• Sara Silvestri, MD FAAP

Is It Really ADHD?

“He just never stops.” “She’s so extra!” “His teacher wants me to talk to you about medication.”

I hear these, and many similar phrases, on a daily basis. Almost everyone has heard of Attention-Deficit/Hyperactivity Disorder or ADHD. Most parents have had at least one moment when they’ve wondered if their child has it. But is it really ADHD? Many professionals feel that ADHD is being over diagnosed. If this is correct, this comes at the expense of missing the true underlying problem.

According to the CDC, in 2016, 6.1 million children aged 2-17 years had been diagnosed with ADHD. Boys were two times more likely to be diagnosed. Seventy-five percent of these children were receiving some sort of treatment in form of therapy, medication or both.

One of the criteria for diagnosing ADHD is to make sure that the symptoms are not “explained better” by another mental health disorder. This is where things get tricky as symptoms of ADHD and other problems, such as anxiety and trauma, overlap. We will explore some of these other problems further, but the list is quite large and more extensive than this article will be able to cover at one time.

Let me pause here and state clearly that I do believe that ADHD exists and I believe there are some children who do wonderfully with behavioral and pharmaceutical treatment for ADHD alone. However, I’ve also seen a large number of patients that have either been misdiagnosed or have additional problems with their ADHD that are not being addressed.

Early in life, ADHD and immaturity can be difficult to tease out. I am always very hesitant to have ADHD conversations for toddlers. Let’s be honest. Most two-year olds are not going to sit down for long periods of time. In a similar thought, there may be almost a full year difference in age between the oldest and youngest students in a classroom. This age difference may not be as notable in the late high school years, but a maturity level difference is likely to be evident in Kindergarten and early grade school years.

Another important distinction to make is between ADHD and a learning disability. If a child does not understand what is being taught, it is an unrealistic expectation that that child will sit quietly and pay attention. For the diagnosis of ADHD, symptoms must be present in at least two different environments. Therefore you may think that distinguishing a learning disability from ADHD would be easy as it would not be present at home. To some extent that is true. However for many kids, the most structured time at home is homework time when this problem would once again be present. Learning disabilities may also be present with other developmental delays that may be more evident at home.

Mood disorders and, in particular anxiety, may present with several overlapping symptoms of ADHD. If a child is worried about being separated from their parents or about the thunderstorm outside, he's not going to focus on his school work.

Finally, we need to discuss the role of traumatic stress being diagnosed as ADHD. This is an important cause of symptoms to be mindful of in any child, but especially in those in foster care or who have been adopted. Over the last several years, there has been increasing focus on the roles that adverse childhood experiences and traumatic stress play in the overall health of people not just during childhood but throughout their lives. Sources of traumatic stress may be obvious things such as a car accident, death of a parent or sexual abuse. Traumatic stress can be from not just something that happened to the child but something that was witnessed. Therefore, sometimes the inciting event may not be easily pinpointed.

Children with traumatic stress may have difficulty concentrating, may be restless, disorganized, hyperactive and easily distracted. That sounds pretty similar to ADHD, right? That is because ADHD can cause the exact same symptoms and these symptoms may be more obvious to see than some of the more internal symptoms of traumatic stress such as one feeling shamed, guilty or always fearful.

So how are the different problems distinguished? A thorough history of symptoms, experiences and a detailed evaluation for other mental health symptoms and disorders needs to be performed. Sometimes this can be done in a pediatrician’s office, but often requires a psychiatrist or neurodevelopmentalist.

The first step for getting a hyperactive child with poor concentration the help that they need is to be aware that many different problems may cause these symptoms and typically several problems can present at once. Advocate for your child and keep your mind open to the many different diagnoses that may be present before limiting him or her to an ADHD diagnosis.

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