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According to the DSM-IV of the American Psychiatric Association, ADHD is a disorder that occurs for the first time in childhood and is usually seen before the age of seven in a child. It is characterized by inappropriate levels for the development of inattention, distractibility, impulsivity and / or hyperactivity. Impairment manifests itself in one or more important areas of life, typically at home, in the classroom, in social interactions, in occupational settings, or other areas of adaptive functioning. The list of symptoms goes on to describe a variety of interferences that can occur with ADHD that can easily disrupt any child’s performance, learning, and behavior. Interestingly, the description of the symptoms does not specify the amount or severity of the symptoms, with the exception that the interference must exceed the normal developmental levels evident in children. As a result, both parents and professionals are challenged to distinguish excessive ADHD symptoms from those that are normal for a child’s specific developmental level.
Good practice requires that an ADHD assessment include the collection of multiple types of information from a variety of sources. A simultaneous effort should be made to rule out as many alternative disorders as may present with similar attention and performance difficulties. This could include, but is not limited to, deficits seen in learning disabilities, developmental delays in younger children, sensory regulation dysfunction, mood difficulties and depression, anxiety, as well as low basic motivational effort. These alternate interruptions will easily and predictably interfere with a child’s optimal performance and learning in the classroom. However, distinguishing these interference in the classroom remains a challenge for teachers and professionals, especially when attention deficits are characteristic of a variety of interfering disorders.
As a child psychologist, I become aware of this professional challenge every time I begin a new ADHD evaluation for a presented child. Then I will regret the absence of an accurate and objective assessment of ADHD that can effectively distinguish inattention from alternative conditions that interfere. At times, I will be fortunate enough to learn crucial information about the presenting child that I have come to recognize as “throwaway” from ADHD. While these exclusion factors are not necessarily absolute in their ability to distinguish, they generally increase my potential to accurately diagnose ADHD.
Age of onset is one of these differential diagnostic factors. The presence of ADHD can be recognized at least by the age of seven in a child. Generally, at this age, a child has developed in multiple areas, including cognitive, social, emotional, behavioral, and physical, in a way that allows them to meet most of the routine expectations that are held for that student in the classroom. The same cannot be said for five-year-olds who may still be developing their ability to self-regulate attention and activity level to facilitate learning in the kindergarten classroom. My comfort level in attempting ADHD assessments improves substantially when the identified child is at least six years old. At this chronological age, I can more accurately use my clinical experience and judgment to determine when activity and inattention is observed beyond expected developmental levels.
I use a related exclusion factor whenever I assess students who are somewhat older in age. Recently, I evaluated a referred fifth grade girl due to her poor academic performance and difficulty attending specifically in the area of ​​mathematics. His absence of symptoms of inattention or worry during the early elementary school years casts serious doubt on a possible diagnosis of ADHD. Not only was there an absence of previous concerns about ADHD, but this student enjoyed excellent academic performance and achievement in all previous elementary years. Unfortunately, her math performance began to show degradation as she progressed through the curriculum that involved greater abstraction in concepts and problem solving. In my opinion, a greater academic challenge will predictably generate higher levels of inattention and poor participation in student tasks and cannot be recognized as the neurological impairment of ADHD.
Dismissal factors are critical when considering any child with ADHD. Specifically, children must show evidence of ADHD by age seven and the symptoms cannot be mistaken for a delay in child development. The interference of ADHD symptoms must be recognized by teachers in every elementary grade without fail, and the interference must be evident in all academic areas. This suggests that a student with ADHD will show some amount of poor attention in all subjects and activities. And finally, ADHD interference will not come on suddenly in fourth or fifth grade and will correspond with the increasing demands of the elementary school curriculum. In the current example, a student who demonstrates developmentally appropriate ability to maintain engagement in homework early in elementary school will not lose this ability in later grades. More precisely, learning weaknesses or motivational problems are frequently present in students struggling with progressive academic demands in the classroom. These students will almost certainly have trouble staying focused and attentive to their assigned work.
These ruling out factors are certainly helpful in arriving at an accurate diagnosis of ADHD in any child or student. Although such ruling out factors can reasonably rule out the diagnosis of ADHD, such factors are largely suggestive rather than absolute in making this diagnostic determination. The non-specific descriptive criteria of ADHD (DSM-IV) in combination with the lack of objective evidence for ADHD will continue to set the stage for meaningful clinical judgment that contributes to your final diagnosis. While there are numerous factors and indicators that will support an accurate diagnosis of ADHD, there are numerous variant presentations of this disorder that must be considered in diagnosing or ruling out this disorder.