Diagnostic Issues in ADHD: A Clinician’s Perspective
I would like to start with an honest confession. When initially writing this article, I thought it will be easy as it meant talking about a condition that I frequently evaluate as a neuropsychologist. However, when I sat down to work on this article, it hit me that while it may have sounded easy to write an article on Attention-Deficit Hyperactivity Disorder (ADHD), it wasn’t. The primary reason for my difficulty stemmed from my dilemma of what new information could I possibly offer about ADHD in this internet era that parents might not already know or cannot Google. I did not want to creatively “repackage” and present the usual and customary information about ADHD that parents might already know. Therefore, I decided to talk about ADHD based on my interactions with families and the questions and comments that frequently surface during these interactions.
To start, even though ADHD sounds like a unitary construct, there is a huge variability in the language that parents use to describe their children when they call my office. For instance, my child….
“….is just lazy”
“….lacks motivation because I know he/she can do it”
“….can spend all day playing with his Nintendo and would have no problems with his attention. So, we know he does not have ADHD.”
“….takes a long time to finish homework”
“…is doing it to drive me crazy”
ADHD symptoms fall into three broad categories:
ADHD, predominantly Inattentive type (yes, it is still called ADHD, even if a child does not show hyperactivity)
ADHD, predominantly Hyperactive-impulsive type
ADHD, combined type
Moving forward, there are three basic points I would like to make with the hope it would be helpful in clarifying a lot of misinformation about diagnostic issues related to ADHD.
First and foremost, ADHD is a neurological condition associated with the brain's chemistry and anatomy, and should not be perceived as “just” a behavioral disorder. Therefore, it is extremely important for parents to understand that bad parenting does not cause ADHD. Nonetheless, a disorganized environment can worsen the symptoms of a child with ADHD.
Second, ADHD is rarely about a total “deficit” of attention. Instead, a better way to think about it is as a condition where individuals experience difficulties in “regulating” their attention; that is, how well can a child regulate or shift attention from a highly preferred activity (e.g. playing video games) to a non-preferred activity (e.g., doing homework), and how long can they sustain their attention when participating in a non-preferred activity. A child with even the most severe form of ADHD will exhibit some capacity to engage in an activity of their choice. Therefore, such selective attentional abilities do not preclude the possibility of ADHD.
Finally, while characteristics of inattention and/or hyperactivity are diagnostic indicators of ADHD, these same features might also present as symptoms for an entirely different condition (e.g., medical, emotional, or learning disorders). I am frequently asked by parents and other professionals if ADHD is being over-diagnosed in children. As per my clinical experience, ADHD is often misdiagnosed. One of the reasons for this misdiagnosis are the diagnostic procedures which are brief, focused only on observable behaviors, and not designed to consider other factors that might account for a child’s problematic behaviors. The most reliable way to diagnose ADHD or to delineate conditions mimicking ADHD-like symptoms is a comprehensive work-up that, at minimum, should include the following:
Careful review of the child’s developmental, medical, social and educational history to rule out other conditions (e.g., social-emotional problems(depression, anxiety, etc.) , learning differences, brain injury, or changes in environmental/educational setting).
Information collected from both parents and teachers. If a child has ADHD, the symptoms must affect a child's ability to function in at least two settings, which is typically at home and at school.
A thorough neuropsychological/psychological evaluation and direct observation of the child’s behaviors. Neuropsychological evaluations are helpful in multiple ways: First, they help in understanding the subtle aspects of a child’s functioning which might go unnoticed, particularly if a child is bright, conscientious, and has been compensating for his/her difficulties. Second, the evaluation highlights areas that might be impacted by ADHD (e.g., processing speed, working memory). Finally, it clarifies if there are other learning or emotional disabilities that could potentially account for the child’s difficulties. For example, a child with language based learning disability or depression might also display ADHD-like symptoms.
This brings us to an additional concern that parents often share; why is a diagnosis so important? Is it really important that a child be labeled?While I appreciate parents’ wishes to normalize their child’s experience by not “labeling”, only an accurate diagnosis and the precise identification of strengths and weakness can help in designing targeted interventions, which, in turn, assists both parents and schools in directing their efforts and allocating valuable limited resources in the right direction.
Another interesting question that parents pose is while my child presented with hyperactivity at age six, he does not engage in such behaviors any more. Could it be that he never had ADHD? The symptoms of ADHD depend largely on age and undergo changes as a child develops. For instance, while impulsivity and overactivity might be a more prominent feature in a younger child, deficits in planning and organization skills might evolve as a more significant characteristic in a teenager. Therefore, close monitoring and periodic evaluations are crucial for ongoing treatment and appropriate education planning.
The most effective treatments are those that are multi-modal and take into account behavioral, educational and emotional components. Therefore, a team effort, with parents, teachers and doctors working together is the best way to help our children. At times, psychopharmacological remediation may also be helpful as it helps the child in “focusing” and making him/her more available to learning. Nonetheless, medication is not a cure, and does not replace any of the accommodations and interventions that the child needs to make appropriate gains. Talk to your doctor about treatment options.
Most of the children that I see are fortunate to have supportive and loving parents. Yet, difficulties related to ADHD presents many challenges to the family system. Children with ADHD can, at times, make even the most patient parent question their parenting style. However, please remember that the behaviors of our children are not motivational. Parents who recognize the neurological basis of the child’s problems and work collaboratively with educators and other care providers, have the best chance of maximizing the child’s overall learning potential and social-emotional adjustment.
If you have have any questions or concerns about ADHD, please feel free to contact me through the contact form below.
~Sangeeta Dey, Psy.D.