Attention deficit hyperactivity disorder (ADHD) is one of the most debated and misunderstood disorders, yet more than 6 million children in the U.S. have been diagnosed with it. As a neurological disorder, ADHD commonly affects organizational skills and impulse control, regulating attention and emotions in a unique way.
To learn more about ADHD, we spoke with Dr. Hitha Amin, neurodevelopmental neurologist at Children’s Hospital Orange County, and Dr. Emily Haranin, child and adolescent psychologist at Children’s Hospital Los Angeles and clinical assistant professor of pediatrics at Keck School of Medicine at USC.
What is ADHD?
The first thing to know about ADHD is that the name isn’t quite accurate. There’s a myth that attention deficit hyperactivity disorder is a “deficit of attention.” The truth is that individuals with ADHD have an abundance of attention; they just have a difficult time controlling it. Check out this video to hear Dr. Edward Hallowell, a leading psychiatrist working with ADHD, explain why moving from “deficit” to “abundance” language is important!
While there is so much nuance in defining and diagnosing ADHD, ADDitude Magazine states that thanks to the information we’ve acquired from neuroscience, brain imaging, and clinical research, “ADHD is not a behavior disorder. ADHD is not a mental illness. ADHD is not a specific learning disability. ADHD is, instead, a developmental impairment of the brain’s self-management system.” And while it is among the most common neurodevelopmental disorders in childhood, with 1 in 10 children between the age of 5 and 17 receiving an ADHD diagnosis, it is also not a phase or condition a child can grow out of.
The complexity and misunderstandings when it comes to ADHD symptoms may make it difficult to distinguish between typical childhood behaviors, such as a child being seen as misbehaving or being disruptive in the classroom, versus actually presenting with hyperactive/impulsive ADHD. This might occur more frequently with boys than girls, as boys who are diagnosed with ADHD are more likely to exhibit signs of hyperactivity. They are also more than twice as likely as girls to be diagnosed with ADHD, though this may be due to clinical and research bias. It’s important to note that research has shown ADHD symptoms are less overt and show up differently in girls than in boys; because of this, they may be completely missed, resulting in lower rates of referral, diagnosis, and treatment.
What are the primary signs and symptoms of ADHD?
When ADHD first appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM-2) in 1968, it was called Hyperkinetic Reaction of Childhood, in response to what was then understood to be excessive motor activity. Twelve years later, with new focus on attention and impulsivity in addition to hyperactivity, the term became Attention Deficit Disorder (with and without Hyperactivity). Today, it is described in the DSM-5 simply as ADHD, with three different presentations:
- Predominantly Inattentive Presentation
- Predominantly Hyperactive/Impulsive Presentation
- Combined Presentation (showing both inattentive and hyperactive/impulsive symptoms)
According to the DSM-5, the inattentive presentation of ADHD is characterized by difficulty sustaining attention or following detailed instruction, forgetfulness, poor focus, etc. Children with this type are usually more easily distracted by external stimuli. Inattentive ADHD is more commonly diagnosed in girls than in boys and can present as “spacey, apathetic behavior.”
The National Institute of Mental Health says symptoms that fall under the inattentive presentation are less likely to be recognized by parents, teachers, or medical professionals, and those with this type are less likely to receive treatment. Inattentive symptoms do not fit the hyperactive/impulsive stereotype, and this may be why ADHD in young girls is often missed (or diagnosed as a mood disorder later on).
The hyperactive/impulsive presentation of ADHD presents as a need for constant movement: fidgeting, getting out of one’s chair, being unable sit still, interrupting others, running around, etc. This type of ADHD is more commonly diagnosed in boys.
The combined presentation of ADHD presents as a mix of both hyperactive/impulsive and inattentive behaviors. For a diagnosis to be made, six or more symptoms each of inattentive and hyperactive/impulsive ADHD must be present.
How and when is ADHD diagnosed?
Who can diagnose ADHD?
How do co-occurring diagnoses affect ADHD interventions?
So how do we make sure our children aren’t being misdiagnosed?
Dr. Amin tells us that multidisciplinary assessments are the most appropriate if co-occurring conditions are present, but it’s sometimes not possible to tease out the root of each individual issue during assessment. In that case, a child can be seen and evaluated, but a diagnosis may be deferred until there is a clearer picture.
In treatment planning, most healthcare professionals will decide which disorder to treat first based on the impairment that those symptoms are producing in the individual’s life. Dr. Haranin says a child’s caregivers, teachers, coaches, and others involved in their daily life are essential reporters when it comes to determining which symptoms are causing a child the most impairment. Clinicians should also include children as much as possible, she says. While asking them about their experience is not always effective, “we try to figure out what symptoms or what specific things are really causing them the most stress. What is the most ‘impairing symptom’ that they’re experiencing? Some of these things can happen at the same time. So we try to figure out what's causing the biggest problem and how we can address that first, then see if those other concerns are still present.”
Having a thorough medical history is key to differentiating between ADHD and co-occurring conditions. For example, symptoms and/or behaviors due to anxiety, a mood disorder, or secondary problems will usually start at a specific time or occur only in certain circumstances (only when taking a test or only upon starting high school), while ADHD symptoms are chronic and pervasive (apparent from childhood and persist in almost every life situation).
For more information about autism and ADHD, read our article Autism and Co-Occurring Diagnoses.
Emotional dysregulation: What is “rejection sensitive dysphoria”?
Treatment for ADHD in children
IEP and 504 accommodations for ADHD
ADHD and a strengths-based approach
There’s a lot of stigma around ADHD, which may make it hard for a child with ADHD to feel understood. A strengths-based approach allows children with ADHD to redefine themselves and form positive-focused concepts of self. It also allows them to explore what makes them unique and gain confidence to do all the things they’re great at. (For more, check out Emma A. Climie and Tasmia Hai’s article “Positive Child Personality Factors in Children with ADHD.”)
To learn how to take a strengths-based approach in special education, including creating strengths-based IEP goals and accommodations, check out our article on the benefits of creating a strengths-based IEP!