What is ADHD, really?

ByDr. Berney

What is ADHD, really?

A few days ago, I was working with a mother who was concerned that her son had ADHD (Attention Deficit Hyperactivity Disorder).  She said that she knows “a little” about ADHD, but was not sure if ADHD explained some of the difficulties that her son was experiencing at home and at school.  So, I thought that I would write a little about what ADHD is and, most importantly, what it is NOT.

Here is a little history about ADHD before we discuss what it is.  ADHD is the newest label of a disorder that has been around for a long time.  It has had many different names and children with impulsivity and restlessness was described in writings since at least the 1700’s.  Prior to the 1960’s, many physicians believed that children with inattention, overactivity, impulsivity, and learning difficulties experienced some type of mild encephalopathy (which basically means a disease in the brain).   They said “mild,” because these people, usually kids, had average to above average intelligence and were not “severely” impaired. Further, there were no true clinical findings of brain damage.  As time passed, it became problematic to “suppose” that there was brain damage in these people.  Therefore, in the late 1960’s, things began to change when several labels began to emerge to describe this condition.  Clinicians began using labels such as “Minimal Brain Dysfunction,” or MDB, and “Hyperkinetic Reaction of Childhood” to diagnose individuals with average or above average IQ who experienced behavioral and learning difficulties.  In the mid to late 1970’s, however, the label changed yet again.  Around that time, there was a great deal of education reform occurring in the US.  In fact, it was not until the mid 1970’s that laws were passed that required public schools to educate all children (remember that, prior to these laws, many children were not educated in schools).  The passing of these laws necessitated a method for identifying children who had difficulties learning.  It was at that time that learning disabilities were first truly identified.  At the same time, the American Psychiatric Association was redefining “Hyperkinetic Reaction of Childhood” and first used the label “Attention Deficit Disorder with or without Hyperactivity.”  As the education system defined learning disabilities, and the American Psychiatric Association defined ADD, the group of children previously diagnosed with MBD or Hyperkinetic Reaction of Childhood were split into one of the two groups, ADD or learning disabled, based upon their symptoms.  ADD with or without Hyperactivity (which was typically abbreviated as ADD/H) was, again, relabeled in 1987, when the American Psychiatric Association referred to it as ADHD (Attention Deficit Hyperactivity Disorder).  ADHD has been the title used for this condition since that time.  ADHD has been around for a long time and has had many aliases over the years.

So, what makes up a diagnosis of ADHD?  Well, you can Google (or Bing) “ADHD diagnosis” and have millions of hits (I just Googled it and got 3,870,000).  Many of those hits will give you the criteria that professionals use to make the diagnosis.  Therefore, to reduce repetition, I will just give you a summary.  There are three subtypes of ADHD: Predominantly Inattentive Type, Predominantly Hyperactive/Impulsive Type, and Combined Type.  The inattentive type suggests that the person has multiple symptoms of inattention.  Typical symptoms of inattention include difficulty focusing, making careless mistakes, forgetfulness, misplacing things, etc.  To meet criteria, a person has to have at least 6 symptoms of inattention (as defined in the criteria).   The hyperactive/impulsive type suggests that the person has multiple symptoms of overactivity and impulsivity.  Typical symptoms include acting as if “driven by a motor,” difficulty sitting still, fidgetiness, interrupting others, and acting without considering the consequences.  To meet criteria for the hyperactive/impulsive type, a person must have 6 symptoms, as defined by the criteria.  If a person must have 6 inattentive symptoms AND 6 hyperactive/impulsive symptoms, then they meet criteria for ADHD, Combined type.

While the symptoms mentioned above are the primary behaviors of ADHD, there are several other things that have to be present before a true diagnosis of ADHD can be made.  First, there must be symptoms prior to the age of 7 years.  A person, based upon the current diagnostic criteria made by the American Psychiatric Association, cannot be diagnosed with ADHD unless symptoms were present early in life.  This, of course, creates some questions related to “Adult Onset ADHD.”  It is certainly possible that a person can make it through their childhood and adolescence without being diagnosed as ADHD, only to be diagnosed with ADHD as an adult.  However, to accurately make the diagnosis, the adult must report symptoms that existed before the age of 7.  This creates some challenges, as there are many conditions that create inattention and forgetfulness that are not ADHD (i.e., depression and anxiety).  Therefore, accurately diagnosing ADHD in adults is somewhat challenging.

The issue of age creates a similar problem when trying to diagnose children.  It is becoming more common that I will have parents bring young children, 3-5 years old, to my office for an ADHD evaluation.  I often resist making a diagnosis of ADHD in individuals that young, though there are some children who obviously have difficulties.  For the remaining young children, however, ADHD-like symptoms is a way of life.  Have you ever seen a kindergarten classroom?  I am awed by those teachers!  They must frequently change activities, keep the children engaged, and be entertaining for 7 and a half hours a day.  Why?  Because most of those children would easily lose their attention to task and become overactive if they were not constantly stimulated.  It is not until children are 8 or 9 years old that we expect them to have calmed down and have the ability to focus on a task for more than a few minutes.  Isn’t it interesting that it is around that time (2 and 3 grade) that we expect kids to be able to read chapter books and answer questions about what they have read?  It is because most of them are not able to focus long enough until they are that old.  It does not mean that they had ADHD!

The second issue that must be addressed before an accurate diagnosis of ADHD can be made is the need for the individual to have symptom related problems in more than one setting.  The majority of patients that I see are self-referred.  That means that they were not referred by another professional or by the school.  In children, that means that I am seeing them because their parents feel as though there is a problem.  I have often begun an ADHD evaluation with a child, only to find that the teacher has no concerns with the child’s behavior.  The teacher indicates that the child can sit and focus, attend to task, and never gets into trouble for being out of his seat.  Situations such as this rarely qualifies a child as being ADHD.  Think about it this way.  If a child has ADHD, it means that they CANNOT focus and attend.  They have significant difficulty sitting still and resisting impulsive responses.  If these are things that they CANNOT do, how is it that they can do it at school if they really have ADHD?  The answer, they do not really have ADHD.  Now I should note that I said it “rarely” qualifies for a diagnosis of ADHD.  There are times when a fabulous teacher (there are a lot of them out there) is able to create a classroom setting that effectively manages children with mild ADHD.  So, of course, this must be taken into consideration.  Nonetheless, 9 times out of 10, if a child has behavioral issues at home, and there are no issues at school, it is not ADHD.  It is something else.

The other scenario is when the child has problems at school and no issues at home.  This one is a little more challenging.  Sometimes children do not have any problems at home because there are no demands placed upon them.  They do not have chores or homework.  They do not have to do things that they do not want to do.  In these situations, ADHD is still a possibility and further testing is needed.

This brings me to the last section to discuss, testing for ADHD.  Today, ADHD is a condition that is diagnosed based upon clinical findings.  Although there are researchers searching for some type of laboratory test to identify ADHD, it remains that the only way to test for ADHD is through neuropsychological testing and observations.  In my clinic, I perform multiple tests to assess intellectual ability, academic achievement, executive functioning (a big topic I will discuss in a different thread. Just note here that ADHD is considered a disorder of executive function), and attention.  In addition, I provide forms to parents and teachers to complete to assess ADHD behaviors at home and at school.  For adults, I perform a similar battery of tests and provide them with self-report questionnaires (questionnaires that they fill out about themselves) and encourage them to have one of their parents help them complete a questionnaire that asks about their childhood.

ADHD is the most common psychological/psychiatric diagnosis made in children.  Further, I believe that the number of ADHD diagnoses will continue to rise.  Though I will save it for a different post, I believe that there are many things happening in education these days that are “causing” ADHD symptoms in children.  As educational expectations rise, and fourth grade students continue to be asked to learn algebra and geometry, students are going to have ever more difficulty focusing and concentrating in school.  Behavioral issues will continue to rise, not because more kids have ADHD, but because we are creating a setting that is not appropriate for them, developmentally.  At many schools, kids can’t even talk at lunch any more!  Wow, I will save that soap box for later …