Wednesday,20 March, 2019
Current issue | Issue 1362, (28 September - 4 October 2017)
Wednesday,20 March, 2019
Issue 1362, (28 September - 4 October 2017)

Ahram Weekly

Not a lack of discipline

Too many ADHD children are still mistaken as lazy or naughty, and the failure to recognise the condition only adds to the plight of children suffering from attention deficit hyperactivity disorder in Egypt, writes Gihan Shahine


The cool morning breeze of the back-to-school season and the sound of school buses bring memories of anxiety rather than happiness to Ahmed’s mother. It is not just that Ahmed used to cry every morning as he took the bus to school.

“He was a difficult child, constantly anxious and in a bad mood, whining and fidgeting all the time,” Ahmed’s mother reminisced as she organised her son’s old, mostly broken toys. “Look at his toys,” she said. “He used to break them even before starting to play. There was always a mess around him, and he would not sit still to play. I didn’t know then that something was wrong. Everybody noticed how smart he was, not just me, and I thought all kids were the same.”

It was not until Ahmed reached the second primary stage that his mother started to sense that something was wrong. “He was doing very well in kindergarten and primary stage, but I started to notice that he was having bad marks in dictation and mathematics, and his teachers said he used to jump and play a lot in class.”

Ahmed had a hard time sitting still to study. He would easily get bored or distracted, and he would answer questions quickly before thinking and hardly pay attention to details that could make him lose marks on trivial questions.

Ahmed was being constantly rebuked by his father for his poor mathematics and dictation marks and for being inattentive. It was then that his mother decided to consult a psychiatrist. Ahmed was diagnosed with ADHD, or attention deficit hyperactivity disorder, which now seems to be affecting a larger and larger number of children, many of whom may remain undiagnosed.

The term ADHD is used for a collection of behavioural problems linked to poor attention span including impulsiveness, restlessness and an inability to concentrate. If undiagnosed, such children may be thought to have issues that can make them seem lazy, naughty, inattentive or careless, even if some people may recognise that they have creative abilities and intelligence. It is just that their minds work differently.

US parent Cristina Margolis has been blogging on the website My Little since her young daughter was diagnosed with ADHD in order to spread awareness about the disorder. She has lamented that despite the fact that her ADHD child is very smart, imaginative and creative, these characteristics are not recognised in grades at school despite her teachers noticing them.

“She isn’t going to get A’s in creativity or thoughtfulness, that’s for sure,” Margolis wrote on her blog recently.


WHAT IS ADHD? Attention deficit hyperactivity disorder (ADHD) is usually defined as a neurological disorder in which problems with executive functions can cause trouble with paying attention, hyperactivity and impulsiveness.

ADHD symptoms can begin early on in children (by the ages of six to 12) and result in behavioural problems that can interfere with school and home life. ADHD affects children and teenagers and can continue into adulthood. It is more common in boys than girls. It’s usually discovered during the early school years when a child is noticed to have problems paying attention.

Children with ADHD may be easily distracted; they may not follow directions and may appear not to be listening; they may make careless mistakes, forget about daily activities, lose things or have problems organising daily tasks.

 They usually don’t like to do things that require sitting still or paying attention. They often squirm, fidget or bounce about when sitting or don’t stay seated and are always on the go. They may have trouble waiting for their turn, blurt out answers, interrupt others or act impulsively without considering the consequences.

Ahmed’s mother used to get frustrated when her defiant son did not listen to her orders and blurted out unpleasant answers, but now she knows that underlying issues in the brain are likely to be the cause of her son’s misbehaviour.

Although the cause of ADHD remains scientifically contested, many researchers agree that it has to do with a neurotransmitter called dopamine, which is one of those “feel-good” chemicals that is responsible for transmitting signals between the nerve cells or neurons of the brain, regulating mood, behaviour, sleep and cognition. It is believed that dopamine has to do with decision-making and creativity.

“Scientists have found that ADHD is linked to a deficiency in dopamine, most probably in the frontal lobe of the brain,” Heba Al-Shahawi, a professor of paediatric psychology at Ain Shams University in Cairo, said.

How the brain functions remains very complicated for scientists to understand, but the consensus is that ADHD is not a disease but is a disorder that can be overcome as the brain matures, reducing its symptoms.

While the cause of ADHD is not known for sure, researchers suggest genetics as one prime reason, followed by poor nutrition, infections and smoking and drinking during pregnancy. Toxins such as lead have also been found to affect a child’s brain development, while injuries causing damage to the front of the brain, called the frontal lobe, have been found to cause problems with controlling impulses and emotions.

The unlucky 40 per cent of kids who carry ADHD through adulthood may have trouble managing time, being organised, setting goals, holding down a job and controlling their impulsive actions and anger, especially when under stress. They may also have problems with relationships, self-esteem, and, perhaps, addiction.

A few psychologists, however, have recently been ringing alarm bells that ADHD could perhaps be “over-diagnosed” and even “misdiagnosed”. The BBC has recently published a study of nearly 400,000 children between four and 17 years old in Taiwan warning that “many children are needlessly prescribed drugs to combat ADHD when they are just immature.”

Jerome Kagan, a psychologist and professor at Harvard University in the US, has recently ruffled feathers by claiming that ADHD could be “a complete hoax”. He has claimed that money may be behind the over-diagnosis of ADHD, adding that the pharmaceutical industry, as well as medical professionals, could be “financially benefiting from promoting and prescribing certain medications”.

“Every child who’s not doing well in school is sent to see a pediatrician and the pediatrician says ‘it’s ADHD; here’s Ritalin,’” Kagan said, referring to a branded medication. “In fact, 90 per cent of these 5.4 million [ADHD-diagnosed] kids don’t have an abnormal dopamine metabolism. The problem is that if a drug is available to doctors, they’ll make the corresponding diagnosis.”

Many psychologists and medical professionals have attempted to discredit Kagan’s statements. Al-Shahawi, for one, insists the consensus among scientists worldwide is that ADHD does exist and there has been much accredited scientific research proving it over recent decades.

“The studies that prove otherwise may have methodological problems,” she suggested. Scientific controversies aside, ADHD is not at all well known in Egypt and can often be mistaken for bad manners or a lack of intelligence.


NOT NAUGHTY: Inside Egypt’s Unrecognised ADHD Problem, a documentary produced by the BBC, provides a look at the lives of children suffering from ADHD in Egypt.

According to the documentary, around one in 10 of Cairo’s six million children under 15 may be suffering from ADHD, even though their families may not be aware of it because the symptoms can be easily confused with the naughty behaviour of an ordinary child. Many of those children may be making their families’ lives unbearable.

According to the BBC documentary, the Ministry of Health has estimated that around one in 10 children have ADHD in Egypt. But the true tally is rarely recognised anywhere in the world because symptoms may be mistaken for naughtiness and parents may suffer for years without realising that their children have a disorder.

Al-Shahawi corroborates the ministry’s tally, adding that with a number of professors from her university she conducted a survey of a number of public and private schools in Egypt and found that 10 to 11 per cent of adolescent students were suffering from ADHD. Some of those undiagnosed children had remained undiagnosed and dropped out of mainstream education to attend vocational education. Others had remained in mainstream education but had low marks and poor academic achievement.

“About 60 per cent of all ADHD children may overcome their symptoms as dopamine levels increase with maturity, but this also depends on the child’s level of intelligence, the support he gets from family and school, and on whether he has a strong social network and friends,” Al-Shahawi told Al-Ahram Weekly. “If these factors are missing, children suffering from ADHD will easily develop a high level of anxiety and depression that negatively impacts their academic and social life and may even make them prone to addiction.”

Early intervention is crucial to help such smart children adapt to their symptoms and lead successful lives. “If a mother notes that her child is hyperactive, does not stay still, creates a mess around him, does not pay attention and is impulsive, she should immediately seek professional help,” Al-Shahawi advised.

Lack of awareness, however, remains a major challenge. The BBC documentary presents the story of three Egyptian boys from different social backgrounds, Karim, Chris and Sameh, whose lives, albeit different, are dominated by their struggle to master their condition.

Karim, a 12-year-old boy displaying striking symptoms of hyperactivity, was a source of trouble to family, neighbours and teachers in the village where he lives outside Cairo. He was constantly seen as naughty and sometimes aggressive towards other children. But Karim did not mean to be naughty; he suffers from ADHD, and the disorder was affecting his thinking, remembering and learning.

No one understood Karim’s condition until his mother took him for a check-up at a charitable organisation in her village.

“I get upset and everyone around him gets upset because of the terrible things he does and his hyperactivity,” Kareem’s mother told the BBC. “I want him to be good, calm and obedient. He doesn’t like to pursue any activity or sit down, and he gets bored very quickly.”

Chris’s more affluent, French-educated mother similarly remained unable to understand her son’s condition for at least four years. Chris did well academically in grade one at school, but his teachers always complained that he moved around a lot in class.

“I couldn’t understand what the problem was. I couldn’t put a label to the situation we were experiencing. Was this a behaviour problem,” Chris’s mother asked. She took her son for tests and ultimately discovered her child was suffering from ADHD.

Although ADHD is treatable, the documentary shows how school remains a challenge for ADHD children in Egypt.

“There are two types of medications: stimulants and non-stimulants. The first stimulates the release of dopamine and is more effective, but is not without side effects and can have a degree of dependency,” Al-Shahawi said. “Drugs are important to alleviate the symptoms, reducing hyperactivity and increasing concentration, in order to help the child and his family cope with the condition. Medication helps children cope academically and socially so that they will not have years missed or lost.”

Sameh’s mother explains how she started to see a big difference in her son’s behaviour when he started taking such medication. Sameh is on two drugs, one to reduce hyperactivity and the other to increase attention. “I saw a big difference when he started on the medication, and I even started to socialise again without fearing he might make trouble,” Sameh’s mother said.  “But I still have one problem: school.”

Sameh understands things quickly, so he gets bored when a teacher repeats things for other children. He will then start to move on, sometimes playing with other kids and distracting them. Teachers, unable to understand what ADHD is, will get upset with Sameh and start calling him naughty or abusing him.

But Sameh has been lucky that his parents can afford the medication and are oriented enough to provide him with sessions to modify his behaviour. Sameh’s parents have also moved him to a school where the system “gives him the supporting environment he needs.”

“His [Sameh’s] teachers understand ADHD and know how to treat it,” Sameh’s mother said. “Now he is doing well.”

Karim, however, has not been as lucky. Medication was beyond the means of his family, but since ADHD can be treated by therapy as well as medication, Karim’s family took him to a charitable organisation called Helm Tefl (A Child’s Dream) that provides therapy for children with a wide range of physical and mental disorders.

Today, thanks to prolonged sessions Karim’s attention span has increased from 15 minutes to an hour. But the problem remains that his school is not equipped to handle cases such as his, and teachers have no time to focus on Karim when there is a huge number of students in the class.

“Karim needs one-to-one education, and this is a problem that holds us back a lot,” Kaim’s therapist told the BBC. “We need someone who understands this, and his teacher also must believe in Karim’s abilities. Kareem’s family also needs to be educated on how to build their child’s self-confidence, which can be challenging,” she said.

Likewise, Chris has also been attending professional sessions to boost his cognitive abilities and attention span in addition to taking medication. He is improving academically, but his French private school seems not to be a better place for an ADHD child.

“School remains a big challenge because the system is too strict and is reluctant to make special allowances,” Chris’ mother lamented. “So now for the eight or nine hours he is there, I do not feel that I can trust the place. This is a problem.”


A MATTER OF AWARENESS: Mohamed Raafat, a specialist in behavioural adjustment and skills development with Ta2heal, a company providing digital programmes for ADHD children, says that schooling issues and a lack of awareness are the main obstacles facing ADHD children in Egypt.

“The problem usually starts in school when neither parents nor teachers are acquainted with this type of disorder and insist it is owing to a lack of discipline,” Raafat told the Weekly. “Even when we tell parents that their children are suffering from a disorder, they may not believe us.”  

Raafat explains that many such children are not lacking in intelligence, and sometimes this is at near or above average levels. What they need is one-to-one education in order to focus. “When these children get this specialised education or private tutoring they may even turn out to be cleverer than their classmates,” Raafat noted. “But such tutoring is not available in state schools, and again awareness remains an issue.”

Al-Shahawi advises that teachers should be trained in how to cope with an ADHD child in class. “An ADHD student should be seated near the teacher and should be given tasks in class like distributing copybooks to other children or clearing desks, so that he will get breaks that alleviate his sense of boredom,” Al-Shahawi said.

“Only international schools currently allow children to get special support in tests, like having questions on a separate paper or having someone alert to ADHD to manage tests and questions, but this should be applied in national and state schools as well,” she added.

Raafat says that Ta2heal has been keen on increasing awareness through training sessions for non-governmental organisations and posting videos on YouTube. “We have designed software programmes that help ADHD children boost their attention span and cognitive abilities online, and we provide professional home visits as well,” he said.

Thanks to such awareness campaigns, Raafat says that many international schools in Egypt are now adopting programmes tailored to help children with ADHD, but that these remain largely unavailable in most private and state schools.

“Many disorders like ADHD and autism are not even listed on the government’s national agenda, which only focuses on severe cases of special needs like Down’s Syndrome,” Raafat lamented. “And that means teachers remain largely unaware of the condition, punishing the children for being unpleasant or naughty.”

On a community level, however, there are a number of private centres and non-governmental organisations providing awareness-raising campaigns and programmes to help children with ADHD and other disorders cope with their challenges.

Gad Al-Beheiri, director of a private centre in Maadi, was quoted in BECAUSE online, a social issues magazine, as saying that the centre is “the first place in Egypt to use the BrainRx training programme, a US cognitive learning programme consisting of intense mental exercises that sharpen the core skills the brain uses to think, learn, read, reason and pay attention.”

He apologised for being too busy to arrange an interview for the Weekly before the paper went to print. But Al-Beheiri was quoted as saying that “after clients go through a computer screening test to classify needs, a programme is set up to provide necessary exercises. These are unique, game-like and guaranteed to help overcome ADHD and other learning disorders without drugs.”

Al-Beheiri lamented that unlike in the UK where every school now has specialised programmes for children with cognitive or learning disorders, in Egypt awareness is low and stigma is sometimes high.

“ADHD children should be looked after on a government and civil society level,” Al-Beheiri said. “In Egypt, there are 17 million students, so even if only one per cent of those have ADHD it’s a huge market for development in terms of teaching the correct ways to detect learning disabilities.”


ADHD PARENTING: Drugs can help children concentrate better and stay still, but once stopped the child may go back to his condition before he started on the drugs.

This means that drugs for ADHD are a tool, not a cure, and they are most effective when combined with other intervention plans. Scientists suggest that there are many other effective treatments that can help ADHD kids improve their ability to pay attention, control impulsive behaviour, and curb hyperactivity. Nutritious meals, play and plenty of exercise, and learning better social skills through smart daily choices are suggested as parts of a balanced treatment plan that can improve performance at school, improve relationships with others, and decrease stress and frustration resulting from dopamine deficiency.

Sports are one of the most effective ways to reduce the symptoms of ADHD because it has been scientifically proven that they boost the brain’s dopamine, norepinephrine, and serotonin levels, all of which affect focus and attention. Behavioural therapy, also known as behaviour modification, has also been shown to be a very successful treatment, or co-treatment, for children with ADHD. For instance, reinforcing desired behaviours through rewards and praise has been found to be crucial for ADHD children who may receive few positive comments outside the home, while decreasing problem behaviours by setting limits.

Last, but not least, it has been found that love and care can help reduce stress levels and the worry that makes ADHD symptoms harder to manage. “ADHD children easily get bored, so they try to calm themselves by being hyperactive,” Al-Shahawy noted. “Mothers should be aware of this so that they act strictly but not harshly and without rebuking because much of the problem is out of their hands,” she said.

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