ADHD 101

Article
Apr. 15, 2021Updated Dec. 7, 2022

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?

According to the CDC, about 75% of children with ADHD are diagnosed before age 9, and one-third of those are diagnosed by age 6. However, Dr. Haranin points out that children may also be diagnosed later in their teens or adolescence. “Part of that is because what we know about ADHD is that some children or teens don’t start to experience that impairment until the demands of the environment outweigh the strategies they’ve been using to get by,” she says. “Often we find in transitions, when children switch from elementary to middle school, we see those attentional capacities being overwhelmed.”

With diagnosis, she says, clinicians are trying to “capture the symptoms and behaviors that a child or an adult is presenting with at any given time.” However, not every child is going to fit perfectly into the specific diagnostic boxes we’ve created, so it’s important to “identify which boxes best fit and best capture what the child is presenting with. That can help us make recommendations about treatment or intervention that might be helpful.”

According to the DSM-5, in order for an ADHD diagnosis to be made, symptoms must:

  • be present for at least 6 months
  • be present before the age of 12 (they often begin between the ages of 3 and 6)*
  • be present to a degree that is inconsistent with a child’s developmental level
  • impact a child’s abilities in at least two areas of life (home, school, friendships, etc.)
  • interfere with or reduce the quality of social, academic, or occupational functioning
  • not be better explained by another mental or psychiatric disorder.

(Children up to the age of 16 must have 6 or more symptoms present in an area in order to meet diagnostic criteria; individuals 17 and over only need 5 symptoms to meet diagnostic criteria.)

The path to diagnosis typically begins when a parent or teacher notices some of the symptoms described earlier, such as having more trouble following directions or staying on task than is developmentally appropriate. Dr. Haranin says it’s important to show that these symptoms cause impairment, which can mean impairment in academics, in parent-child relationships, or in a child’s social relationships. She also cautions that symptoms will show up differently in different environments. “It’s not just that in school, a child is having trouble paying attention — it means that you might also see that at home, or you might also see that swimming or in baseball or in other environments.”

“It’s really important to gather information beyond just ADHD symptoms,” Dr. Haranin says. “That’s one way to know whether your child is receiving a quality assessment or if all the concerns are being addressed. Questions about sleep, for example. We also know that things like constipation can impact a child’s behavior. Thorough interviewing around concerns and behaviors and gathering information from various individuals in a child’s life can [help us] make sure we’re getting the most comprehensive picture possible.”

An ADHD diagnosis will be based on interviews with a child’s caregivers and usually several members of their school team, and occasionally, for older children, with the child themselves. An ADHD screening evaluation that uses a standardized ADHD rating scale may also be used. This can help rule out other conditions, such as learning disorders, anxiety, autism, etc.

The interviews will focus on answering two questions: What patterns of behavior have adults in the child’s life observed, and how are those behaviors impacting the child’s life? There are many different rating scales used by healthcare providers to guide the interviews and evaluate symptoms. Depending on the age of the child, some practitioners may also use computer tests that measure attention, impulsivity, and inattention. The entire process will take time and a lot of paperwork, including a physical exam and a thorough interview about social history, family history, and symptom history.

The American Academy of Pediatrics (AAP) recommends testing for other developmental issues when making an ADHD diagnosis, testing eyesight and hearing, and screening for [learning disabilities]/resources/1315) and mood disorders to see if other conditions are contributing to the behaviors.

After the interviews and tests, the family will have the results along with an action plan to manage symptoms, including:

  • Accommodations to help the child in school, which would be added into the IEP or 504 plan
  • A plan for follow-up with an ADHD expert, therapist, or psychologist
  • Recommendations for ADHD medication (if considered)
  • A schedule for future appointments with the health care professional to continue care and follow-up with treatment plans.

Who can diagnose ADHD?

You can learn more about special education evaluations in our article IEP Assessments 101.

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

Of the 13 eligibility categories that qualify a child for an IEP, ADHD falls into the classification of “Other Health Impairment (OHI).” But because IDEA is very specific with what qualifies as a disability, sometimes children are denied services unless the ADHD is shown to be severe enough to cause major impairment and adversely impact educational performance. However, children who are unable to qualify for an IEP may still be able to receive services and supports under a 504 plan.

The following are some common accommodations that may be included in a child’s IEP or 504 Plan to help them succeed in school:

  • Adjust formats for reading and writing assignments to help with visual scanning and/or remaining seated. (This includes using technology such as audiobooks to help a child complete tasks.)
  • Combine tasks with a physical action, such as using manipulatives.
  • Provide a visual schedule.
  • Provide prompts to help a child stay on task.
  • Allow more time to complete tests and homework.
  • Provide more breaks and opportunities to move around throughout the school day.
  • Address any learning gaps in math, reading, and writing that may have resulted from previously undiagnosed ADHD.
  • Create goals to improve how they socialize with their peers, since kids with ADHD are more likely to be bullied.
  • Provide positive reinforcement and feedback.

You can find additional suggestions in our article List of Accommodations for IEPs and 504s.

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!

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Contents


Overview

What is ADHD?

What are the primary signs and symptoms of ADHD?

How and when is ADHD diagnosed?

Who can diagnose ADHD?

How do co-occurring diagnoses affect ADHD interventions?

The link between executive functioning and ADHD

Emotional dysregulation: What is “rejection sensitive dysphoria”?

Treatment for ADHD in children

IEP and 504 accommodations for ADHD

ADHD and a strengths-based approach

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Related Parent Questions

How is ADHD treated?
Depending on your child’s age, their doctor will likely suggest behavior therapy (which includes parent education) or a combination of behavior therapy and medication. Medication is not recommended for children under six years old since it is known to cause more side effects in younger kids.
Who can diagnose my child with ADHD?
The professionals who can diagnose ADHD include a psychologist, a psychiatrist, a pediatrician, or a developmental pediatrician who specializes in developmental, learning, and behavioral issues.
What are the primary signs and symptoms of ADHD?
The common signs of ADHD include short attention span, hyperactivity, impulsivity, and fidgeting or restlessness, among others. Symptoms must be present for at least six months and impact their abilities in at least two areas of life: home, school, and/or friendships.

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