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PREVALENCE & PROBLEMS OF ADHD

STUDENTS IN PAKISTAN; A CASE-STUDY OF
EARLY CHILDHOOD EDUCATION
Tehmena Bukhari
Ph.D. Scholar,
Department of Education, Bahauddin Zakariya University, Multan,
Punjab, Pakistan
Email: [email protected]

Erum Aslam khan

Assistant Professor,
Department of Education, Bahauddin Zakariya University, Multan,
Punjab, Pakistan
Email: [email protected]

Sumaira Khan
Principal,
QAED Academy, Multan,
Punjab, Pakistan
Email: [email protected]
------------------------------------------------------------

ABSTRACT
Parents and teachers are the stage players in a child’s mental and physical growth
including learning progress. Attention deficit hyperactivity disorder (ADHD) is a
neurological disorder in which children displays an excessive and unusual amount of
inattention, hyperactivity and impulsivity. The study was conducted to examine issues
and challenges faced by the parents and teachers while teaching and fostering ADHD
children in mainstream classes. Particularly, teachers’ understanding of an ADHD
child brain functionality and their classroom strategies to counteract those challenges.
The researcher used “Vanderbilt ADHD Diagnostic Teacher Rating Scale” to identify
and classify ADHD students. Parents and teachers of ADHD students were
interviewed through a questionnaire (close-ended & open-ended). In order to
determine major issues and challenges faced by the teachers and parents in classroom
or at home, two different on-line questionnaires were administered. Teachers &
parents were mainly recruited through snowball sampling from all over Pakistan.
Mostly private school teachers participated and few government teachers. Many
parents (out of 35 only 8 responded) didn’t respond to the questionnaire. Twenty
parents of ADHD children were also recruited via WhatsApp/Instagram/Facebook
ADHD parents’ groups, total 28 (20+8) parents participated in the study. Major
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problems forwarded by the teachers were; time management, lack of AV aids, large
groups of students, little cooperation from parents and lack of special training.
Whereas, parents of ADHD kids were suffering a lot due to their children being bullied
and humiliated at school. They complained of teacher’s negligence and urged for
special care given to their children. Also, lack of specialized teaching programs and
lack of counseling by school authorities. The study also revealed that hundreds of
students being diagnosed with severe ADHD, were left untreated, and left out of
schools due to improper policies for Inclusive education and ECE programs.

KEYWORDS
Neurological Disorder, Hyperactivity, Inattention, Impulsivity, Adulthood-ADHD

INTRODUCTION
Are the hyperactive kids new ‘Normals’ in coming days? This question constantly
haunted the researcher, as the researcher witnessed one at home, two in the
neighborhood and many at schools in the suburbs. To be hyperactive and being
impulsive is normal for growing children. But a persistent pattern of hyperactivity,
impulsivity or inattention among kids is not normal. Attention Deficit Hyperactivity
Disorder (ADHD) is an acknowledged and widespread neurodevelopmental
dysfunction. It is mainly a childhood disorder but can last into adulthood if not
diagnosed and treated properly. According to The Centers for Disease Control and
Prevention (2020) children with ADHD may have trouble paying attention to finish
their classroom tasks on daily basis. ADHD learners experience more difficulties in
their education and schooling than a regular student. Symptoms like failure to focus,
difficulty in sitting at one place for a while, difficulty in controlling impulses, and
anger-management issues can make it hard for an ADHD child to perform well in
school. Sooner or later these children left behind in their education by scoring low
grades but earning highly effected self-esteem. Moreover, their impulsive behavior and
poor self-control make them socially rejected. Their fellow peers call them names and
make fun of them. This situation can worsen their mental and emotional health. It is
thereby very important for school aged children to be diagnosed earlier for treatment
to help prevent the expansion of ADHD into adult ADHD.

Amen (2020) in his book “The End of Mental Illness” hit the world by placing
horrendously shocking numbers of suicide attempts, drug overdosage causing deaths,
adults suffering from mental diseases and anxiety traumas in teens in United States.
The situation is not very different in other parts of the world. According to The World
Health Organization (2020) mental health conditions are growing worldwide. Mainly
because of demographic changes, there has been a 13% rise in mental health conditions
and substance use disorders in the last decade (to 2017). Around 20% of the world’s
children and teenagers have mental health problems. Suicide is the second principal

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cause of death between 15 - 29 years old. Nearly, one in every five people in post-
conflict situations have brain health issues. Evidence-based studies disclosed that lots
of people suffering from mental diseases are committing suicide on daily basis and
consuming drugs/alcohol to suppress their anxiety attacks and traumas. One of the
major reasons behind the increase of mental stress and anxiety is to let children
outgrow childhood into adult ADHD. Adult ADHD is the continuation of childhood
ADHD. Comparatively, adults with ADHD have to suffer a lot while adjusting in their
personal, social and professional life. They live in isolation, have poor self-esteem and
poorer mental health conditions. By this means, it is extremely important to identify
ADHD at younger age to possibly treat and address the recoverable problems.

The Centers for Disease Control and Prevention (2013) roughly 11% of 4- to 17-year-
old children were detected with ADHD, this increase in number was very upsetting.
But this doesn’t mean that ADHD is only an American disorder. In Pakistan, medical
research studies and clinical referral ratio of ADHD kids made it very obvious that
things are getting multifaceted day by day in here too. Primary and pre-primary schools
in Pakistan need to be vigilant to make early diagnosis of ADHD, to make learning
and classroom environment effective and more inclusive in nature. To help children
fighting against ADHD, children need continuous assistance from family, and
sufficiently well-informed school teachers, counsellors to establish an appropriate
educational system.

Pasha, Ijaz, & Qadri (2021) in their research study marked the research gap that in
Pakistan no exact data is available to study cases diagnosed with ADHD. There is very
little information available about prevalence of ADHD in Pakistan, which means that
behind the scene there is the possibility of many undiagnosed or misdiagnosed cases
related to behavioral problems linked with attention deficit hyperactivity disorder
among children. ADHD indications are highly prominent in primary grades; hence, it
is very important to make necessary arrangements for its diagnosis and treatment at
school level to help prevent children outgrow with ADHD. ADHD children might
exhibit different problems related to schools such as following commands given by
teachers, sitting on chair during oral lessons, completing class assignments
independently or active participation in class activities. Eventually, children earn very
low grades and poor self-esteem. Nursery and Primary school teachers need complete
understanding, knowledge and experience in this part to support and appreciate these
children, and to successfully change their behaviour with effective self-regulated
tactics. According to Mirza, Nisar, & Ikram (2017) studies suggest that introducing
classroom interventions and specialized training programs improves teachers’
perception of ADHD learners.

Also, according to research study conducted by Khan, Qayyum, & Iqbal (2019) it is

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quite evident that prevalence of ASD and ADHD among adult psychiatric patients of
Pakistan is high. Which is a clear indication of untreated childhood ADHD cases
expansion into adult ADHD cases. Also “Illicit substance use and poor response to
treatment also emerged as independent risk factors linked with presence of ASD and
ADHD among the adult psychiatric patients” (p.423)

Katzman, Bilkey, Chokka, Fallu, & Klassen (2017, p.2) “ADHD has an estimated
childhood prevalence of 4% to 7% with increasing evidence pointing to its
continuation into adulthood for between 15% and 65% of individuals. Recent evidence
supports the view that children with ADHD do not “outgrow” the disorder when they
reach adulthood”. Unfortunately, in Pakistan we don’t have an exact figure of reported
or unreported ADHD cases data available to assess trends in both adult and childhood
ADHD. This study was thereby needed to understand the present scenario of ADHD
in Pakistan.

Hamid (2020, p. 1671) according to the Journal of the Pakistan Medical

Association “ADHD and learning disorder (LD) remain prevalent globally and are also
speculated to have a high occurrence in Pakistan although very little information is
available”. Research studies related to kids diagnosed with ADHD at early years of
education is very important for their overall learning including their mental and
physical growth in right direction. The study was thereby, designed to picture the
classroom challenges and issues faced by the teachers and parents of students being
diagnosed with ADHD. To assess classroom strategies adopted by the teachers, their
understanding of ADHD learners and their participation need to be explored in detail
for future prospects, and for more conducive learning environment.

Amen (2020, p.2) “We are not dealing with mental health issues, but we are dealing
with brain health issues, and this one idea has changed everything”. Hence, the study
is very much needed to change people perception of an ADHD child. It is not a mental
disorder rather it is a brain with different functionality. The society need to better
understand their brain functionality, their personality traits and their emotional needs
to help them in their struggle with defeat ADHD.
The present study focused on subsequent research questions:
 Are the primary school teachers well-prepared to teach kids with special
needs especially ADHD children?
 What are the problems faced by the teachers while dealing with an ADHD-
learners in mainstream classrooms?
 What are the recommendations suggested by the teachers?
 What are the major areas for concern of ADHD parents?
 What are the suggestions forwarded by the parents to improve classroom
setting and schooling of ADHD children?
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What are the suggestions/recommendations to bring improvement in ECE & Inclusive

education programs?

LITERATURE REVIEW
The study was quantitative in approach and followed the survey research procedure.
Surveys are the most useful methods to gather information about people’s general
beliefs, knowledge, attitudes, thoughts and satisfaction level, which cannot be measure
efficiently through any other means. Survey research method collects information
using a questionnaire, administered to a sample set of papulation and generalizing the
results to a larger population. However, interpretations of survey results require a
strong, organized and detailed explanation of results. Survey-research studies are easy
to administer and data can be acquired way faster than other means of data-collection.
In short survey research studies are easy to conduct and cost-efficient in situations like
COVID-19. During the pandemic survey research methods have surpassed all other
methods due to its interconnectivity and accessibility into distant areas of the world
within no time. (Gaur, 2020). Various digital tools are now available for designing
surveys like Survey Legend, Survey Monkey and Google forms Unlimited etc. The
researcher intended to establish the prevalence/challenges and understanding of
ADHD among parents and teachers of young ADHD learners. For this reason, survey
research design is the most suitable approach for the study. The present study used
online Google Forms unlimited to design survey questionnaires.

A subset of ADHD kids’ parents and teachers were recruited through Snowball
sampling. Snowball sampling is a sampling method that researchers apply when the
subjects are difficult to trace. So, is the case with tracing and diagnosing ADHD
kids/parents and teachers. In such cases, by using snowball theory, researchers can
track a few categories to interview and derive results. In the following study, the
researcher also faced difficulty as not many victims (parents of ADHD) were willing
to respond to the questionnaire. Still, the researcher tried to contact as many people as
possible through various resources and platforms (i.e., WhatsApp groups, Facebook
Groups, etc.)

The researcher of the following study used three different types of research instruments
to collect data according to the objectives and research variables of the study. Firstly,
in order to identify attention deficit hyperactivity disorder children in primary classes,
a standardized tool developed by Wolraich ML, Feurer ID, Hannah JN, et al. (1998)
“Vanderbilt ADHD Diagnostic Teacher Rating Scale” was used to assess and examine
the most hyperactive kids in their classrooms. After being diagnosed with ADHD,
teachers and parents of those children were asked to fill an online google survey
regarding classroom environment, teaching strategies and learning status of ADHD
kids. The online google survey questionnaire administered to teachers, was based on

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twelve close-ended and two open-ended responses. Items of survey questionnaire were
mostly taken from established rating scales and others were derived through research
literature and requirement of the study. Third questionnaire or study tool was
administered to the parents of ADHD kids based on eight close-ended and two open-
ended responses asking about major challenges and recommendations for better
schooling conditions of ADHD kids.

Survey analysis refers to the process of analyzing results from others, means
participants’ points of views. Data on its own means nothing without proper analysis.
The researcher needs to make sure that the survey analysis produces meaningful results
to make decisions and ultimately to establish valid results for the reasons you
conducted a research study. In this study, the researcher collected two types of text
responses; open-ended and close-ended. Close-ended questions were designed to
create data that was easily quantifiable, and easy to code, so they’re final in their
nature. They also allow researchers to categorize respondents into groups based on the
options they have selected. In order to deduce best possible results and judgements,
the researcher followed these steps to interpret survey result analysis. First, main
questions were organized into frequencies. Then, results were sieved by making
comparisons of groups. The developing trends from the responses were questioned,
scrutinized and categorized. Finally, the conclusions were drawn.

DATA ANALYSIS AND RESULTS

Teacher’s perception of an ADHD child
Private school Teachers’ overall perception of an ADHD child was significantly
positive and appreciable. Unlike, 2% of teachers (Very few teachers from government
schools) participated in the study and for them it was a mental disorder with learning
disability. Overall, 65% teachers agreed that it is a redeemable disorder, if only
effective teaching strategies would be adopted. They also declared that by adopting
multiple effective teaching strategies, 45% ADHD learners showed significant change
over time in terms of behavior, attitude and grades. 40% children were slow yet their
progress was steady and consistent.

Instructional strategies adopted by most of the teachers

In order to counterfeit inattention, hyperactivity level and aggressive behavior in kids,
majority of the teachers had very positive approach. A huge number of teachers, almost
85% teachers were willing to give limited freedom and empower the kid through self-
regulation strategies while, only 14% teachers some from private and government
schools wanted to control them strictly. In order to engage distracted students 54%
teachers, help the kids to make use of their imagination into expressive arts and
verbalizing skill story-telling, singing and self-expressing activities. Teachers of
private schools (31%) with high fees are even more forward in engaging child by using

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multi-sensory techniques. In which children are asked to do touch, type and see
activities to enhance their focus span. Whilst, to modify aggressive behaviors, mostly
teachers (57%) preferred to adopt rewarding and appreciating behavior toward an
aggressive and agitated child. Again, only 14% (2% government and 12% private
school teachers) opted for punishments. 28% teachers advocated to set positive role-
models’ strategies to improve behavior of impulsive child. Extreme activity level
among ADHD kids is very common, however, 51% teachers were trained enough to
teach them physical-relaxation skills to calm their fretful and irritated state of mind.
34% teachers were in favor to allow them moving around as they can understand their
squirming and fidgety behavior is an inbuilt characteristic of disorder and not a
purposeful act. 14% teachers believed in typical authoritative classrooms. Where
ADHD children have no freedom to move but they are forced to stick on their chairs
all the time.

Lack of Teachers Training and physical resources provided by schools

Statistical data revealed that majority of teachers (46%) individually researched on the
topic that how they can deal with and communicate effectively with an ADHD child.
While, only 34% teachers of highly-paid private schools stated to have special
trainings for dealing with hyperactive kids and have sufficient resources to facilitate
kids. Teachers from government schools and private schools with low fee structure
complained to have limited resources. Although they can understand special needs of
ADHD kids yet they are helpless to create an interesting, engaging and vibrant
environment for ADHD learners. There is a lack of physical resources, audio-visual
aids and instructional material for special kids.

Major Challenges and Issues for Class Teachers

Approximately, all teachers regardless of the fact that they are from government or
private schools; complained to have discipline issues and time management. ADHD
kids need extra time to complete class tasks every day. To keep them together with
other kids is very bothersome. They create hurdles in the learning process of their
class-fellows and peers. Also, counselling with the kids, is not possible every time they
show tantrums. Giving them freedom to move around distracts other students. A
teacher very beautifully explained “Children and teens with ADHD often pay the price
for their problems in low grades, scolding and punishment, teasing from their peers,
and low self-esteem. Meanwhile, you, the teacher, feel guilty because you can’t reach
the child with ADHD and wind-up taking complaints from parents who feel their kids
are being neglected in the classroom. But it doesn’t have to be this way”. There must
be some strategies to deal with the situation. Also, assessment criteria for these kids
should be minimized or flexible. Teaching an ADHD child effectively is a two-way
process. Families need to be equally vigilant and cooperate with the teacher for smooth
sailing in learning process of the kid.

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Suggestions placed by Teachers

Various important suggestions placed by teachers in their own words are “More
knowledge and extra coaching should be given to teachers for such students to handle
them in better way”. And “Extra time on tests; Instruction and assignments tailored to
the child; Positive reinforcement and feedback; using technology to assist with tasks;
Allowing breaks or time to move around”. Teachers also suggested to change their
sitting positions. Such kids should never be back-benchers rather make them sit at
front, where they can clearly see written classroom rules pasted in big letters on walls.
Also, “Engage student in off-class practical activities like arranging the desks, cleaning
the white board, participating in school functions for speeches or skits, etc”.
“Classroom should be equipped with all new technology”. One of teacher from highly-
paid private school put it in a nutshell by saying “Create a quiet area free of distractions
for test taking and quiet study. Use visuals charts, pictures and colour coding. Create
worksheets and tests with fewer items, give frequent short quizzes rather than long
tests, and reduce the number of timed tests. Test students with ADHD in the way they
do best, such as orally or filling in blanks. Divide long-term projects into segments and
assign a completion goal for each segment....” This is the same as three-pronged
strategy suggested and documented by U.S. Department of Education (2006) in their
research report “Teaching Children with Attention Deficit Hyperactivity Disorder:
Instructional Strategies and Practices”. In three-pronged strategy “the teacher
determines how, when, and why the child is inattentive, impulsive, and hyperactive.
The teacher then selects different educational practices associated with academic
instruction, behavioural interventions, and classroom accommodations that are
appropriate to meet that child’s needs. Finally, the teacher combines these practices
into an individualized educational program (IEP) or other individualized plan and
integrates this program with educational activities provided to other children in the
class” (p.3).

Parents’ Biggest Fear

Parent’s responses disclosed some very disturbing facts. The greatest fear is that their
child is being bullied, harassed and even humiliated by their fellow peers outside
classroom during play times and breaks. Among other major problems recorded by
parents were teacher’s irresponsive attitude, lack of emotional support, lack of
facilities, proper psychiatric assistance and counseling with the kid. Other than
academic skills their training for socializing is least concerned by school. Unfriendly
environment causing children to resist going school. Another parent complained stated
that “As a parent I’m facing issues like incomplete and dirty classwork. Seems like,
teachers are not paying attention to build child capability to work, rather he is left on
his own, unguarded, unattended and clueless”.

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General Dissatisfaction
Parents’ responses clearly indicated a general dissatisfaction among parents (41% were
satisfied & 51% were not). 51% parents faced difficulties in order to get admission in
normal schools due to poor grades and academic performance. Also, their children
emotional well-being and growth is in question. 59% children were often misbehaved,
being called useless and dumb by their class fellows. Although, 70% parents agreed
that their child’s academic progress or performance is properly communicated through
class tests and progress reports, however, their behavioral check status was not
maintained properly. Almost, 63% parents ranted “no special care is given to my
child”. A parent commented “A proper feedback for behavioural check is never given,
such kids need to be protected from bad comments and behaviours of fellows. More
creative or special need-based content be introduced at primary level”.

Need of continuous meetings for feedback/follow-ups

“I am clueless and depressed” mostly mothers fumed over limited access to their
children’s classrooms. One of the mothers stated “I come to school to help my child
but am not allowed to”. Their concern regarding their kids daily and weekly progress
is very important. Parents demanded to have a continuous feedback meeting with
school teachers.

Shadow-Teachers for ADHDs

Majority of parents stressed upon the need to hire shadow teachers in primary classes.
As one of the mothers stressed upon the fact that “They should arrange an extra helping
teacher in the classroom for the child”. Another stated “School should have their own
qualified and experienced shadow teacher”. Or “For reading and writing Shadow
teacher should be hired for week students”.

Suggestions placed by Parents

Parents recorded various suggestion to change instructional material, strategies, extra
time for tests and for other class assignments. A mom suggested “We need to improve
our ways of teaching; today's children want more activity-based learning system which
help them to understand easily”. Another suggested “ADHD or other children with
learning difficulties need more time, space and attention to learn, adapt and grow.
Normal curriculum and ways of teaching actually refrain many special children from
learning as they need more time and interactive ways to understand concepts and to
develop academic skills”. Also, “Schools should have a child psychologist in their
staff, they can understand what special needs are and how to handle them, have extra
resources in school, should have a smaller number of children in class”. Also, parents
demanded to educate teachers more about ADHD/ ASD and ADD kids.

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DISCUSSION
The outcomes of the study made it crystal clear that parents and teachers in general are
not very well informed about ADHD and Its consequences on later stage. The study
also revealed some shocking facts regarding the prevalence, treatment, and diagnosis
of ADHDs. As mentioned earlier, no confirm figures are available in Pakistan for
ADHDs. Very few studies are conducted by medical students and clinicians only.
Which indicated that the ratio of undiagnosed ADHD is high in Pakistan. The
researcher in the present study only included school going students being identified
and diagnosed with ADHD by their parents and teachers. But there are many children
suffering from severe ADHD and comorbidities. These children were either rejected
for any kind of schooling or the kids themselves rejected the school. The researcher
through social media platform contacted many ADHD parents. Among them almost
200 ADHD kids were out of school. This figure is very alarming. According to them
there are no special education plans for them, no therapies centers for them, availability
of proper medical treatment is lacking everywhere. These ADHDs needs specialized
individual program. The government need to make proper legislation for the inclusion
of these kids. Or provide them special educational centers.

RECOMMENDATIONS
After analyzing the facts and figures provided by the teacher participants and parents,
the researcher become able to confidently pass some judgements and draw
conclusions. The whole study revolved around 28 ADHD students’ parents, and 35
teachers mostly from private schools (both high/low fees). The present study
confirmed that more boys are diagnosed with ADHD than girls. As among 28 ADHD
students 75% were boys and 25% were girls. Most research studies proposes that Boys
are more likely to be diagnosed with ADHD than girls (CDC, 2016). No exact figures
are available for ADHD prevalence in Pakistan. However, this does not mean that we
don’t have ADHD related issues and problems in our children. In Pakistan, early
childhood education policies need amendment to make diagnosis of children at
primary years of education.

Academy of Pediatrics (2000) “The assessment of ADHD should include information

obtained directly from parents or caregivers, as well as a classroom teacher or other
school professional, regarding the core symptoms of ADHD in various settings, the
age of onset, duration of symptoms, and degree of functional impairment” (p.9).
Diagnosis of ADHD at early stage is very important for the betterment of kids
diagnosed with ADHD. Previously, it was supposed that ADHD was outgrown in mid
to late teenage years. It is now clear that two thirds of children with ADHD will
continue to have problems attributable to ADHD as adults and because ADHD is a
long-lasting disorder, will require treatment throughout their lives.

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The study results revealed that somehow private schools are doing great in this regard.
Teachers’ understanding of the brain function and impulsive behavior of an ADHD
child is appreciable. Their teaching strategies and classroom environment is
comparatively better than government schools. The researcher couldn’t get enough
data from government schools; hence it is not a valid judgment to say that government
schools are not properly dealing with ADHDs. However, there is a lot more to do. As
we can see a clearer dissatisfaction from parents’ side. Parents demanded extra care,
special attention and a shadow teacher for their kids to keep them well assisted in
classrooms and even outside the classroom. Also, these kids are being bullied and
humiliated by their fellows in the absence of teachers, which hurt their self-respect.
ADHD kids need more time and space to finish their tasks and assignments. It is the
pressing need of the time due to an increase in hyperactive-inattentive kids that primary
school system needs to be changed and adapt according to the special needs of
ADHDs. ADHD kids are not abnormal but they are also not normal and leaving them
untreated would be a great injustice. It is better to treat complexities at right time rather
than struggling with these complexities during adulthood.

It was also determined by teachers that dealing with hyperactive kids in a class of
approximately 20 to 30 students is very difficult for them. Their continuous movement
and impulsiveness distract other students. There must be some helper or shadow
teacher in the class to help students with reading and writing. Lots of activity corners
are needed to set up for continuous engagement and involvement of inattentive and
hyperactive kids.

Parents exclusively showed their disturbance over the lack of daily/weekly feedback
and follow-up meetings by teachers. Parents should have walk in access into the
classroom to make it a more familiarized place for their kids, who are reluctant to
attend school or dislike school. The study also revealed some shocking facts regarding
the prevalence, treatment, and diagnosis of ADHDs. As mentioned earlier, no confirm
figures are available in Pakistan for ADHDs. Very few studies are conducted by
medical students and clinicians only. Which indicated that the ratio of undiagnosed
ADHD is high in Pakistan. The researcher in the present study only included school
going students being identified and diagnosed with ADHD by their parents and
teachers. But there are many children suffering from severe ADHD and comorbidities.
These children were either rejected for any kind of schooling or the kids themselves
rejected the school. The researcher through social media platform contacted many
ADHD parents. Among them almost 200 ADHD kids were out of school. This figure
is very alarming. According to them There are no special education plans for them, no
therapies centers for them, availability of proper medical treatment is lacking
everywhere. These ADHDs needs specialized individual program. The government
need to make proper legislation for the inclusion of these kids. Or provide them special

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educational centers.

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