PREVALENCE : ^(6) (7)

Ø  It affects around 7.2% of children globally, but its prevalence varies widely across different countries, ranging from 0.1% to 10.2% among children and adolescents. ⁽⁶⁾

Ø  A recent review on attention deficit hyperactivity disorder among children in India found: ⁽⁷⁾

o   Its prevalence varies from 1.30% to 28.9%, with a pooled prevalence of 7.1%.

o   Male children have a 9.40% prevalence, while female children have a 5.20% prevalence.

o   The age range for prevalence is 8 to 15 years for males and 7.6 to 15 years for females.

o   These findings indicate that it is widespread among Indian children, aligning with global trends.

AETIOLOGY: ^{(1) (2) (5) (8)}

Ø  Attention deficit hyperactivity disorder is a complex condition with genetic, environmental, and neurological factors influencing its development. ⁽¹⁾

Ø  There’s a strong genetic link, associations have been reported with variations in genes for the dopamine receptors 4 (DRD4) and 5 (DRD5) and a dopamine transporter (DAT1). ⁽²⁾

Ø  In studying attention deficit hyperactivity disorder, experts are looking closely at dopamine. They focus on the prefrontal cortex, an area that uses a lot of dopamine and connects with other brain parts responsible for attention, decision-making, memory, and control. This helps us understand how symptoms may arise. ⁽⁸⁾

Ø  Brain abnormalities include dysregulation of frontal subcortical circuits, small cortical volumes, widespread brain volume reduction, and cerebellum abnormalities. Brain injury and attention deficit hyperactivity disorder may have a bidirectional relationship, with each potentially increasing the risk of the other. ⁽¹⁾

Ø  Some factors linked to it include birth complications like toxaemia, prolonged labor, complicated delivery, premature birth, low birth weight. ⁽¹⁾

Ø  Maternal drug use, including smoking, alcohol consumption during pregnancy, and exposure to lead, may contribute to attention difficulties in children with attention deficit hyperactivity disorder ⁽¹⁾

Ø  Food coloring and preservatives inconsistently show a connection to increased hyperactivity. ⁽¹⁾

Ø  Psychosocial family stressors like poverty, unwanted pregnancy, family structure, parental psychiatric disorders, low parental education, mother’s occupation, low socioeconomic status, male gender, birth order, single parenthood, prolonged use of mobile phones, exposure to violence and undernutrition or malnutrition can contribute or worsen symptoms. ^(1) (5)

SYMPTOMS  &  DIAGNOSTIC  CRITERIA: ⁽⁶⁾ 

Ø  Many children may have struggle in sitting still, waiting their turn, paying attention, being fidgety, and acting impulsively. However, children who meet DSM-5 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder, their hyperactivity, impulsivity, organization, and/or inattention are more than expected for their age or developmental level. These symptoms can cause a lot of trouble at home, school, or in relationships. 

Ø  There are three main types:

o   F90.0 Predominantly inattentive presentation

o   F90.1 Predominantly hyperactive/impulsive presentation

o   F90.2 Combined presentation 

Predominantly inattentive type : 

Ø  Inattentive refers to challenges with staying on task, focusing, and organization. 

Ø  For a diagnosis of this type of attention deficit hyperactivity disorder, six (or more) (or five for individuals who are 17 years old or older) of the following symptoms of inattention have persisted for ≥6 months to a degree that is inconsistent with development level and that negatively impacts directly on social and academic/occupational activities: 

a.  Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

b.     Often has difficulty sustaining attention in tasks or play activities.

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

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

e.     Often has difficulty organizing tasks and activities.

f.    Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork, homework).

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

h.  Is often easily distracted by extraneous stimuli. I.e. is often forgetful in daily activities.

Predominantly hyperactive/impulsive type:

Ø  Hyperactivity refers to excessive movement such as fidgeting, excessive energy, not sitting still, and being talkative. Impulsivity refers to decisions or actions taken without thinking through the consequences.

Ø  For a diagnosis of this type of attention deficit hyperactivity disorder, six (or more) (or five for individuals who are 17 years old or older) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:

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

b.     Often leaves seat in classroom or in other situations in which remaining seated is expected.

c.      Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness).

d.     Often has difficulty playing or engaging in leisure activities quietly.

e.     Is often “on the go” or often acts as if “driven by a motor.”

f.       Often talks excessively. Impulsivity.

g.     Often blurts out answers before questions have been completed.

h.     Often has difficulty awaiting turn.

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

Combined type:

Ø  This type of attention deficit hyperactivity disorder is diagnosed when both criteria for both inattentive and hyperactive/impulse types are met.

Ø  A diagnosis is based on the presence of (A) persistent symptoms that have occurred over a period and are noticeable over the past six months. While attention deficit hyperactivity disorder can be diagnosed at any age, this begins in childhood. When considering the diagnosis, (B) the symptoms must be present before the individual is 12 years old and (C) must have caused difficulties in more than one setting. Evidence suggests that (D) the symptoms interfere or reduce the quality of, social, academic, or occupational functioning, & (E) symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder. However, it can be present in mild, moderate, or severe form. 

ASSOCIATED  DIFFICULTIES   IN CHILDREN  WITH  attention deficit hyperactivity disorder: ⁽¹⁾

Ø  Children with attention deficit hyperactivity disorder display several other difficulties in addition to their core symptoms. If not handled properly, it can be tough for parents, and the child may deal with issues like struggling in school, underachievement, behaviour and emotional problems, difficulty making relations & employment difficulties as they grow older. 

Ø  About 15-25% of children with attention deficit hyperactivity disorder have learning disabilities, 30-35% have language issues, 15-20% have mood disorders, and 20-25% also experience anxiety. It can also come with other conditions like sleep problems, memory issues, and reduced motor skills. 

EVALUATION AND MANAGEMENT OF A CHILD WITH attention deficit hyperactivity disorder: ^(1) (9)

Ø  Diagnosing and treating a child with this disorder requires a team of experts. A physical check-up and some tests may be done if needed based on the child’s history or symptoms. A thorough psychiatric evaluation is essential to identify any other problems that may seem like it.

Ø  Several well-known behaviour rating scales effectively distinguish between children with attention deficit hyperactivity disorder and those without. These include the Vanderbilt ADHD Diagnostic Rating Scale, Conner Rating Scales (for parents and teachers). Additionally, broader checklists like the Behavioral Assessment Scale for Children (BASC) are helpful, especially when a child may have other issues like anxiety, depression, or conduct problems.

Ø  According to the American Academy of Paediatrics (AAP) guidelines (2011) behaviour therapy is recommended as the first line of treatment for attention deficit hyperactivity disorder in young children and should be tried before medical therapy. The most widely used medications for the treatment are the psychostimulant medications, including methylphenidate, dexmethylphenidate, amphetamine, and various amphetamine and dextroamphetamine preparations. A combination of stimulants and psychosocial interventions in which the parents and teachers work as partners with the paediatrician and clinical psychologist, can help a vast majority of children with this disorder.

HOMOEOPATHY &  MENTAL STATES:

ADDRESSING ATTENTION DEFICIT HYPERACTIVITY DISORDER : ^{(4) (10) (11) (12)}

Ø  Human growth, studied in developmental psychology, involves the interplay of nature and nurture. It encompasses physical, behavioral, cognitive, and personality changes from conception through childhood and beyond. A child’s expressions, influenced by both inherited biological characteristics and environmental influences, forms the canvas upon which their personality is painted. ⁽¹⁰⁾

Ø  From the very inception of life, a child’s emotional palette begins to unfold, which closely tied to their physical and biological needs. The primal expressions of basic emotions, rooted in the pursuit of physical protection or survival. As children mature, their emotional palette broadens to include more complex sentiments like sadness, anger, and fear. These emotional reactions, often transient in nature, may crystallize into more enduring ’states’ and eventually mold into persistent ’moods,’ shaping the child’s perception and interaction with the world. ⁽¹⁰⁾

Ø  The culmination of these emotions forms what is termed a ’mental state’- A mosaic of symptoms shaped by environmental circumstances and individual disposition. This mental state serves as a barometer, providing insights into the individual’s present phase, evolution, and relationship to suffering. ⁽⁴⁾ Recognizing the significance of mental states, especially in childhood, is crucial for a homeopathic physician. Proficiency in identifying common emotional traits allows physician to distinguish ’normal’ from ’abnormal’ symptoms, paving the way for precise and successful prescriptions. 

Ø  Reflection in Aphorism 211 “the state of disposition of the patient often chiefly determines the selection of homoeopathic remedy, as being characteristic symptom which can least of all remain concealed from the accurately observing physicians” brings the idea that the characteristic state of disposition cannot escape the keen observation of a skilled physician. ⁽¹²⁾ Understanding the precise state of mind generating symptoms, guiding the selection of an appropriate remedy. So far the efforts at curing patients depends on one’s ability in hunting through the mass of symptoms. ⁽¹¹⁾ Establishing a precise hierarchy of mental states, Kent emphasized the paramount importance of prioritizing them.

Ø  Children with attention deficit hyperactivity disorder might find themselves struggling in school tasks and activities, leading to a cycle of perceived failure. This cycle can contribute to a sense of shame, as they may feel inadequate compared to their peers. It’s essential to approach such disorder from an individualized perspective too, as each child’s experience with attention deficit hyperactivity disorder is unique.

Ø  Thus, delving into the psyche of attention deficit hyperactivity disorder children unveils the foundations of their mental states, providing a comprehensive perspective for treating the child as a whole. This exploration fosters a deeper comprehension of the fundamental nature of attention deficit hyperactivity disorder and its intricate relationship with the disease-producing phenomenon, propelling us toward more effective treatment strategies.