Is your child having difficulties in school? Have you wondered whether it might be ADHD? Perhaps your child’s school psychologist, doctor, therapist, or neuropsych evaluator has diagnosed your child with this disorder.
According to a Centers for Disease Control and Prevention (CDC) study, the percentage of children with an ADHD (Attention-Deficit/Hyperactivity Disorder) diagnosis continues to increase. It is an issue that requires our attention, and now.
ADHD is a diagnosis that is frequently given to children who are struggling in school. Whether your child has some of the symptoms that we associate with this disorder, or whether you accept or dismiss this diagnosis, I urge parents and clinicians to continue to open the door to additional possibilities, rather than have any diagnosis, ADHD or otherwise, close doors to further inquiry.
As both a clinician and mother, I’ve observed and assessed children in the clinical setting, at home, and at school. I can attest to the fact that children can behave very differently given their circumstances. I’ve seen children’s behavior influenced by various factors on any given day.
Medical and mental health professionals can arrive at diagnoses in many ways. The clinician will usually use a combination of observation and a questionnaire, and sometimes a test for the child to take. The DSM 5 (the manual used to diagnose mental health issues) states that a child must exhibit, “in most situations,” at least six symptoms from either (or both) of the following lists in order for an ADHD diagnosis to be made:
- Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or during other activities.
- Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
- Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
- Often does not follow through on instructions and fails to finish school work, chores, or duties.
- Often has difficulty organizing tasks and activities (difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
- Often avoids or is reluctant to engage in tasks that require sustained mental effort (e.g. schoolwork or homework.)
- Often loses things necessary for tasks or activities (e.g., doesn’t come home from school with his jacket.)
- Is often easily distracted by extraneous stimuli.
- Is often forgetful in daily activities.
- Often fidgets with or taps hands or squirms in seat.
- Often leaves seat in situations when remaining seated is expected.
- Often runs about or climbs in situations where it is inappropriate.
- Often unable to play or engage in leisure activities quietly.
- Often “on the go” acting as if “driven by a motor.”
- Often talks excessively.
- Often blurts out answers before questions have been completed.
- Often has difficulty awaiting turn.
- Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities. May start using other people’s things without getting permission).
You may know some children who have at least six of these behaviors. Perhaps they indeed have ADHD, but perhaps not.
Some examples of issues that have similar symptoms to ADHD are:
Auditorily-sensitive children may act differently in a noisy restaurant or classroom. They suddenly cannot sit still, are jumpy, or may start climbing on things. Just a few moments earlier, when they were outside, they were fine. Sometimes the classroom may change – construction might’ve begun outside the window, or new, louder students joined the group. Imagine trying to concentrate on something while someone is playing a tambourine in your ear. A child with sensitivities can experience what we perceive as moderate sounds in this way.
Some auditorily-sensitive children may get more fidgety or fearful when in a car or plane. Their symptoms could be that they suddenly “talk excessively” and “butt in on” a conversation. The underlying cause could be a sensitivity to movement combined with auditory issues. This is called vestibular hypoacusis and is often overlooked.
Have you ever felt kind of “off” walking through a brightly-lit grocery store? Or noticed a “blinking” happening in a light above you? This could be a sensitivity to fluorescent lighting. Imagine this 100 times brighter while you’re trying to get school work done. A child who is acting agitated in the classroom and unable to focus could be experiencing this scenario without the ability to articulate what is bothering him or her.
Deeper visual developmental issues such as amblyopia (often known as “lazy eye”) or tracking issues are difficult to diagnose unless a child is seen by a developmental ophthalmologist. School screenings do not cover this, and children can have 20/20 vision in a regular vision test while the issues such as tracking or amblyopia remain undetected. These children can appear to have difficulty paying close attention to their written homework, or may appear to not be “paying attention” because they bump into other children or cannot follow a ball when playing sports.
Treatment of sensory processing disorders (SPDs)
Undergoing sensory integration therapy (through occupational therapists, vision therapists, and audiologists) could make a child become temporarily “unglued” while in therapy or after. For one child I worked with, the reintegration process manifested as extreme anxiety. Every child is different, but you might be able to check every item on the ADHD symptom lists (plus a few more!).
Imagine having someone help you to reset how you use your eyes, ears, sense of balance, where your body is in space in relation to the world, how you taste, and how you feel things on your body. Not only are you having to get used to all of these new feelings independently, but your brain must work on integrating them all to work together. It can be very disorienting. Some practitioners who specialize in SPDs are finding innovative ways to more quickly and gently help children integrate their sensory issues and to prevent this “integration reaction” from happening at all.
Boredom and giftedness
Giftedness can include sensitivities and talents that are often misunderstood in the regular classroom setting. Giftedness may, ironically, create difficulties in the typical school setting and can make a child appear “not so smart or talented.” A child who is bored with a topic may look like they have ADHD in the classroom. Because they are able to think so fast and digest information so easily, especially (and sometimes only if) they are interested in the topic, it makes other topics or going too slowly on a topic very painful.
Imagine someone explaining to you all the steps required to brush your teeth. Every detail of it. And then giving you a quiz on all the steps and marking you incorrect if you got the tiniest detail wrong. This is how a gifted child may experience the classroom setting. Giftedness exists on a spectrum. A common story of children in high school is that they take medication to get through homework that is monotonous and repetitive. These same children often have issues with anxiety and depression.
Some children need to move when processing information. This type of child may fidget in his desk while trying to solve a problem in his head. A child like this may do better if he could get up and move around while trying to think or while listening to a lecture.
Some children can be sensitive to the feeling of clothing such as tags or the seams in socks. Others are particularly sensitive to what an adult or other children think of them. An example of this might be a child who gets jumpy or hides under a desk when an adult perceived as negatively judgmental is present. Others may have food sensitivities that might manifest as hyperactivity after eating a frosted cupcake. Still others might fall to pieces before lunchtime when their blood sugar takes a dive from not eating.
This is just a short list of examples of what can be causing ADHD-type symptoms. As with any diagnosis, a child can have one or many from the list above and ADHD.
Another consideration in the diagnosis of ADHD in children is that we are still trying to understand how and when parts of a child’s brain develop. An article in Medical News Today stated that the findings of a recent study show that, “[a]s children age into adolescence and on into young adulthood, they show dramatic improvements in their ability to control impulses, stay organized, and make decisions.”
The area of the brain most relevant to ADHD is the prefrontal cortex, which controls executive functioning. Executive functioning is the term used for the neurologically-based skills involving mental control and self-regulation, in other words, the skills needed to regulate the symptoms of ADHD. Some say that this area does not fully develop until after adolescence, others say there is a big boost at about age 12. Either way, we know that it is not fully developed in children and may, therefore, contribute to symptoms that are linked with ADHD.
Some examples of executive functioning skills are:
- Being able to pay attention
- The ability to control what one does or says (A child might observe “That kid smells!” then think, “Will I blurt something out, or will I think about how this will affect things?”)
- Working memory
- Cognitive flexibility (“I know she doesn’t like broccoli, but I do and that’s okay.”)
- Problem solving
- Following through on plans
These are all things that most children are working on at some level. What ADHD is diagnosing is the ability (or inability) to use our executive function. If some of the events from the “What else looks like ADHD” list above are happening while a child is trying to figure out their executive functioning skills, or if their prefrontal cortex is developing at a different rate, you can imagine how it could look like ADHD to parents and clinicians.
With these developing years being so crucial to setting the stage for the adults we are actualizing, I urge parents and clinicians to consider the additional or alternative explanations for behaviors we associate with ADHD. Some non-ADHD issues are easily detected and addressed and others may take more of our time and resources, but the results can be remarkable. Even when ADHD was an accurate diagnosis, I have seen profound and positive changes in children whose parents have dared to look further.