Who has ADHD?

The Pediatric Insider

© 2009 Roy Benaroch, MD

Kristin would like to know, “How do you actually ‘diagnose’ a nine year old boy with ADHD? Descriptions of ADHD are so vague. Most of what is described as ADHD symptoms seem like normal boy behavior to us. Can a child be a straight A student and still have ADHD?”

It’s a fair question. There is no objective test for any psychiatric or mental health disorder, including ADD (Attention Deficit Disorder; one subtype is ADHD, or Attention Deficit-Hyperactivity Disorder), depression, anxiety disorders, autism—none of these can in any way be “tested for” or diagnosed with the kind of precision expected of ordinary medical diagnoses. I’m convinced that in 100 years, doctors will look back at my generation of physicians and chuckle knowingly, saying things like “¡ssǝ1ǝn1ɔ ʍoɥ ‘suɐıɹɐqɹɐq ǝsoɥʇ”. (Apparently, in the future, people speak upside down.)

In an effort to codify and standardize the language and diagnoses of psychiatry, the American Psychiatric Association first published the “Diagnostic and Statistical Manual of Mental Disorders” in 1952. The current version, last revised in 2000, is called the DSM-4-TR. It’s been criticized as “cookbooky”, relying on lists of symptoms to establish mental health diagnoses using checklists reminiscent of ordering a family meal at a Chinese Restaurant. Choose at least one from Column A (eg “inability to sit still”) and one from column B (“starting not older than seven years”), plus some qualifiers, and you’ve either got Mongolian Beef or Major Depression, maybe even both.

Though there are legitimate criticisms of the DSM, in fairness to psychiatry there are important caveats that are often overlooked. The book states explicitly that the diagnostic labels are mainly useful as “convenient shorthand for professionals,”  and that only well-trained professionals should interpret the standards and apply diagnostic criteria. So consider the DSM as a starting point for mental health diagnoses, not a straightjacket (sorry, poor time for a straightjacket joke).

DSM-IV Criteria for ADHD

I. Either A or B

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level.

Inattention

  • Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
  • Often has trouble keeping attention on tasks or play activities.
  • Often does not seem to listen when spoken to directly.
  • Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
  • Often has trouble organizing activities.
  • Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
  • Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
  • Is often easily distracted.
  • Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level.

Hyperactivity

  • Often fidgets with hands or feet or squirms in seat.
  • Often gets up from seat when remaining in seat is expected.
  • Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
  • Often has trouble playing or enjoying leisure activities quietly.
  • Is often “on the go” or often acts as if “driven by a motor.”
  • Often talks excessively.

Impulsivity

  • Often blurts out answers before questions have been finished.
  • Often has trouble waiting one’s turn.
  • Often interrupts or intrudes on others (e.g., butts into conversations or games).

II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

In summary: children with ADD have either inattention or impulsivity & hyperactivity, have these to a greater extent than expected for the developmental age, have these starting in early childhood, and have these as a more-or-less permanent part of their behavioral makeup. The symptoms must occur in multiple settings, and must occur to such an extent that they interfere with social, school, or occupational functioning. Part V is especially helpful—it says, essentially, that it’s ADD unless it is something else. Clearly, attorneys were involved in the preparation of this document.

To help “standardize” the diagnosis and hopefully make the assessment more objective, many clinicians rely on standardized testing instruments. Parents and teachers are asked a number of questions, like “How often does he fidget,” and answer something like always, sometimes, or never. The answers are decoded in a manner similar to the quizzes in Glamour Magazine (“What kind of guy is perfect for you?”), and the total score can be compared with thousands of other children who took the test. The “outliers”—the ones with the highest scores, above some set statistical set point—are said to have ADD.

Though these tests are helpful, it’s easy to see how parent or teacher preconceptions could color their answers. There are strong feelings about ADD and medication for ADD, and I’m not sure that making adults bubble in answers recalling a child’s behavior is likely to cut through their own feelings in a way that can reliably reveal what’s going on with a child. ADD “testing” has a role—in my mind, chiefly to rule out learning disorders and other problems that often go together with or appear very much like ADD—but a more reliable diagnosis I believe requires a thorough medical history and evaluation, as well as multiple observations over time by a skilled examiner. It’s not easy, and not quick, to do it right.

In answer to the final question, “Can a straight A student have ADHD?”—according to the DSM criteria, ADD characteristics like hyperactivity and inattention must occur to a degree to cause problems in school, home, or work. If your child is getting along well at home and with friends, and is getting straight As at school, he would not meet DSM criteria for ADD and should not be diagnosed as having ADD. Nonetheless, he may  benefit from behavioral interventions to encourage better sustained attention—but that’s a subject for a future post!

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11 Comments on “Who has ADHD?”

  1. Allison Says:

    Oh boy, do I dare suggest to correct Dr. Roy?

    Dr. Roy, I disagree with your answer to her last question. A “straight A” student certainly can have ADHD. “Significant impact upon school” does not ONLY concern academic performance, but behavior as well.

    So you might have a student who is getting “straight As” because they’re so smart that it takes very little for them to learn the material, but who is horribly disorganized (ADHD-inattentive type), or who can’t sit still/fidgets/drops pencils (ADHD-hyperactive type), or has a combination of these two. These types of students can still do well academically, because they’re smart, but still exhibit the characteristics of ADHD and (usually) get in trouble for these manifestations (especially those hyperactive types that disrupt class). It’s that “getting in trouble” that is the educational impact of the disability, rather than poor grades.

    In fact, many kids with ADHD-hyperactive type can learn BETTER when given a fidget to keep that need satisfied, allowing the to better concentrate on the material being presented.

    Just my thoughts….

    Allison B. Vrolijk, Esq.

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  2. Shannon Says:

    Allison,

    I think that you missed that Dr. Roy didn’t just say straight A students cannot have ADHD. He put forth additional criteria “If your child is getting along well at home and with friends, and is getting straight As at school, he would not meet DSM criteria for ADD and should not be diagnosed as having ADD.”

    (1) Getting along well at home +
    (2) Getting along well with friends +
    (3) AND making Straight As +
    = “he would not meet DSM criteria for ADD and should not be diagnosed as having ADD. Nonetheless, he may benefit from behavioral interventions to encourage better sustained attention”

    It was not exclusive of other criteria. My take-away is if the child is making straight As but is having social/behavioral issues elsewhere, i.e. friends and/or family, there may still be an ADHD/ADD problem and a further qualified evaluation may be necessary.

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  3. Allison Says:

    Shannon,

    But that’s the thing. Even if the child is getting along well at home and with friends and getting straight As, they COULD still have ADHD.

    Such a child could be terribly disorganized in school, or disruptive in class. Still not having social or academic problems, but having behavioral problems that interfere with school.

    I point this out because that combination of characteristics (getting along well at home and with friends and making straight As) is a frequent reason for schools denying services to children with ADHD. And it’s wrong. If the child with ADHD has behavioral manifestations of the ADHD that do not affect him socially or academically, but do affect him behaviorally in school, he is still entitled to services. And parents should know that.

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  4. Shannon Says:

    If that’s the case, in my opinion (I’m not a doctor), it’s a discipline issue not a medical one, and it is parental issue not a school or tax payer one. That’s all I have to say about that.

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  5. Allison Says:

    Fortunately, Shannon, the law disagrees with you. These children need our support and assistance, not our dismissal and ignorance. Be thankful that your own children don’t have any special needs (I’m assuming they don’t, or you would not have made the statement you did). It’s a tough road to travel.

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  6. Ginger Says:

    Okay… we’ve gone through the DSM and feel that our child has at least 7, or maybe all 9 of Inattentiveness. Her teacher agrees.

    What next?

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  7. Dr. Roy Says:

    Ginger, if you suspect ADD or ADHD is impairing your child’s progress in school, contact your pediatrician. Depending on practice style, local resources, and your preferences sometimes they may direct you to a local psychologist for formal “testing”, or they may suggest a less formal approach. You could also seek treatment though a child psychiatrist or neurologist.

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  8. Ginger Says:

    Inattentiveness in school… Unfortunately, we are likely heading down an ADD path. We’ve tried a couple of therapists, but haven’t seen massive changes. What’s our next step? The school is recommending we see a developmental pediatrician… What do you think we should do next?
    Our child is 5.5 years and having significant attention issues in Kindergarten… she’s bright enough, but can’t seem to pay attention to the directions to get the work right.

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  9. Sheilah Says:

    Hi, Ginger, I was told this same thing about my son, who is now 8.5 years old. I saw a lot of the things “they” said may indicate an ADD issue: zoning out, not paying attention, not following directions, not listening, twitching, repeated motions with hands, eye/head rolling, etc. The first grade teacher suggested mentioning it to the doc, which I did. She even thought he had a hearing problem, in addition to the ADD symptoms.I learned something: Kindergarten may be too young to tell about ADD if the child is smart, can focus on what that which he/she is interested (like playing, TV, etc), and is progressively learning. I was ready to proceed w/ testing, but I waited and he improved; kind of adjusted as he matured. He’s now in 3rd grade, still has some attention issues, doesn’t always follow directions (because he thinks he knows how to do everything), but is exceeding academically, socially, and emotionally. I don’t know your history, or if you have other children, etc., but my experience has been that people in Kindergarten may not always have attention-paying skills developed yet. Just IMHO. I hope everything works out for you.

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  10. Dr. Roy Says:

    Ginger, at least in my area developmental pediatricians are difficult to get appointments with, and really wouldn’t typically become involved with care unless there were big atypical issues going on. More typically ADHD is treated by pediatricians (sometimes in concert with psychologists), child psychiatrists, or sometimes neurologists.

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  11. Robyn Says:

    I am not a doctor, but I have found a lot of info. regarding gifted(smart) children being diagnosed with ADHD because the behavioral symptoms are mostly the same. Smart kids get finished with the work fast and usually spend 1/4 to 1/2 of the time waiting on others to catch up. Google “Gifted children misdiagnosed for ADHD”

    Here’s a couple articles: http://www.brighthub.com/education/special/articles/22575.aspx

    http://www.sengifted.org/articles_counseling/Webb_MisdiagnosisAndDualDiagnosisOfGiftedChildren.shtml

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