THE Government said recently that it plans to expand capacity in special education schools. Many assume that this is for children with autism, among other conditions. But there is less public awareness about ADHD, or Attention Deficit Hyperactivity Disorder, which, unlike autism, is largely treatable.
The ADHD child is disorganised, forgetful, and cannot focus or obey instructions. He behaves impulsively and is constantly restless. The overactive child is bogged down with poor social skills, learning disabilities and sleep problems. Like autism, ADHD is not a psychiatric condition and, like autism, ADHD is caused by a brain disorder. Experts estimate that, globally, 3 per cent to 7 per cent of school children have ADHD. According to the Society for the Promotion of ADHD Research and Knowledge, this “translates into two such students in a class of 40 in Singapore’s context”.
However, this might be an overestimate. An Australian survey of Malaysia’s primary schoolers this year found ADHD in 1.6 per cent of that population. Given that ADHD is very likely a genetically-determined neurobiological condition and given also the similarity in our racial groups, it seems probable that it may affect about 1.5 per cent of schoolchildren in Singapore or 600 in a cohort of 40,000 pupils. Treated with stimulants, ADHD children can focus on the tasks assigned to them better. They also become less disruptive and less offensive to their peers, siblings and authority figures like teachers and parents. Because caffeine is also a stimulant, some mothers wonder if giving the child coffee every day may be safer since it is “more natural” than the stimulants prescribed for ADHD.
A Starbucks grande-sized coffee is a shot of caffeine. It contains about 300mg of caffeine, whose chemical name is trimethylxanthine. Once ingested, caffeine is quickly absorbed into the bloodstream and crosses into the brain, where it immediately stimulates the release of neurotransmitters, thus causing alertness. But too much of it makes you agitated and gives you the shakes, headaches and sleeplessness. Unlike coffee, ADHD medications have been used for decades to treat patients, work well in 60 per cent to 80 per cent of cases, are generally safe and have only mild side-effects. Most trials comparing coffee to the standard drugs were largely conducted in the 1970s.
Generally tiny, these studies found that, overall, caffeine did not do any better than placebo. In sum, the children are better off with the tried-and-tested stimulants like Ritalin. Such drugs have a calming effect, so the child is less disruptive and can improve his relationships with others. These drugs work by stimulating the brain’s executive control system which is underaroused in ADHD. Its under-arousal is indeed the basic problem in ADHD.
Located in the pre-frontal cortex – the very front of the brain at the forehead – the executive system manages attention, moral decision-making and social self-control. It enables us to adjust our behaviour so it is consonant with the expectations of others in our surroundings. That is, its executive functions regulate our behaviour so we function socially. So when the system is under-aroused in ADHD, there is loss of self-control. The good news is that the pre-frontal cortex is the final part of the brain to mature. This occurs only when we are late into our adolescence or early into our adulthood. When it does mature, its neurons begin to transmit signals faster, at which time some ADHD symptoms (especially impulsiveness) decline somewhat. This is why some ADHD symptoms may decline slightly with age. But the biological deficits largely remain.
A 2010 Harvard study that followed ADHD patients for 10 years found that some symptoms persist into adulthood in 78 per cent of cases. This would indicate a persistence of the lack of self-control in a grown-up. This persistence of ADHD symptoms was correlated with substance abuse, delinquency and criminality. A review of 100 studies reported in Criminology: A Global Perspective (2000), found that all except for one study also reported a similar correlation.
A 2009 meta-analysis of cross-border studies found that, in a number of countries, a quarter to two-thirds of their adult prisoner populations had ADHD. Thus accurate diagnosis of this treatable condition in children is important. But diagnostic errors occur because ADHD symptoms can also occur in autism. This overlap in symptoms is because both conditions arise from problems with the executive control system, albeit with different parts of it. This means that children with autism may be misdiagnosed as having only ADHD. Conversely, some studies of children with ADHD are now frequently reporting autistic symptoms in them too.
This suggests that all children with ADHD should be tested for autism so this can be ruled out, and vice versa, so they can get appropriate treatment. After all, ADHD is eminently treatable and continuing to take medication well into adulthood may help reduce delinquency and criminality. A few coffees a day may not help much but they probably won’t hurt either.