Joey has a hard time in the fourth grade. He is restless and has difficulty staying on task when doing work at his desk. His teacher complains that he daydreams a lot, and he frequently does not finish his classwork. During class discussions, though, he is focused and on task. He relates well to classmates, and plays games with friends at recess.
Allison, a third-grader, would rather daydream than do her work. Her worksheets are messy, and she makes a lot of errors. Her teacher says that she does not read or follow instructions.
William, also in the third grade, finishes his classwork and, with the help of his mother, completes his homework most days. In class, though, he loses focus and drifts off, and does not relate well to classmates. He prefers to be by himself during recess.
The above descriptions are what each set of parents told me about their child. They all asked me the same question at the end of the phone conversations: "Does my child have ADHD?" I could not answer that question because I had never met their children. An ADHD diagnosis can't be made from a description of behaviors. A full history and assessment are necessary. I get upset when a parent tells me that, after telling their physician that their child could not sit still and focus, the physician started the child on Ritalin or Adderall.
That is not a diagnosis. That is guesswork. There are clear guidelines for diagnosing ADHD. If a child's or adult's behaviors start at a certain time (when she began fourth grade or after her parents separated) or occur only in certain situations (at bedtime or when called upon to read in class, or, for adults, when asked to lead a meeting at work), then the person probably does not have ADHD. He or she should be evaluated for another condition.
For a child to be diagnosed with ADHD, the presenting behaviors (high activity, inattention, impulsivity) have to have been present for most of his or her life, and must occur in most situations. In other words, ADHD behaviors are chronic and pervasive. ADHD is a neurologically based disorder that reflects how the brain is wired and functioning. Hyperactivity, inattention, or impulsivity may be apparent from the early months of life or only a later age.
"Pervasive" is easy to understand; "chronic" may be tougher to comprehend. A mom might notice increased muscle (motor) behavior — hyperactivity — during a child's earliest months of life. She might not notice impulsivity — not stopping to think before saying or doing something — until these behaviors are expected to show, at age two or older. Inattention, like impulsivity, is not always obvious to parents, but may be observed by a teacher in preschool or kindergarten.
The fact is, diagnosing ADHD is more difficult these days because the criteria have shifted. The earlier literature described inattention as the inability to block out unimportant stimuli, visual and auditory. In other words, a child is distractible. Based on research and clinical observations, the concept of distractibility has changed. The focus now is on what is called "executive function."
In the current medical diagnostic manual, DSM-IV-TR, as well as the soon-to-be-published revised manual, DSM-5, inattention is described as being more than distractible. There are nine behaviors listed that might indicate "inattention." An individual must show six or more of these nine examples. Only one of the nine reflects what most people think of as attention deficit — "often easily distracted by extraneous stimuli." The other eight indicate executive function disorder (EFD).
Next: EFD 101
This article appears in the Spring 2013 issue of ADDitude.
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To discuss symptoms of ADHD and related conditions, visit the Is It ADHD? support group on ADDConnect.