Wednesday, June 10, 2009


Rahul is a perfect example of being in constant motion: running, jumping, talking, fidgeting, never a still moment … it’s difficult to hold his attention. As you speak, within seconds, he’ll break eye contact and you’re left talking to the air.

“So what? He’ll grow out of it,” say many. The problem is Rahul is 12 years old. A stream of complaints — restless, distracted, lack of concentration, disturbing other children — has seen him move schools in quick succession. A family friend, who works with special children, suggested that Rahul be evaluated for Attention Deficit Hyperactivity Disorder (ADHD) but the diagnosis has to be made by a psychiatrist. “How can I take him to a psychiatrist?” asks his mother Radhika.

Take 17-year-old Nisha. For years, she struggled with lessons, spending hours where others needed only minutes. No amount of effort seemed to get her any closer to that holy grail of our education system — the marks. Lazy, stupid, not enough effort… were some of the milder epithets hurled her way till, three years ago, a new teacher gently suggested evaluation for dyslexia. Bingo! “The relief of knowing it was not my fault was enormous,” smiles Nisha, now facing her board exams with less trepidation than before.

“Both common enough cases,” sighs Dr. Mohan Raj, Chennai-based consultant psychiatrist. “And it highlights two crucial issues in dealing with such problems: one, the need to sensitise teachers. Two, accept that the child has a problem.”

These sentiments seem to echo across the country. Dr. Jacob Puliyel, consultant paediatrician at New Delhi’s St. Stephen’s Hospital, points out that even kindergarten has become “a high pressure” zone. “Teachers scold and ridicule children who don’t score marks instead of focusing on what they are good at. Result: the child ends up with poor self-esteem and oppositional behaviour.”

Both cannot emphasise enough the need for early identification. And agree that the first line of defence is teachers.

Teachers’ views

Do the teachers agree? Ekta Malhotra from Sanskriti School, New Delhi; Sudha Rangarajan, a teacher at Carmel Convent, New Delhi; Girija Varma, a Bangalore-based Montessori teacher and special educator; and Lalita Srimurthy, a counsellor who runs a pre-nursery school in Bangalore accept that conclusion but point out that very few actually know enough to spot the problem.

“Some teachers are sensitive almost instinctively, says Ekta, “but you need a special educator to handle these children.” Sudha remembers how a 6-7 year old was made to stand outside the class every day and beaten. “Teachers don’t know what to look for,” she says.

Girija, however, feels that awareness may have increased but “not to the extent that immediate assistance can be provided. These children are dealt with strictly or disciplined.”

Gayatri Kiran, a Bangalore-based psychologist, finds “almost all “naughtiness” is termed ADHD and serious ADHD is termed “lazy-stubborn” combination. I think it is part of the teachers’ job and duty to screen children. They require only keen and patient observation (and a positive mindset/attitude).” The consensus here is for training the teachers to identify early the signs of both ADHD and dyslexia.

In the case of children with ADHD, one can’t help wondering if the paediatrician can help in early diagnosis. The doctors agree that it is possible if the paediatrician is aware of such problems and secondly sees the child more regularly. But Gayatri feels it might work with severe cases but “teachers would be a better first screening for LD and, to an extent, ADHD. Paediatricians could watch out for and make the family aware of developmental social/language/cognitive and motor milestones so that at-risk children can be identified and early intervention provided. Proper referral after identification is a must.” Once the identification is made, the parents’ reaction is crucial. Often it is denial or not knowing what exactly is wrong.

“We thought Attention Deficit meant deficit of attention from our side,” say Nikhil and Maya sheepishly. So they lavished attention on their son, compounding the problem with a spoilt kid, till matters were explained. Dr. Puliyel also stresses that guilt is not a factor here. “These are not caused by faulty upbringing,” he says.

Parents’ reactions

In general, says Lalita, teachers have trouble convincing the parents that “their child may have a problem. Parents are critical of the teacher/school and sometimes change the child’s school a couple of times before coming to terms with the problem” , an issue that Sudha also raises.

Agrees Aparna Singh, counsellor at Carmel Convent, New Delhi, “The main job begins after identification. Often parents too need counselling about handling the children, the use of behaviour-modification techniques. Participative activities where parents and child are involved help.”

But it is an uphill task. Where ADHD is involved, severe cases require medication and Dr. Pulieyl admits “we doctors do tend to medicalise problems excessively and use drugs more often than they are absolutely required.” But there are times when there is no other option, says Dr. Mohan Raj, though he too admits that “the concern over medication is genuine.”

While medication can help control hyperactivity, the child will also need counselling and therapy appropriate for him/her like occupational therapy, behaviour modification therapy, special tutoring.

This is crucial because ADHD carries over into adulthood.In most cases, though not in all, hyperactivity may reduce but the attention deficit component has to be dealt with. Also, ADHD can overlap with other problems like oppositional or conduct disorders, learning disabilities, anxiety or mood disorder. So the need for a specialist diagnosis cannot be over emphasised.

With dyslexia the only way out is remedial training and the sooner it begins the better. “If the problem is caught or diagnosed early and remedial treatment started the child in later years can easily merge into the mainstream without much difficulty or stigma.”

“Sometimes I feel my schedule revolves around my child’s,” says Prema who quit her banking job and moved house so that she could take her son around to his various classes. When pressed she admits to regret for her own dreams but “what else can I do?” she asks. “If my husband quits to care for the child, can you imagine the consequences?”

Caring for a child with ADHD can be stressful and Dr. Mohan Raj emphasises the importance of not over-reacting. “Some mothers get too involved and shut out the siblings and even the father. That can cause resentment and trouble in the family.”

The other issue involved is visiting a psychiatrist/psychologist. The stigma of mental illness hangs over the children. and concerns for the future often stray into social realms. Expressing the attitude of the teachers and doctors, Gayatri doesn’t mince words. “I think it is a matter of priorities: is temporary stigma preferable to lifelong difficulties and inefficiencies? After all, if your child needed to visit a Urologist regularly you wouldn’t hesitate, would you?” she asks forcefully.

But that’s not enough to convince hesitant parents. Radhika shudders, “What would people say if they knew I was taking Rahul to a psychiatrist?” Aparna has a sensible solution. “Don’t tell the world,” she says matter-of-factly. “Just the immediate family.”

Battle in the family

But sometimes even that’s battle enough. “Both my parents and my in-laws had major issues with the fact that we chose to consult a psychiatrist for Abhishek,” says Priya. Home was more like a battlefield since both sets of grandparents were involved in caring for the child. Priya’s response was to quit her job and take over her child’s care. The next salvo was to organise a joint sitting for the grandparents with the psychiatrist. “It’s not all hunky dory yet,” smiles Priya “but they’re definitely more tolerant of the idea now.”

If this doesn’t work, Gayatri is firm that “lines may need to be drawn with the clear understanding that this is for the child’s benefit and no other reason.”

Ask them what else can be done to help these children and a pretty much unanimous answer is “reform of our education system”. “Our system is a total no for any kid not just children with problems,” says Sudha firmly. Lalita also says, “The emphasis on exams and marks certainly exacerbates the problem. These children know much more and are far more intelligent than what they can express on paper or in a written exam.” Schools now offer special privileges but many parents are either unaware of or unwilling to opt for these; the latter because they don’t want it to be known that their child has a problem.

“I wonder how many kids went undiagnosed or were labelled and punished in the past,” muses Dr. Mohan Raj, “because ADHD is hereditary. If you look back carefully, you’ll probably see where it comes from