By: Cassandra M. Faraci, Psy.D.
If you’re wondering if your child (or a child with whom you work) has Attention-Deficit/Hyperactivity Disorder (ADHD), you’re not alone. It’s true that some children are very active, impulsive, and/or off task, seemingly more so than his or her peers. One can easily surf the internet for answers; it’s easy to find a multitude of sites that list diagnostic symptoms of ADHD. If you’re like many parents, teachers, or other adults working with kids, you can easily assign the symptoms you find online to a particular child, concluding with confidence that this child has ADHD.
There’s a problem with diagnosing this way: It’s not abnormal for almost all of us to show symptoms of ADHD at certain times or in certain situations.
True ADHD is a neurological, developmental disorder that affects approximately 8% of children in the United States. Children with ADHD manifest behaviors that are developmentally inappropriate in two domains: attention and hyperactivity-impulsivity. In the attention domain, children with ADHD often show some of the following:
- Difficulty paying attention to details
- Unable to maintain attention to the tasks at hand
- Not listening when spoken to
- Trouble following through on instructions
- Difficulty organizing him- or herself
- Unable to sustain mental effort when engaging in difficult tasks
- Struggles to remain focused despite external distractions
- Unable to remember important pieces of information
- Losing things necessary to complete tasks.
In the hyperactivity-impulsivity domain, children with ADHD often manifest some of the following:
- Being squirmy or fidgeting with his or her hands and feet
- Leaving his or her seat when it’s inappropriate to do so
- Running around or climbing
- Unable to play quietly
- “On the go” behavior, seemingly unable to slow down movements
- Excessive talking
- Blurting out answers
- Struggles to wait his or her turn
- Interrupts on others games, activities, conversations, etc.
Based on this list, most parents would probably diagnose their own children! Adults might even diagnose themselves! Today, as I’m writing this article, my young children are incredibly active. I would very much say they’re both “on the go” and running around despite knowing the rules about when running is okay (at the park) and when running is not okay (near the fireplace). One of my children has not been listening to me at all today and has interrupted almost every conversation I tried having. Do my children have ADHD? Can we diagnose only using a symptom list checklist?
The answer is: NO!
It’s important to understand human behavior in terms of dimensions and not categories. When using a categorical approach, one either has a disorder or doesn’t; this makes sense in the medical field – you either have a cold, or you don’t. In the psychological field, it’s not always appropriate to define normal and abnormal behaviors that way. If we think in terms of dimensions, meaning you “more or less” have a certain characteristic or trait, this makes significantly more sense when applying this to mental and emotional health. You can be very anxious, not anxious at all, or somewhere in the middle. You can be extremely happy, very depressed, or just plain old bummed. Mental health professionals currently use the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) which tries to incorporate dimensional distinctions (mild, moderate, severe), but ultimately, it has specific criteria that is expected to be met before a diagnosis is given (categorical approach).
So, how is one to know if a child truly has ADHD, another disorder, or no diagnosis at all?
Providers with extensive training in evidence-based assessments and treatments of ADHD know what to look for prior to confidently providing a diagnosis of ADHD.
Here are the questions I ask myself when considering if someone has ADHD:
- Does this child have multiple symptoms of ADHD?
According to the DSM-5, children need to show at least 6 symptoms of ADHD, whether they be 6 from the inattention list or 6 from the hyperactive-impulsive list (many children demonstrate 6 from each list!). We want to see that a child has many of the symptoms that comprise the disorder of ADHD, not just a small number of symptoms that could be seen in the general population. What makes a disorder a disorder is the combination of certain symptoms occurring together, not individual symptoms on their own. Think about it. Do you ever struggle to pay attention? Do you ever feel fidgety? Of course you do. You’re human! Being inattentive in and of itself does not mean any one person has ADHD. Therapists have more confidence in giving the diagnosis of ADHD when many of the symptoms occur together.
- Have the symptoms persisted long enough to be considered a disorder?
Sometimes, there are short periods in which any of us might display ADHD symptoms. After a fight with a loved one, we might seem to be “on the go” and distractible. If we have an important meeting coming up the following day, our loved ones might wonder why we can’t focus on today’s tasks. Have you ever seen a child’s activity level on the morning of his or her birthday? It almost seems as though they have “ants in their pants”, right? Because these situations describe people displaying symptoms of ADHD, does that mean they have the true neurological, developmental disorder? Of course not! These are situational, and the ADHD-like behaviors will likely remit in a relatively short period of time. It is much more likely that a child has ADHD when symptoms have persisted for a long time. The DSM-5 requires a duration of 6 months or longer, but there is ample research suggesting that a preschooler should have ADHD symptoms for 12 months or more before we can confidently assume that it’s not just part of the normal development of a preschooler.
- Are the symptoms developmentally inappropriate?
Almost all children show the symptoms of ADHD at some point. Most children are very active. Most children struggle to pay attention at times. Most children are quite impulsive (Have you ever seen a child not look both ways before crossing the street?). So, how do we determine what crosses the line between “normal” and “abnormal”? The DSM-5, as mentioned above, requires 6 symptoms of ADHD to be present in order to qualify for a diagnosis. So, even though individual ADHD symptoms occur in average children, it’s less likely for the average child to display 6 or more ADHD symptoms. Note that, despite the DSM-5 requiring 5 or more symptoms for older adolescence and adults, there is evidence supporting a lower threshold to be used for adults (4 or more). Additionally, many experts in the field recommend requiring a higher number of symptoms for preschool children to help ensure that typically developing, very active preschool children are not misdiagnosed as having ADHD.
- Did the symptoms begin during childhood or adolescence?
ADHD is a lifelong neurological disorder that begins in childhood or early- to mid-adolescence. It more than likely does not begin in late adolescence or adulthood. Ninety-nine percent (99%) of those with ADHD will have an onset of symptoms prior to age 16. So, if a 17- or 18-year-old reports having difficulties focusing that began recently, I would be looking for other causes of this aside from ADHD. Of course, it’s possible that someone’s recollection of the onset of his or her own symptoms is inaccurate. When making an accurate diagnosis of ADHD, it’s important to have evidence that a person struggled with ADHD symptoms during their childhood or adolescent years.
- Do the symptoms occur in different settings?
Because ADHD is neurological disorder, we would expect that children with true ADHD would display ADHD symptoms in more than one setting (home and school are the most likely places). If symptoms are only occurring in one setting, it is more than likely that something about the environment is contributing to those behaviors, not ADHD.
- Do the symptoms cause significant impairment in the child’s life?
Just because a child displays many ADHD symptoms compared to average peers does not necessarily mean that a child has ADHD. To have a diagnosable mental disorder, it’s important for us to distinguish “disordered” behaviors from “normal” behaviors, remembering that human behaviors occur on a dimension, or continuum. When do behaviors cross the boundary between “disorder” and “normal”? If a child’s ADHD symptoms are causing impairment in the child’s life (academic performance, peer relations, etc.), then this would support diagnosing a mental disorder and give diagnosticians the confidence that a child truly has ADHD. It wouldn’t make sense to say that someone has a mental disorder if he or she is functioning in life to the same degree as same-aged peers.
- What are other possible causes of similar symptoms, and have they been ruled out?
A thorough and competent provider will consider this question before giving a diagnosis. Individual symptoms can be suggestive of many disorders and must be considered before a final diagnosis is given. If someone comes to me and reports, “I can’t focus,” my final thought isn’t, “You have ADHD.” I acknowledge that ADHD is one of many possibilities, but I also scan the different diagnoses to determine what else is possible. Anxious people often struggle to focus. Depressed people often report difficulties concentrating. It’s true that children with ADHD are often hyperactive, but anxious children might also display hyperactive behaviors as well, for example.
So, to answer the questions posed by the title, if a child meets the criteria above, it is very possible ADHD is an accurate diagnosis. If a child does not meet the above criteria but still displays behaviors that are impacting the child’s life in negative ways, then there is very likely something else going on that needs to be addressed. It’s also possible that a child is just an average child who falls well within the wide range of normal childhood behaviors.
Remember, children (and adults!) might display symptoms of ADHD. We all can at times! The question is whether the symptoms are occurring to a level that is above and beyond what is developmentally expected and if the symptoms impair one’s success in various areas of life such as school, jobs, and relationships.
Diagnosing a mental disorder is no easy task. There are so many factors that can lead to certain behaviors. To make it more complicated, sometimes there are factors that mimic a disorder but are not actually due to the disorder in question. There is currently no laboratory test that definitively lets providers know that a person has ADHD. For a formal, accurate diagnosis, it requires the education, experience, and expertise of a professional trained in recognizing mental disorders. So, if you’re a parent, teacher, or other professional who is unsure if a child meets criteria for ADHD, consult a professional well-versed in evidence-based assessments and treatments for ADHD. You are this child’s advocate!
Please feel free to give us a call at (908) 914-2624 or email us at firstname.lastname@example.org if you suspect that your child has ADHD, and you want more information.
This blog article is meant to be informational only and should not be taken to be professional advice.