Ask the Experts

Are You Sure It’s Attention Deficit?

All individuals who show hyperactivity, inattention, and/or impulsivity do not have ADHD. Consider all behaviors before a diagnosis is made.

Boy on a swing might have ADHD or executive function disorder
Boy on a swing might have ADHD or executive function disorder

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.

Diagnosis Basics

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) must 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-V, 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).

EFD refers to the brain’s ability to act like a chief executive officer. When faced with a task, you have to analyze it and develop a plan for completing it. As you work on the task, you may need to make adjustments to your plan, but still complete it correctly and in a timely way. A person with executive function difficulties has problems organizing and planning how to approach and carry out a school-related or family-related task, and completing it to meet a deadline.

EFD might look something like this: Your 10-year-old son walks into the house after school. He drops his coat on the floor near the door and takes his shoes off in the living room. You can follow his trail by the mess he leaves behind. His room can be described as chaotic. Clothes are on the floor, and all the dresser drawers are open, with items falling out. The clean clothes that you put on his bed are on the floor, along with his dirty clothes.

What about homework? If you sit with him to help structure the assignments, he may get it done. If you say, “Go do your homework” and check in later, it won’t be complete, probably not started. If he does manage to finish his homework, he may leave it at home. At school, his desk and backpack are a mess. He can’t finish class assignments unless the teacher provides some structure.

Which Child Had ADHD?

Based on the revised, more complex, criteria for diagnosing ADHD, which of the three children mentioned before has it?

Joey is hyperactive and inattentive, but these behaviors are not observed all the time. They crop up during specific tasks or activities. He has difficulty doing independent classroom work, but he always participates in class discussions, a verbal task. Thus, his difficulties are not pervasive. Joey’s second- and third-grade teachers didn’t see such behaviors in their class. In other words, his behaviors were not chronic.

So I ruled out ADHD. Based on my discussions with Joey and his teacher, I requested psycho-educational testing. Tests revealed a learning disability, and we started treatment.

Allison showed inattention and problems with organization at home, in school, and in Sunday School. Her first- and second-grade teachers had seen similar behaviors. After taking her history, I concluded that Allison had a chronic and pervasive history of attention and organizational problems. I diagnosed her with ADHD, Inattentive Type, and started her on methylphenidate, adjusting the dose and time of coverage. Her family and teachers (and Allison) noted a significant improvement in her ability to stay on task and to complete assignments. Her backpack and bedroom became less messy. She began to work with an organizational tutor.

William’s difficulties in relating to children or adults had been noticed since his preschool days. He was a loner who did not seek interactions or relationships at home, with the kids in the neighborhood or in school. He was always “lost in his own thoughts.” William liked to watch a certain TV show over and over, and knew its episodes so well that he could recite the lines with the characters. Based on the evaluation, William was diagnosed as having Autism Spectrum Disorder (ASD).

All three students had behaviors that looked like ADHD. Each was found to have a different cause of his problems. The point is that all individuals who show hyperactivity, inattention, and/or impulsivity do not have ADHD. Work with your clinician to make sure that all factors and behaviors are considered before a diagnosis is made.

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