ADHD testing for children in India

Attention Deficit Hyperactivity Disorder (ADHD) is a disorder that affects the ability to focus, manage energy levels, and control impulses. While ADHD can occur in people of all ages, it is commonly diagnosed in children. Early detection and appropriate intervention are crucial for helping children with ADHD thrive academically, socially, and emotionally. In India, the awareness of ADHD and the availability of testing and treatment options have been on the rise. 

‍

‍

Symptoms of ADHD in children

Although ADHD is a complex disorder, with varied manifestations, these are some of the core symptoms:

• Inattention: Children with ADHD often have difficulty sustaining attention, following through on tasks, and organising their belongings.
• Hyperactivity: Children may exhibit excessive restlessness, fidgeting, or difficulty sitting still.
• Impulsivity: Children with ADHD may interrupt people, act without thinking, or have difficulty waiting their turn.
• Difficulty in school: Struggling with schoolwork, forgetfulness, and careless mistakes may be indicative of ADHD.
• Challenges in social situations: Children with ADHD may have difficulty making and keeping friends due to impulsive behaviour or difficulty sharing and taking turns.

‍

‍

Based on these symptoms, there are 3 main types of ADHD as seen in children.

• Predominantly hyperactive and impulsive type: with this type, children show hyperactive and impulsive behaviours.
• Predominantly inattentive type: This type was previously referred to as attention deficit disorder (ADD). These symptoms cause difficulty in paying attention and sustaining attention. These symptoms are harder to identify than the first type.
• Combined type (inattentive and hyperactive/impulsive): This is the most common type of ADHD seen in children. The symptoms are usually a combination of the first 2 types.

‍

‍

Importance of early intervention

ADHD is a lifelong condition, but early detection and intervention can make a significant difference in a child's life. Detecting ADHD early allows for the implementation of strategies and interventions that can help children manage their symptoms effectively. Without proper intervention, children with ADHD may struggle in school, experience low self-esteem, and face challenges in forming positive relationships. Early intervention can also help with some of the comorbidities associated with ADHD such as low mood, anxiety, sleep issues, and relationship concerns. 

‍

‍

ADHD testing for children

Testing and diagnosis of ADHD in children is done by an RCI-registered clinical psychologist/clinical psychologist (associate) or psychiatrist, with experience of working with children with ADHD. The process of testing involves several steps, and seeks to gather as much information as possible from varied sources, such as parents and teachers. 

‍

The process starts with clinical evaluation, to understand the symptoms and manifestations of ADHD in the child. Here, parents will be asked to provide information on the child’s prenatal and postnatal development, how the child completed developmental milestones, and the behaviour of the child in different situations. 

‍

Furthermore, diagnosis of ADHD will be based on the specific criteria outlined in diagnostic manuals such as the DSM and ICD. The criteria for diagnosis include:

Observation of at least 3 attention problems:

• Short duration of activity
• Leaving play activities unfinished
• Frequent changing between activities
• Lack of “persistence” at tasks given by an adult
• High distractibility during any assignments or study sessions

‍

Observation of at least 3 activity problems:

• Inability to remain still
• Excessive fidgeting
• Difficulty remaining still in places where it is required
• Difficulty with playing silently

‍

‍

Observation of at least 1 impulsivity problems:

• Difficulty with waiting for one’s turn in group play
• Interrupting others
• Blurting out answers in class out of turn.

• Abnormality of attention and activity in school or nursery, as per the age and development of the child.
• Negative diagnosis of a pervasive developmental disorder, mania, depressive disorder, or anxiety disorder.
• Onset of the symptoms before the age of 7 years.
• Duration of the symptoms for at least 6 months.
• An IQ level of over 50. 

‍

To aid the diagnosis, psychologists will conduct a behavioural interview through the use of certain questionnaires and rating scales. Commonly used scales include the Child Behaviour Checklist (CBCL), Conners Rating Scale (CRS-Revised), and Vanderbilt ADHD Diagnostic Rating Scale (VADRS). These scales take information from the child, their parents, and their teachers to have a more holistic understanding of their ADHD symptomatology. However, these tests have been devised on Western populations of children with ADHD.

‍

The INCLEN Trust published a diagnostic tool for ADHD, designed to the Indian context in the journal Indian Pediatrics. The INDT-ADHD assesses inattention and hyperactivity-impulsivity, along with detailed history taking. The questions are also available with regional translations. IQ testing using Binet-Kamath Intelligence Test or Wechsler Intelligence Scale for Children might also be done. 

‍

Physical and neurological assessment might also be conducted by medical professionals to rule out any medical conditions that could be causing the child’s symptoms. 

‍

When conducting ADHD testing in India, cultural sensitivity is paramount. Varied cultural norms may influence the interpretation of ADHD symptoms; what might be perceived as hyperactivity in one culture could be deemed typical in another. Healthcare professionals must consider these cultural nuances during assessments. Additionally, it's crucial to emphasize that a singular ADHD test may not suffice. A comprehensive psychometric evaluation is essential to grasp the complete clinical context, ruling out other psychological disorders for a thorough understanding.

‍

‍

Challenges in accessing ADHD testing and treatment

While there is growing awareness of ADHD and its impact on Indian children, there are still several challenges in accessing testing. These include:

• Limited awareness: Many parents and teachers may not be aware of the signs and symptoms of ADHD, and can chalk it up to the child’s personality or gender. This can lead to delayed diagnosis and intervention for the child.
• Biases in diagnosis: often cultural backgrounds of people from different regions of India are chalked up as ADHD. 
• Stigma: The stigma around mental health concerns and seeking help for their child from a psychologist or psychiatrist can discourage families from reaching out. There might also be acceptance issues due to a diagnosis, leading to “denial of diagnosis,” which then causes attrition from the treatment program. 
• Limited access to specialists: In some regions of the country, there can be a shortage of healthcare professionals who specialise in ADHD diagnosis and treatment. This can then lead to misdiagnosis.
• Misdiagnosis: there are growing concerns of self-diagnosis and internet-driven diagnosis. Sometimes, untrained health professionals misdiagnose ADHD as normal childhood hyperactivity, especially in young boys. Furthermore, most missed cases of ADHD are un young girls due to variances in ADHD manifestation compared to boys. 
• Affordability: Access to healthcare and treatment can be very challenging to many families, especially in rural areas. 

‍

However, efforts are being made by NGOs and private healthcare provision companies to address these challenges. This has been done through increased awareness, training of healthcare professionals, and improved access to services in both urban and rural areas.

‍

‍

Treatment options

Once a diagnosis is confirmed, there are various treatment options available for children with ADHD in India:

• Behavioural therapy: This involves parent training and classroom interventions to help children manage the behavioural manifestations of ADHD in an easier manner. Parents will be taught how to manage different aspects of their child’s inattention and hyperactivity. 
• Counselling or psychotherapy: here, the child will be taught ways to cope with challenges associated with their disorder. This can include stress management, coping with low self-esteem, anxiety, depression, and relationship concerns. They can also be taught strategies for dealing with disorganisation, forgetfulness, and managing distractions. 
• Educational support: Children with ADHD may benefit from special education services and classroom accommodations. This can help develop individualised education plans or cope better with the classroom environment. However, this might be more feasible in private schools than in government schools.
• Medications: In some cases, children might be prescribed methylphenidate or amphetamine based stimulants to deal with the symptoms of ADHD. This is done by a psychiatrist, in liaison with a clinical psychologist. 
• Other holistic treatments: This can include improving physical activity of the child, altering diets, and improving mindfulness.

‍

Thus, ADHD testing for children in India is a crucial step in identifying and addressing this disorder. Early detection and intervention are essential to improve a child’s quality of life. While challenges exist, efforts are being made to raise awareness, reduce stigma, and improve access to testing and treatment services across the country. By understanding the testing process and available interventions, parents, educators, and healthcare professionals can work together to support children with ADHD and help them reach their full potential. Rocket Health helps provide testing and therapeutic services for children with ADHD and their caregivers. 

‍

‍

References

Chang, L-Y. et al. (2016). Diagnostic accuracy of rating scales for attention-deficit/hyperactivity disorder: A meta-analysis. Pediatrics, 137(3). https://pubmed.ncbi.nlm.nih.gov/26928969/.

‍

Drechsler, R. et al. (2020). ADHD: Current concepts and treatments in children and adolescents. Neuropediatrics, 51(5), 315-335. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508636/.

‍

Gulati, S. et al. (2020). The development and validation of DSM 5-based AIIMS-modified INDT ADHD tool for diagnosis of ADHD: A diagnostic test evaluation study. Neurology India, 68(2), 352-357. https://www.neurologyindia.com/article.asp?issn=0028-3886;year=2020;volume=68;issue=2;spage=352;epage=357;aulast=Gulati.

‍

Kandola, A. (2023, February 17). “What to know about psychotherapy for ADHD.” Medical News Today. https://www.medicalnewstoday.com/articles/adhd-psychotherapy.

‍

Mukherjee, S. et al. (2014). INCLEN Diagnostic Tool for Attention Deficit Hyperactivity Disorder (INDT-ADHD): Development and Validation. Indian Pediatrics, 51, 457-462. https://www.indianpediatrics.net/june2014/june-457-462.htm.

‍

Parent training. (2022, August 9). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/behavior-therapy.html.

‍

Taylor, A. et al. (2019). An exercise program designed for children with Attention Deficit/Hyperactivity Disorder for use in school physical education: Feasibility and utility. Healthcare, 7(3), 102. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787573/.

‍

Teaching students with ADHD. (n. d). HelpGuide. https://www.helpguide.org/articles/add-adhd/teaching-students-with-adhd-attention-deficit-disorder.htm.

‍

Venkata, J. A., & Panicker, A. S. (2013). Prevalence of Attention Deficit Hyperactivity Disorder in primary school children. Indian Journal of Psychiatry, 55(4), 338-342. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3890923/.