ADHD – diagnosis

Everybody says my kid’s hyper. Should we start him on some medicine?

Whoa! Wait a minute! Wait a couple of minutes! You may be thinking that because your child is “hyper” he or she may have ADHD and needs some form of treatment. That may be true, but let’s be sure of what we’re talking about. This is a common cause of being “hyper,” but not the only one. And since it is so common, we need to know something about it.

Let’s start with the name. ADHD stands for attention deficit hyperactivity disorder. That’s the last time we’re going to write it all out, but we need to keep all of this in mind, because it defines the condition.

There are two components to ADHD—attention deficit and hyperactivity. Both of these affect behavior, emotion, and thinking, as well as academic, and social functioning. And both of these have their own set of “core symptoms.” That’s important, because those symptoms alert us to the presence of this disorder and also allow us to monitor their improvement through various forms of treatment. We’re going to start with the hyperactivity part.

This is what we’re most familiar with, and most accustomed to seeing, either in our own child or someone else’s. Hyperactivity almost always occurs with impulsive behavior, and is usually seen by the time a child reaches four years of age. The symptoms will increase over the next three or four years, and peak when the child reaches seven or eight. After that, the hyperactive symptoms begin to subside. By the teenage years, the hyperactivity may barely be noticeable, yet the adolescent may still have feelings of restlessness and the inability to settle down. The impulsive symptoms, on the other hand, frequently persist throughout life. That’s a real problem for the untreated individual, since in the wrong environment, this impulsivity can put them at risk for alcohol abuse, the abuse of other substances, and involvement in what should be obviously dangerous activities. Even driving can become dangerous when the impulsivity leads to recklessness.

Here are some of the symptoms we see with hyperactivity and impulsivity:

• Difficulty remaining seated at school or work
• Fidgeting (squirming while seated, tapping feet or hands)
• Difficulty playing quietly
• Excessive talking
• In younger children, running around or climbing on any available object
• Feelings of restlessness in adolescents
• Blurting out answers too quickly
• Difficulty waiting turns
• Interrupting others when they’re talking
• Always “on the go” and difficult to keep up with

Now for the attention deficit part of this problem. This is usually referred to as “inattention” and is marked by a reduced ability to focus attention and a reduced speed of thinking/cognitive processing, including correct responding. These children will be described as being sluggish thinkers and frequently appear to be daydreaming. Usually the complaints will center on thought and academic problems. These symptoms typically are not apparent until the child is eight or nine years of age, when academic abilities begin to shake out. Similar to what we see with the impulsive component of this disorder, symptoms of inattention usually last a lifetime.

(Before we go further, this is a good time to stress those two important points—the impulsivity and inattentiveness of ADHD can last a lifetime. Many of us think this is only a disorder of young children, maybe pushing into the teenage years. After that, they should “grow out of it.” It doesn’t work that way. There are many adults who go through their lives needlessly struggling with this. Their work suffers, their relationships suffer, and their ability to parent suffers. Give it some thought.)

So what are the core symptoms of this attention deficit? Here’s what we see:

• Difficulty maintaining attention in school, at play, and in the home
• An inability to pay close attention to detail, and making careless mistakes
• Failure to follow through with chores at home or homework
• Appearing not to listen, even when being directly addressed
• Avoiding tasks that will require consistent and focused mental effort
• Losing objects/tools needed for specific tasks and activities (school books, musical and sports equipment)
• Forgetfulness in routine activities, such as homework and assigned household chores
• Difficulty organizing tasks, activities, and personal belongings
• Being easily distracted by things that are unimportant and inconsequential

With these “core” symptoms in mind, we can begin to determine if our child might have a problem with ADHD. In order to meet this diagnosis, their needs to be evidence of impaired functioning. This means that our child has significant problems with academic and social activities. Here’s how the American Psychiatric Association (APA) currently defines criteria for the diagnosis of ADHD:

For children 17 years of age and younger, there must be six or more symptoms of hyperactivity and impulsivity or six or more symptoms of inattention. (For those of us adults who are counting, that number is only five symptoms in these categories.) In addition, these symptoms must:

• Occur often
• Be present in more than one setting, such as school or home
• Persist for at least six months
• Be present before the age of 12 years
• Significantly impair function in academic and social activities
• Be excessive for the developmental level of the child

I think my child has just about all of these! Does that mean he has both the hyperactive type and the attention deficit kind?

That’s possible. Let’s take a moment to work through this. Let’s say your child has six of the core symptoms of hyperactivity/impulsivity but only three of those listed under attention deficit. That would satisfy the APA’s criteria for ADHD of the hyperactive subtype (there are three subtypes, with this being one of them). On the other hand, if only three of the hyperactive/impulsivity are met, but six of the attention deficit, this still qualifies as having ADHD of the inattentive subtype. If you’re right about your child, and he has six or more core symptoms in each group, he would fall into the subtype of having a combined ADHD disorder. This subtyping is important, since it will guide appropriate treatment, help us set reasonable and achievable goals, and give us framework for monitoring your child’s progress.

If these criteria are met, there are validated screening tools that can be used to firmly establish a diagnosis of ADHD. While you can find some of these online, if you think your child has many of these symptoms, you’ll be better served by having your pediatrician or family physician provide you with further guidance. The important point is to think through this, know your child, and if you think they need help, get it. Untreated, the negative consequences are poor academic performance with limited future opportunities, poor social functioning, peer rejection, poor self-esteem, increased risk for depression and anxiety, and for your teenager, greater risk taking. With the correct diagnosis, the treatment can be straightforward and effective.

But getting back to your question. If someone thinks your child is hyper, don’t take offense. Take notice. This issue is not about you, but your child. There’s no room here for anyone else, and there’s absolutely no room for denial. Make no mistake, your child’s happiness and well-being may depend upon this.

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This is an excerpt from the new book I wrote with pediatrician Dr. Robert Alexander. Ask the Family Doctor addresses questions from parents regarding their children’s health. Feel free to email us with questions: askthedox@yahoo.com