With modernization comes associated pressure on children to achieve ever higher academic standards. It is therefore important to identify children who are struggling to meet expectations but could respond to intervention. Attention deficit hyperactivity disorder (ADHD) is one of the commonest reasons for academic under-attainment worldwide [1], and the prevalence rates in India are comparable to other countries [2]. As ADHD is a treatable condition, the need for accessible diagnostic instruments – that are appropriate for use in local setting – is readily apparent. Lack of universal education and established pathways of communication with schools, combined with poor awareness, make establishing the diagnosis a real challenge.

The INCLEN Trust has adapted the diagnostic criteria of the American Psychiatric Association (DSM-IV TR) by rewording them to make them more applicable to an Indian setting [3]. The development of such a tool based on the DSM-IV TR criteria, and validation in the local population, are major advancements to assist in diagnosis. This should translate into increased awareness of ADHD, and ultimately to better management of these children. The INCLEN diagnostic tool is divided into sections A and B; section A derives directly from the DSM diagnostic criteria. However, the fundamental principle of diagnosing ADHD is not that the child meets the diagnostic criteria, but rather the presence of pervasive functional impairment deriving from the core symptoms. This is addressed in Section B of the tool. Recognition of the way that the particular symptoms can lead to impairment would need to be emphasized in the follow-through training in the use of the tool to prevent overdiagnosis. This is particularly important when considering section B item 4, that lists some modalities of functional impairment. For example, the failure to form stable friendships may result from a child not attending or listening to a playmate and therefore being bossy. A short attention span may mean that the child gets bored and tries to change the rules of the game. Alternatively a bored child may try to make life more interesting by being deliberately annoying or playing for attention. Children with ADHD tend to live in the present and not consider the future. They may be prone to injury through not stopping to consider the risks or consequences of an action. Their short term view of life can place unreasonable stress on parents and teachers. For example, a child may try to put off a task for as long as possible, on the basis that every minute spent arguing is time well spent because they are not doing the task. The fact that in the end it still has to be done may not appear to have any relevance to the child. Similarly, when punished the child may not be interested in the reason for the punishment, which therefore takes away its effectiveness. Academic underachievement may result from a short attention span and difficulty with sustained concentration. When assessing the acuity of ADHD it is also important to consider its impact on the child and the child’s self esteem. In the absence of any biomarkers for ADHD, the diagnosis relies on accurate history using multiple sources of information, including parents, school and other caregivers. It is important to rule out significant hearing loss, language impairment or intellectual disability which in themselves can cause attentional problems and frustrations in a child and result in disruptive behaviour. A large number of rating scales – both paid and free – are currently available as screening tools for ADHD and its co-morbidities. Within the Western world, the diagnostic pathways rely on accurate information from the school teachers and school counsellors through formal reports and rating scales. These are combined with information from parents or carers during history taking or through more objective parent rating scales.

Frequent association with significant co-morbidities like learning difficulties, oppositional defiant disorder, conduct disorder, anxiety, mood disorders, depression and sleep disorders, can also aid in early recognition and treatment of ADHD. Hence, the importance of accurately diagnosing the condition and intervening early cannot be overemphasized. Management may involve a combination of behavioral interventions, extra help with learning, and in some cases medications. We look forward to further validation studies on the use of the INCLEN Diagnostic Tool in the general Indian population, including children, preschoolers and adolescents.

Funding: None; Competing interest: None stated.

1. Polanczyk G, de Lima MS, Horta BL, Biederman J, Rohde LA. The worldwide prevalence of ADHD: a systematic review and metaregression analysis. Am J Psychiatry. 2007;164:942-8.　

2. Juneja M, Sairam S, Jain R. Attention deficit hyperactivity disorder in adolescent school children. Indian Pediatr. 2014;51:151-2.