When talking with others about my job, a common question I come across is: How do you tell when the symptoms of ADHD are part of a psychiatric disorder or a normal part of a child’s development? This is an understandable question. The symptoms of ADHD listed in the DSM-IV, sound a lot like a list of behaviors of the average child: difficulty waiting for his or her turn, fidgeting or squirming, doesn’t seem to listen when spoken to directly. I can tell you that ADHD is one of the most studied childhood psychiatric conditions, and the criteria psychiatrists use to make the diagnoses have been rigorously researched, debated, and revised. What we are left with are 18 symptoms. Of the 18 symptoms, the patients needs at least 6 to make the diagnosis of ADD and 12 to make the diagnosis of the combined subtype of ADHD. A boy who just fidgets in his seat does not have ADHD. A child who has substantial problems staying in his seat, talks incessantly, often runs around when it’s not appropriate to, can’t wait until the end of a question in order to answer it, intrudes into others’ games or conversations, and is having problems at school or at home because of these behaviors, well, this boy may need some help.
I’ve decided to devote some space to looking at the symptoms a little more closely and explain some of the differences between symptoms of ADHD, normal behavior, and other psychiatric disorders. The first behavior we’ll discuss is inattention. Of course, a girl who doesn’t know the answer to her teacher’s question because she was daydreaming hardly constitutes a psychiatric emergency. However, if you ask a small girl with ADHD why she didn’t finish her test by the end of class, she may tell you she was trying very hard but kept getting distracted by the window, the kid in front of her, or got lost thinking about yesterday’s cartoons. She may do this on every test and it may result in her repeating the 5th grade. To me, this girl doesn’t have normal childhood distraction, but problems with attention.
The key concept here is PROBLEMS with attention; regular, repeated problems with paying attention that lead to getting lost, doing poorly on tests, or not being able to finish homework in a timely manner. Not being able to filter out external noise is a clue to attention problems. Another is not finishing work on time. Kids with ADHD may be the brightest in the room but the last to complete the assignment, if they complete it at all. Kids with ADHD who can’t finish a test in time aren’t idle; their minds are often a beehive of activity, jumping from one distraction to another. Usually seasoned teachers, parents, psychologists, and psychiatrists can come to a consensus on whether a child has problems with attention or not.
Once we agree that a child has a problem with attention (as evidenced by problems at school, home, or other settings) due to not being able to resist distractions, follow through, or sustain responses to tasks, the next question is whether this inattention is because of ADHD and not something else. There are at least 14 disorders listed in the DSM-IV that have poor concentration or inability to maintain attention as a diagnostic symptom. These include post-traumatic stress disorder, major depressive episodes, manic episodes, schizophrenia, and delirium. My next entry will discuss some of the challenges faced in trying to figure out whether inattention is due to ADHD or another psychiatric illness. Of course as always I welcome your questions and comments.