Is It Attention Deficit Hyperactivity Disorder or Simply Boy Behavior? By Troy Parrish, MA LCPC
Someone has questioned whether or not it's possible your son has Attention Deficit or not, maybe that person is a teacher, a child care worker or grandparent, or maybe even yourself. Is his behavior the symptoms of this disorder or is he just an active boy? Unquestionably there is a growing awareness of the disorder known as Attention Deficit Hyperactivity Disorder (ADHD). But is there a growing understanding of what it really is and how to determine if your child really suffers this disorder or is there another problem going on causing the problems concerning your child? Historically speaking, the medical understanding of ADHD has changed over time, as has the understanding of many disorders. In the 1950s a child suffering this disorder would have been labeled as having Minimal Brain Dysfunction, in the 1960s and 1970s they would have been diagnosed as having Hyperactivity Disorder, a unified disorder that covered both attention problems as well as over activity. The current understanding diagnosis children with Attention Deficit Hyperactivity Disorder with subtypes of ADHD primarily inattentive type, ADHD primarily hyperactive-impulsive type or ADHD combined (with inattentive and hyperactivity). Recent abilities to see inside the living human body has allowed scientist to see that the brains of people with ADHD definitely show differences in terms of blood flow, metabolic activity as well as other forms of brain activity when compared to people without ADHD. This physical evidence is convincing in terms of the reality of the disorder.
With boys being diagnosed three times more often with ADHD than girls, the question of whether it is ADHD or merely boy behavior becomes very relevant when determining if your boy has ADHD or not. The number of children diagnosed with ADHD is difficult to pin down. However, the number of children being treated with psychostimulants is a bit easier to find. The number of children who were enrolled in HMOs from 1987 to 1996 saw a 600% increase in the prescription of stimulants to treat ADHD in that time frame (there was only a 17% increase in enrollment during that same time period)1 The number of children diagnosed with ADHD also seems to have some significant variance from state to state with a high rate of diagnosis in one state being 11%.2 There is also still a small community of researchers and doctors who claim that ADHD doesn't exist, they insist that either it is a construct built to suit pharmaceutical companies or simply ignorance. However, the vast majority of reputable researchers and doctors accepts that ADHD is a valid disorder. But with the he increase in the use of psychostimulants and the variability from state to state in terms of prevalence of ADHD among children it becomes clear that diagnosing this disorder is not a simple matter and you really have to wonder if good diagnosing is going on all the time.
Attention Deficit Hyperactivity Disorder, as noted above has three subtypes, ADHD primarily inattentive type, ADHD primarity hyperactive-impulsive type and ADHD combined type. The diagnostic criteria established by the American Psychiatric Association in the Diagnostic and Statistical Manual 4th (DSM-IV) addition is as follows:
DSM-IV Criteria for ADHD. Either A or B:
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. 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).
Some symptoms that cause impairment were present before age 7 years.
Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
There must be clear evidence of significant impairment in social, school, or work functioning.
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). Based on these criteria, three types of ADHD are identified:
ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
ADHD, Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met for the past six months
ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion 1B is met but Criterion 1A is not met for the past six months.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
So how do you get a good diagnosis? Just how do you make sure that it is ADHD or not simply boy behavior or maybe some other problem. Children are rarely diagnosed with ADHD prior to the elementary school age. This is largely due to the fact that the symptoms of ADHD and the normal range of toddler behavior are just too similar. The tendency to be distractible, difficulty staying on task and a lot of jumping running and climbing as well as the incessant talking are both core behaviors in ADHD and toddlerhood. It is only when a child has begun to develop the ability to sustain attention and sufficiently and maintain self control of their behavior can you even begin to hope to successfully diagnose ADHD.
There are no blood tests, X-rays or other definitive diagnostics tools to determine ADHD in children or adults. The state of the art diagnosis of ADHD still relies heavily on trained observation, a thorough clinical interview of both parents and the child as well as structured questionnaires given to both parents as well as teachers to fill out. The clinical interview should be thorough to begin to tease out the issues that are contributing to the behaviors bringing the child to the attention he is receiving. It is well known that there are other disorders that may be causing symptoms similar to ADHD (We will touch on these other disorders a little later). There are a number of structured questionnaires that can be used to aid in the diagnosis of ADHD. These structured questionnaires are constructed with normative data provided in order to really compare your child's behavior with children of his own age in a scientific fashion. This is to eliminate the "opinion" factor as much as possible. Observation, with an observer using a prepared checklist can also aid in the accurate diagnosis of ADHD.
The use of brain imaging technology to differentiate those with ADHD and those who do not is showing promise. There are also computer programs and equipment that can be used to test a child's ability to sustain attention and perform tasks without an undue amount of errors (Continuous performance tests or CPT). However, these tests and technologies are either in their infancy (such as brain imaging) or have not proven to add significantly to the quality of differentiating between ADHD and non-ADHD children (CPT). They can also be very expensive and not readily accessible. The use of a subscale on the WISC III intelligence test, the freedom from distractibility scale is influenced by too many factors to be considered a valid scale to determine ADHD. Consequently, given their being still in the developmental stages and the cost and inaccessibility being a problem, these assessment tools are not considered a part of the arsenal in the diagnosis of ADHD.
ADHD can also be seen as a "rule out" disorder. A rule out disorder is a disorder that is typically diagnosed by ruling out other disorders that can create the same symptoms. The need to do an accurate diagnosis is highlighted by the fact that ADHD like symptoms can be caused by other disorders. An ABC News on Line story showed that in one region in Australia that 75% of the children diagnosed with ADHD were in fact misdiagnosed.3 As a result of that misdiagnosis, many of these children were being treated with psychostimulants when they did not need to be. Disorders such as depression and anxiety, particularly in boys, can create symptoms that mimic ADHD. A depressed boy can manifest with distractibility, irritability, loss of focus, difficulty staying on task and restlessness. Anxiety can exhibit symptoms of restlessness, being distracted, being off task, tearfulness as well other symptoms. Learning disabilities have long been known to create symptoms that look on the surface to be ADHD. A child with Learning Disabilities will avoid work, get off task, and misbehave in order to avoid the problems associated with not doing well with their work. Other issues such as a mild pervasive developmental disorder, oppositional defiant disorder or simply immaturity may all be inaccurately diagnosed as ADHD. Add to this mix that there can be overlapping disorders such as ADHD and Learning Disabilities and you begin to appreciate the need to do a very thorough assessment of children suspected of having this disorder.
If you suspect that your son may have ADHD what should you do? Well, the first thing that you shouldn't do is take the word of the teacher who insists that your son has ADHD. While most teachers will only suggest this as a possibility, there are those teachers that will insist that your son is ADHD and that he needs to be medicated for his own good. What this teacher really is saying is that his behavior is a problem that I can't handle in my classroom, you need to get him medicated in order to bring his behavior into line. You should also avoid the rapid diagnosis of the pediatrician who claims that indeed you son is ADHD after discussing the issue with you and your child in a routine 10 to 15 minute visit. This indeed does happen and your son ends up on medication based on the pediatrician running down the diagnostic checklist. With some illnesses, this is more than adequate, but as noted previously, ADHD is not the easiest disorder to diagnose. Fortunately, the American Academy of Pediatricians has established guidelines for the diagnosis of ADHD that mirror the diagnostic methods accepted as being proper for this disorder.4 Make sure your pediatrician is operating with these guidelines in mind, if in doubt, ask. If the doctor is not familiar with the guidelines, consider seeing another doctor for this issue or ask to be referred to a child psychiatrist. Do not allow anyone to suggest that you use a trial of medication to determine if your child has ADHD or not. Studies have shown that giving anyone psychostimulants will increase their attentiveness, whether they have ADHD or not. The use of medication as a diagnostic tool is inappropriate, we wouldn't use it with any other disorders, we shouldn't use it with ADHD.
What you should do is make sure that the evaluation is thorough. The individual doing the evaluation should take a thorough history, taking time to look at other potential problems that could be causing the behavior you are seeing. Look to see that they are using well constructed questionnaires designed to evaluate for ADHD in addition to other disorders. Don't be afraid to ask about the nature and construction of the questionnaire. The evaluator should be able to answer such questions to your satisfaction, after all they are using them to evaluate your child for a serious disorder. They should be giving these questionnaires to as many individuals who can honestly evaluate your child as possible. Behavior that shows up in only one setting is very unlikely to be ADHD. Those doing the evaluations should be from the various places your child spends significant time. If you can get someone to do an observation of your child with a structured set of questions to answer in settings in which you do not see your child this can add valuable information to the overall evaluation. The use of the other measures mentioned such as brain imaging can be pursued, but you will find they are difficult to locate and you will be responsible, most likely, for the cost. If you have any doubts about the diagnosis, seek a second opinion or approach the school for a psychoeducational evaluation to be done by the school psychologist. Because of public law 94-142 you have certain rights to make sure that your child is being educated with any potential disabilities being accommodated. Remember, ADHD is a "rule out" disorder, make sure they your child is not dealing with some other issue.
If you feel confident that the evaluation has been thorough and your son does indeed have ADHD, begin to look for some behavioral ways to address the problems his disorder is presenting. As with many other psychiatric disorders, ADHD has a continuum quality to it, that is some have it worse than others. For some boys, all that is needed is behavioral modification interventions to help them be successful, both at home and at school. Providing routine and structure almost always makes things a little easier for you and your son. Use medication to address attention problems not behavioral problems. Again, research shows that when a child is medicated properly in order to deal with the attention issues, some of the motor activity and impulsivity may remain. Increases in the dosage of medication to deal with these behavioral problems can be effective but at the cost of your child having a sedated quality to him. In addition, there are some side effects to these medications, including appetite disruption, increased irritability when coming off the medication in the evening and at times very unpleasant headaches.
Lastly, continue to educate yourself. There are organizations like CHADD that exist to provide support for parents of children with ADHD as well as provide good information. The National Institute Of Mental Health will also have reliable information on this disorder. Ask the individual who did the evaluation for sources for further educational material. You should also stay informed, keep up with the science. With increasing ability to see what is going on in the brain, our ability to understand and diagnose psychiatric disorders may continue to improve. Stay involved in your son's education and treatment. With this involvement you can hope to keep the use of medication at a minimum while keeping your son's success at a maximum. Below you will find some sources to help you continue your education on ADHD.
Additional Information:
1. Definitive text on ADHD by a leading authority of ADHD, Russell Barkley, Ph.D. This book is written primarily to therapists and doctors but if you can read through some of the jargon, you will get a complete discussion of the disorder as well as interventions for ADHD. Attention-Deficit Hyperactivity Disorder, Third Edition: A Handbook for Diagnosis and Treatment (Hardcover) by Russell Barkley (Click here to go to Amazon.com for this book)
2. Support Groups: Children and Adults with Attention Deficit Hyperactivity Disorder - CHADD They have information of ADHD as well as local chapters all over the United States that meet to provide support for those diagnosed with ADHD or who have children or loved ones diagnosed with ADHD. (Click here to visit their home page).
3. National Institute of Mental Health Information on ADHD Information about the diagnosis and treatment of ADHD (Click Here to visit their site)
4.Information on brain imaging Healing ADD: The Breakthrough Program That Allows You to See and Heal the 6 Types of ADD By Daniel Amen (Click here to go to Amazon for this book) (Click here to visit his website).
Sources:
1. United States Department of Health and Human Services-Substance Abuse and Mental Health Administration. National Mental Health Information Center, Center for Mental Health Services, Section 3, Chapter 12. (<http://mentalhealth.samhsa.gov/publications/allpubs/SMA01- 3537/chapter12.asp>)
2. United States Department of Health and Human Services-Center for Disease Control. Epidemiological Issues in ADHD (2003). (<http://www.cdc.gov/ncbddd/adhd/adhdprevalence.htm>)