Dr. David Palmiter's Blog for Hectic Parents

How can the difference between a boy being a boy and ADHD be determined? Many parents of young active boys, who run into trouble at school, struggle with this question. This blog entry is meant to provide some guidance.

ADHD involves two clusters of symptoms: problems with inattention and problems with hyperactivity; the later of which can usually be traced back to difficulties with impulsivity (i.e., the problem is more with poor brakes than a revved up engine). In order to qualify for an ADHD diagnosis a child should  be more inattentive and/or hyperactive than 93% of his peer group (i.e., a standard deviation and a half above the mean in a normal distribution), and the symptoms are usually required to have been present for six months or longer, have had an onset in childhood (the first symptom usually by age 7) and not be attributable to any other viable cause. For this reason a boy whose activity level does not rise to this level, even when it causes adults distress, would not typically meet diagnostic criteria for ADHD.

In my clinical experience (which is an albeit very limited parameter), there are three common instances when ADHD is misdiagnosed:

1. A very active boy (but not a boy with ADHD) is also defiant. Oppositional Defiant Disorder (ODD), which involves problems with anger control and doing what adults expect, is very distressing. If the evaluation is not sufficiently thorough, it can be easy to misdiagnose ADHD in this scenario.

2. The primary assessment tool, for a boy who is illustrating behavioral problems that are not attributable to ADHD, is the response to a stimulant medication. Even kids who do not have ADHD may have a positive response to medications that are designed to treat ADHD. So, it’s important to avoid using a medication response as the primary assessment tool.

3. A boy has an internalizing disorder (e.g., a mood or an anxiety disorder) but the evaluation misses this (usually because it has not been thorough enough). For example, a child who is very anxious can be quite inattentive.

In order to avoid these kinds of misdiagnoses it is important that the evaluation include some key elements. These are some assessment methods that can be helpful in ruling ADHD in or out:

1. The use of teacher, parent and self-report (if a child has ≥6^th Grade reading level) behavior rating scales. These measures can help determine if a child’s level of activity or ability to concentrate are typical (i.e., among children of the same sex and age group). There are measures designed to rule out ADHD as well as an assortment of potential collateral problems. It is important to survey all three groups of people (i.e., parents, teachers and the child of concern), when they are available and able to participate that is, in order to increase the odds of arriving at an accurate impression.

2. A review of school records. What can be especially helpful is to review behavior grades and ratings in the early elementary school years.

3. Family and individual child interviews (or play sessions for very young children). These interviews can help in determining if there is another viable theory to explain any symptoms of hyperactivity or inattentiveness that are being displayed. These interviews would typically inquire regarding all important domains (e.g., the developmental history, the school history, the medical history). As I mentioned, ADHD is a diagnosis by exclusion; if another problem viably explains the symptoms, the ADHD diagnosis is usually set aside until the other problem(s) can be treated.

4. Diagnostic testing that measures attention and/or other executive functions. This testing can add considerable cost to the evaluation. So, I often prefer to not do it unless the first three methods leave the ADHD question in doubt. (However, if cost is not a significant consideration, it can be helpful to include this testing anyway.)

Three closing thoughts:

1. A child with ADHD often meets diagnostic criteria for at least one other disorder (e.g., ODD, a learning disability). So, and for example, documenting that a child suffers attentional problems secondary to anxiety does not automatically mean that said child does not also have ADHD.

2. A child whose behavior is causing impairment, at school or home or both, will usually meet criteria for some diagnosable problem, even if it is not ADHD.

3. Parents do well to educate themselves as to the nature of ADHD (or any other diagnosis that is suggested). Being an informed consumer of mental health services is very important. Please see Chapter 10 of my parenting book, or other articles on this blog site, for guidance.