Medical Diagnosis

The following section is adapted from ADHD and Behavior Disorders in Children by Richard Milich and Walter Roberts.

ADHD is a neurodevelopmental disorder that impacts the prefrontal cortex of the brain — the area responsible for executive functions, emotional regulation, and impulse control, among other things. All children can occasionally be inattentive, impulsive, or overactive. For students with ADHD, those behaviors are typical and often severe. Deciding whether a child has ADHD is a multi-step process. There is no single test to diagnose ADHD. Mental health professionals use the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5) to help diagnose. The core symptoms of ADHD are organized into two clusters, including clusters of hyperactivity/impulsivity and inattention.

Indicators of Hyperactivity and Impulsivity

The hyperactive symptom cluster describes children who are perpetually in motion even when expected to be still such as during class or in the car. The impulsive symptom cluster describes the difficulty in delaying a response and acting without considering the repercussions of behavior. Hyperactive and impulsive symptoms are closely related, and boys are more likely than girls to experience symptoms from this cluster. The following is a list of hyperactive and impulsive indicators:

• Often fidgets with hands or feet or squirms in their seat
• Often leaves their seat in the classroom or in other situations in which remaining seated is expected
• Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents and adults, this may be limited to subjective feelings of restlessness)
• Often has difficulty playing or engaging in leisure activities quietly
• Is often “on the go” or often acts as if “driven by a motor”
• Often talks excessively
• Often blurts out answers before questions have been completed
• Often has difficulty awaiting their turn
• Often interrupts or intrudes on others (e.g. butting into conversations or games)

Indicators of Inattention

Inattentive symptoms describe difficulty with organization and task follow-through, as well as a tendency to be distracted by external stimuli.  The following is a list of inattention indicators:

• Often fails to pay close attention to details or makes careless mistakes in schoolwork, work, or other activities
• Often has difficulty sustaining attention in tasks or play activities
• Often does not seem to listen when spoken to directly
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books, or tools)
• Is often easily distracted by extraneous stimuli
• Is often forgetful in daily activities

Two children diagnosed with ADHD can present with very different symptoms

Children can be diagnosed with different subtypes of the disorder (i.e., Combined Type, Predominantly Inattentive Type, or Predominantly Hyperactive-Impulsive Type) according to the number of symptoms they have in each cluster. Because attention problems in the early years can put a child at risk for later educational difficulties, it is essential to provide preventive and corrective interventions as early as possible (Pingault et al., 2011; Breslau et al., 2009). Unfortunately, while educators readily flag the more visible behaviors of hyperactivity, problems with attention are less noticeable and less likely to be identified in a timely fashion.

Many critics argue that ADHD is not a “real” disorder. These individuals claim that children with ADHD are only “disordered” because parents and school officials have trouble managing their behavior. These criticisms raise an interesting question about what constitutes a psychiatric disorder in children: How do scientists distinguish between clinically significant ADHD symptoms and typical childhood impulsivity, hyperactivity, and inattention? After all, many four-year-old boys are hyperactive and cannot focus on a task for long.

ADHD Criteria

Several criteria are used to distinguish between normal and disordered behavior to address this issue such as the following:

1. The symptoms must significantly impair the child’s functioning in important life domains (e.g., school, home).
2. The symptoms must be inappropriate for the child’s developmental level.

The first criterion states that children with ADHD should show impairment in the major functional domains. This is certainly true for children with ADHD. These children have lower academic achievement, compared with their peers. They are more likely to repeat a grade or be suspended and less likely to graduate from high school. Children with ADHD are often unpopular among their peers; many are actively disliked and socially rejected. Children with ADHD will likely experience comorbid psychological problems such as learning disorders, depression, anxiety, and oppositional defiant disorder. As they grow up, adolescents and adults with ADHD are at risk of abusing alcohol and other drugs and experiencing other adverse outcomes.

The second criterion examines whether a child’s symptoms are indicative of normal development patterns. Many behaviors that diagnose ADHD in some children would be considered developmentally appropriate for a younger child. This is true for many psychological and psychiatric disorders in childhood. For example, bedwetting is quite common in three-year-old children; at this age, most children have not gained control over their nighttime urination. For this reason, a three-year-old child who wets the bed would not be diagnosed with enuresis (i.e., the clinical term for chronic bedwetting) because their behavior is developmentally appropriate. Bedwetting in an eight-year-old child, however, is developmentally inappropriate. Children are expected to remain dry overnight at this age, and failure to master this skill would prevent children from sleeping over at friends’ houses or attending overnight camps.