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Your attention please!

A seven-year-old boy who wets his pants is not uncommon. But when Norway arrested Sai Sriram’s parents last week — for alleged child abuse — the developments threw light on a syndrome that affects hundreds of thousands of Indian children and yet is largely ignored — attention deficit hyperactivity disorder (ADHD).

Doctors treating the boy in Hyderabad believe that Sriram is suffering from ADHD. “Children suffering from ADHD exhibit inappropriate levels of hyperactivity, impulsiveness and inattention,” explains Krishnadas Nandagopal, a professor of genetics at the University of Calcutta who has been studying the disorder since 2003.

The disability varies from mild to moderate to severe. Children can have one or more symptoms, depending on the severity. “In extreme cases like that of Sriram, kids can’t follow instructions even for a minute,” says Kalyan Chakravarthy of Hyderabad’s Rainbow Children’s Hospital, who has been treating the boy for four months since his return from Oslo.

According to reports, Sriram’s Oslo school got in touch with his parents over incidents of perceived misbehaviour such as urinating in the school bus. The boy told his schoolteacher that his parents threatened that they would leave him back in India if he continued to wet his pants. The parents were subsequently jailed by a Norwegian court for reportedly punishing the boy for his actions.

“Those with severe forms of ADHD live in a world of their own. For them, the line between reality and illusion is often blurred,” points out Chakravarthy. “The answers you often get from ADHD children need not be correct, as they often speak without thinking. So it is inappropriate for the authorities to punish the parents without understanding the context,” he contends.

If left untreated, severe ADHD children can grow up with several social and behavioural problems. They often have poor academic records, find it difficult to stay in a job and a relationship and are easily addicted to alcohol and other habit-forming substances.

What worries doctors is the fact ADHD often goes untreated in India. Globally, it is found to affect 5-7 per cent of children. In certain African and south American countries, ADHD rates are as high as 8-13 per cent among school-age children. “But there hasn’t been any epidemiological study in India to establish how prevalent the disorder is,” says Nandagopal.

Studies worldwide have shown that boys, more than girls, are at a higher risk of developing ADHD. “Nearly 80 to 90 per cent of ADHD cases are reported in boys. We don’t know why,” Nandagopal adds.

Experts have drawn some conclusions from studies on ADHD. Nine out of 10 children with ADHD are believed to be extremely intelligent. “Their brains work much faster than normal brains. They will not wait for the question to be over before they blurt out an answer. But they are also very impatient. They can’t sit still in a classroom. They are disruptive and engage in actions without thinking about the consequences,” stresses Sayyara Ansari, an educational psychologist working at the Columbia Asia Hospital in Gurgaon.

Take the case of seven-year-old Sumedh. “When he was brought in for consultation, he immediately ducked under my table and started answering questions sitting there,” says Ansari.

When Sumedh shed his inhibition, he climbed on to the window railing and started jumping from there. He did that for a while, and then went back to his hiding position. Upon investigation, it turned out that he had both autism and ADHD. “This is a very deadly combination,” says Ansari.

Nandagopal says ADHD is an “executive dysfunctional” disorder. Children know that when they have to go to school, they have to pack their school bag with the right books or find their school shoes and tie the laces to be ready on time. “But an ADHD child finds it difficult to follow the routine,” he says. Most small children would normally find such schedules difficult to begin with, but will later learn to adapt. “But an ADHD child never learns (to do so),” he explains.

One reason ADHD is not always detected is that the symptoms are often confused with the actions of “naughty” or “disobedient” children. But doctors point that children with ADHD are actually hyperactive and have little control over their actions. They can, for instance, be very destructive with their belongings. Quite frequently, they end up injuring themselves or people around them.

“Punishments meted out will not have any effect on them as they have very little memory of such punishments in the short term,” says Chakravarthy.

Scientists still do not know what causes ADHD, though faulty genes are implicated in nearly 75 per cent of the cases. Surroundings also play a role. Studies have indicated that exposure to lead, which is used in paint, toys and cosmetics, could trigger ADHD in children.

Nandagopal carried out a study with his team among a small population of ADHD children in Calcutta two years ago when he was with the city’s Manovikas Biomedical Research and Diagnostic Centre. It showed that the levels of a brain chemical called serotonin — whose inappropriate production in the brain is linked to many psychiatric disorders — is lower in children suffering from ADHD.

ADHD can be treated with behavioural therapy and drugs. “In mild cases, behavioural therapy works. Moderate ADHD can be treated with a combination of both. It is the severe cases that require constant medication,” says Chakravarthy, who has been treating children with ADHD for the last 10 years.

There are effective drugs — stimulants — to treat ADHD. “In most cases, the drug can be discontinued after a while, but a small minority has to take it lifelong,” says Chakravarthy.

A section of experts, however, frowns upon the use of medicines to treat ADHD. They believe that the restlessness of children or youth should not be treated as a medical problem but as a “moral challenge” for society. Very often, continuous use of stimulants suppresses a child unnaturally, they argue.

“The medicines are important but equally important are measures taken by the family and society as a whole to bring up such children,” stresses Ilina Singh, a bioethicist at King’s College London, who interviewed 150 ADHD children in the US and UK to understand how they perceive the impact of medication.

Doctors hold that support from parents, immediate family members and teachers is very important for an ADHD child. Sriram , for instance, was responding well to treatment within 10 days, says Chakravarthy. “Now that his mother has left for Oslo (to comply with the Norwegian court order), his condition has deteriorated,” he rues.