children are sometimes restless, sometimes act without thinking, sometimes daydream the time away. When the child’s hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships with other children, or behavior at home, ADHD may be suspected. But because the symptoms vary so much across settings, ADHD is not easy to diagnose. This is especially true when inattentiveness is the primary symptom.

DSM-IV Criteria for ADHD
I. Either A or B:

1. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Is often forgetful in daily activities.

2. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat.

2. Often gets up from seat when remaining in seat is expected.

3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4. Often has trouble playing or enjoying leisure activities quietly.

5. Is often "on the go" or often acts as if "driven by a motor".

6. Often talks excessively.

Impulsivity

1. Often blurts out answers before questions have been finished.

2. Often has trouble waiting one's turn.

3. Often interrupts or intrudes on others (e.g., butts into conversations or games).

2. Some symptoms that cause impairment were present before age 7 years.

3. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

4. There must be clear evidence of significant impairment in social, school, or work functioning.

5. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Based on these criteria, three types of ADHD are identified:

1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months

2. ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months 

3. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.

Can you diagnose a child with ADHD? And what do you do next?

While it is one thing to talk fashionably about the DSM criteria, making a diagnosis of ADHD remains a challenge, not only to a dentist but also to Pediatricians and even experienced clinical psychologists. As Prof Malavika Kapur, one of India's leading psychologists told us, " We took a group of trained teachers and asked them to diagnose 300 students for signs of hyperactivity, of the 30 children diagnosed by them, only 10 had ADHD". It has often been reported that the chances of either under-diagnosing or over-diagnosing ADHD are indeed high. So what can we do.

Patients who are Known to suffer from ADHD

In such cases the dentist can gear up to treat the child and be prepared to handle the hyperactivity or absence of attention. See section on treating a child with ADHD

Patients whom you suspect of having ADHD

Telling any parent their child may not be normal can be a daunting task. Telling them this when there is a good chance you may be wrong makes the task even scarier. The anxiety of telling the parent can be greatly reduced by adding a few questions to your history.

"What Class is your child studying in?" This seemingly innocent question will give you a good idea if the child is having trouble keeping up with lessons. Or if the child is continuously fidgeting, then a ,"Is he like this in school?" is often enough to get the parent talking about the child's problem. A surprisingly large number of parents actually want to talk about the difficulty their child is having with a doctor. But it is important to note that a parental history of the child being a bit overactive is not diagnostic of ADHD.

If however you still feel the child has the signs and symptoms of ADHD then you are better off referring the child to an experienced clinical psychologist. In India a visit to the Psychiatrist or Psychologist is still viewed as a sign of madness. It is therefore better to put the matter as gently as possible and explain to the parent that ADHD is not mental retardation and in most cases it does not persist into adulthood. If all else fails then of course you can always point out the example of the  man who is arguably the most famous ADHD sufferer of all time : Micheal Phelps

Autism - The disease and Implications for Dental Care

Dr Sharat Chandra Pani

Autism is a severe developmental disorder that affects the way a child sees and interacts with the rest of the world. It limits their ability to interact with others socially, in fact many autism suffers avoid human contact. Autism is part of a larger group of disorders called pervasive developmental disorders (PDD).

In 1911 a  Swiss psychiatrist Eugene Bleuler, coined the term Autism to describe pepole who had a difficulty in communication, he however was referring to adult schizophrenia. The term as we know it today is attributed to Leo Kanner, an American Psychiatrist, who in 1943 coined the term while studying children at Johns Hopkins University. He based his discovery on findings from 11 children he observed between 1938 and 1943. What he studied were children who had withdrawal from human contact as early as age one.Until the 1960’s Autism was thought to be a form of schizophrenia, a misdiagnosis that led many parents to blame themselves for the problem.  It has only been in the last few decades that the medical fraternity has truly  begun to understand Autism; so it is not surprising that a great deal of confusion exists, even among the medical fraternity about the diagnosis, treatment and dental management of children with autism.

In this series of Posts DCSN looks at Autism, it's causes, probable management strategies and useful tips for the parent who is anxious about taking the child to the dentist for the first time; and also the dentist who is probably equally anxious about treating a child with autism.

 Posts for parents

 Posts for Dentists

Diagnosing Autism  

What causes Autism?  

Is a child with Autism always mentally retarded?  

Preparing your Child for a vist to the Dentist 

Preparing yourself to treat an autistic child 

Autism in India - the challenges of misdiagnosis  

Autism in India - Support Centers in India

Diagnosing Autism

Autism Symptoms vary widely in severity, include impairment in social interaction, fixation on inanimate objects, inability to communicate normally, and resistance to changes in daily routine. Characteristic traits include lack of eye contact, repetition of words or phrases, unmotivated tantrums, inability to express needs verbally, and insensitivity to pain.

Behaviors may change over time. Autistic children often have other disorders of brain function; about two thirds are mentally retarded; over one quarter develop seizures. Symptoms of autism can begin immediately after birth, but often parents begin to notice them when the child is between 12 and 18 months old. This is the age at which most infants begin to use language and show interest in social activities. A diagnosis of autism is usually made when the child is between 2 and 3 years, but new research is looking at ways to diagnose children as young as 12 to 14 months. Children with Asperger syndrome (one of five developmental disorders that represent the autism spectrum) may be diagnosed later because they do not have the same language or communication problems children with autism exhibit early on.

Some Common Signs Exhibited by Autistic Children

Spinning	Repetitive behavior (perseverance)
No speech	Balancing, e.g. standing on a fence
Flapping hands	Behavior that is aggressive to others
Walking on tiptoes	Lack of interaction with other children
Lack of eye contact	Extreme dislike of touching certain textures
Self-injurious behavior	Desire to keep objects in a certain physical pattern
Lack of interest in toys	Desire to follow set patterns of behavior/Interaction
Dislike of being touched	Treating other people as if they were inanimate objects
Non-speech vocalizations	Delayed echolalia: repeating something heard at an earlier time
Preoccupation with hands	Confusion between the pronouns "I" and "You"
Lack of response to people	Echolalia: speech consisting of literally repeating something heard
Extreme dislike of certain foods	Either extremely passive behavior or extremely nervous, activebehavior
Delayed development of speech	When picked up, offering no "help" ("feels like lifting a sack of potatoes")
Extreme dislike of certain sounds	"Islets of competence", areas where the child has normal or even advanced competence. Typical examples include drawing skill, musical skill, arithmetic, calendar arithmetic, memory skills, perfect pitch

Etiology of Autism

There is no theory of the cause of autism which everyone has found convincing. There may be multiple causes. Thus we will review some of the proposed causes. Most researchers are absolutely convinced that the cause is biological rather than psychological. Bernard Rimland in his book Infantile Autism (1965) cited the following evidence for a biological genesis and against the idea that parents cause their children to be autistic:

1. MERCURY poisoning in a genetically predisposed child 
2. Some clearly autistic children are born to parents who do not fit the autistic parent personality pattern.
3. Parents who do fit the description of the supposedly pathogenic parent almost invariably have normal, non-autistic children.
4. With very few exceptions, the siblings of autistic children are normal.
5. Autistic children are behaviorally unusual "from the moment of birth."
6. There is a consistent ratio of three or four boys to one girl.
7. Virtually all cases of twins reported in the literature have been identical, with both twins afflicted.
8. Autism can occur or be closely simulated in children with known organic brain damage.
9. The symptomatology is highly unique and specific.
10. There is an absence of gradations of infantile autism which would create "blends" from normal to severely afflicted.

Autism and the Brain

Even though the precise cause of autism remains unknown the following areas of the brain have been implicated in autism

What Does Not cause Autism

 

Of the many supposed causes for Autism, the one that created the greatest stir when published was the supposed association with the MMR (measles, mumps, rubella) vaccine . When published in Lancet in 1998 the study created a flurry of lawsuits, with parents in the United States rushing to sue the drug companies that manufactured the vaccine. However later investigation showed that the lead author of the article had a conflict of interest. In 2004 the New York Times reported that 10 of the original 13 authors had retracted their claims. Ealier this year a case control study proved without doubt the absence of any link between autism and the MMR vaccine

Hornig M, Briese T, Buie T, Bauman ML, Lauwers G, et al. 2008 Lack of Association between Measles Virus Vaccine and Autism with Enteropathy: A Case-Control Study. PLoS ONE 3(9): e3140 doi:10.1371/journal.pone.0003140

Autism in India - The Challenges of Misdiagnoses

Numerous studies have placed the occurrence of autism at a rate of approximately 1 in 500 people. At India’s current population, this means there are an estimated 1.7 million autistic persons in the country, assuming that there are no significant variations in this rate worldwide, which is a question that has not yet been addressed by epidemiologists outside the West. While the disorder is not rare, the majority of autistic people in India have not been diagnosed and do not receive the services they need. The main reason for this is a lack of awareness and misunderstanding about autism among medical professionals, who may either misdiagnose or under diagnose the condition.

One of the major difficulties faced by parents of children with autism in India is obtaining an accurate diagnosis. A parent may take their child to a paediatrician only to be reassured that their child is just "slow." Unsatisfied, they may visit a psychologist, to be told their child is "mentally subnormal." Convinced that their child does not fit the typical picture of mental retardation, they may visit a psychiatrist, to be told that their child has attention deficit disorder, and must be put on medication to control hyperactivity. After months of sedation and unsatisfactory progress, they may again begin a cycle of searching for the correct name for their child’s problem.

It is therefore very likely that a dentist may find himself/herself treating an Austistic child when the parents are unaware of the condition. It is therefore necessary for the dentist to be able to recognize the symptoms of autism and be aware of the steps he/she may take to render optimal care to autistic individuals. It is similarly important for parents to know the symptoms their child may face, and be mentally prepared for a visit to the dentist.

Large parts of this post have been based on information made available free by the NGO action for autism. Readers can read more at http://www.autism-india.org/afa_autisminindia.html

DCSN does not endorse or take responsibilty for information provided by external sources; we have however verified the information in this post and find it to be accurate to the best of our knowledge.