Attention Deficit Hyperactivity Disorder
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Direct answer
Diagnosis of attention deficit hyperactivity disorder rests entirely on structured behavioural criteria — there is no blood test, scan or EEG. DSM-5 requires at least six of nine inattention symptoms and/or six of nine hyperactivity-impulsivity symptoms, present for six months or more, beginning before twelve years of age, evident in two or more settings (home and school), and impairing function, beyond what is developmentally expected. Combined presentation is commonest, followed by predominantly inattentive (the daydreaming girl who is missed) and predominantly hyperactive-impulsive. Treatment layers behavioural parent training and classroom accommodations with medication for children above six — stimulants such as methylphenidate first line, atomoxetine and alpha-2 agonists as non-stimulant options — while under six years, behaviour therapy comes first.
What you must remember
- Criteria counts: six of nine inattention items (careless mistakes, losing things, not listening, avoiding sustained mental effort, easily distracted, forgetful, fails to finish tasks, difficulty organising, loses track in tasks); six of nine hyperactive-impulsive items for six months, onset before 12, two settings, functional impairment.
- Prevalence and biology: roughly 5-8 per cent of school-age children, boys diagnosed about two to three times more often; high heritability (around 70-80 per cent) with dopaminergic and noradrenergic pathway genes implicated.
- Rating instruments: Conners rating scales (parent and teacher versions) and the Vanderbilt — DSM-based checklists quantifying symptoms across settings; teacher input is mandatory, not optional.
- Medication hierarchy: above six years, stimulants (methylphenidate, or amphetamines in some markets) have the largest effect size; non-stimulants — atomoxetine, clonidine, guanfacine — when stimulants fail, are not tolerated, or with comorbid tics or anxiety; under six years, parent behaviour training is first line.
- Stimulant practicalities: short-acting methylphenidate two to three times daily or long-acting once daily; monitor appetite, weight, height velocity, sleep, heart rate and blood pressure; avoid late-day dosing for insomnia.
- Comorbidity ladder (the rule, not the exception): specific learning disorders, oppositional defiant disorder, conduct disorder, anxiety, tics, language disorders, and epilepsy; treatment plans must sequence these.
- Mimics to exclude before diagnosing: hearing or vision impairment, sleep disorders (OSA is a classic masquerader), absence epilepsy, thyroid dysfunction, lead exposure, attachment and trauma-related behaviour, and simply inappropriate classroom demands on a bright or immature child.
- Outcome honesty: symptoms persist into adolescence in over half and into adulthood in a substantial minority; structured environments, medication and treating comorbid learning disorders improve academic and social trajectory.
How to work through it
Sequence a real referral: a seven-year-old, diary full of complaints from three teachers, homework battles at home, and a mother already labelled "poor disciplinarian" by the family. Step one, reframe: obtain parent and teacher rating scales (Conners or Vanderbilt) and a detailed developmental and perinatal history, and screen hearing and vision. Step two, map impairment — is it inattention at desk tasks, impulsive aggression, or both — and probe comorbidity: reading level, tics, anxiety, sleep quality (ask about snoring). Step three, decide: under six, refer for parent behaviour training; above six, combine school accommodations (front seat, short tasks, movement breaks, written instructions) with a trial of methylphenidate, titrated weekly against teacher reports. Step four, monitor growth, appetite, sleep and blood pressure at every visit, and review the diagnosis if response is poor — a child who worsens on stimulants may have bipolar disorder or a learning disorder doing the driving.
Where the Indian context bites
Three Indian realities shape practice. First, under-recognition of the inattentive girl: the quiet child staring out of the window fails silently in large classrooms of 40-plus students and is written off as lazy, while the disruptive boy at least gets noticed. Second, the stigma-and-suspicion cycle around stimulants: methylphenidate is a Schedule X drug in India with tight prescription and pharmacy rules, and parents frequently refuse "addictive medicine for a behaviour problem" — counselling that stimulants reduce, not raise, later substance misuse risk is part of the prescription. Third, comorbidity dominates outcomes: an undiagnosed specific learning disorder makes medication look like a failure, so every ADHD child with school decline needs an educational assessment, and under the Rights of Persons with Disabilities Act and Samagra Shiksha provisions, formal certification unlocks accommodations such as scribes and extra exam time.
Frequently asked questions
How many DSM-5 symptoms are required to diagnose ADHD?
At least six of nine inattention and/or six of nine hyperactivity-impulsivity symptoms, for six months, onset before age 12, in two or more settings with functional impairment.
What is the first-line treatment for a four-year-old with ADHD?
Parent-mediated behaviour therapy, not medication; stimulants are reserved for age six years and older (with some regulatory allowance for five-year-olds at specialist discretion).
Which rating scales support the diagnosis?
Conners 3 and the Vanderbilt scales, using both parent and teacher forms; diagnosis is never made on a single informant.
What must be monitored in a child on methylphenidate?
Appetite, weight, height velocity, sleep, pulse and blood pressure at each review, plus misuse potential in adolescents.
Which common condition mimics ADHD and must be excluded?
Obstructive sleep apnoea from adenotonsillar hypertrophy — fragmented sleep produces inattention and hyperactivity that resolve with the sleep disorder treated.