Attention Deficit Hyperactivity Disorder: Module 1
Symptoms and Diagnosis
The information in this training module was taken
from an online article by the National Institute of Mental
Hyperactivity Disorder (ADHD) is a condition that becomes apparent in some
children in the preschool and early school years. It is hard for these children
to control their behavior and/or pay attention. It is estimated that between 3
and 5 percent of children have ADHD, or approximately 2 million children in the
United States. This means that in a classroom of 25 to 30 children, it is likely
that at least one will have ADHD.
A child with ADHD faces a
difficult but not insurmountable task ahead. In order to achieve his or her full
potential, he or she should receive help, guidance, and understanding from
parents, guidance counselors, and the public education system. This document
offers information on ADHD and its management, including research on medications
and behavioral interventions, as well as helpful resources on educational
The principal characteristics of ADHD are
These symptoms appear early in a child’s life. Because many normal children may
have these symptoms, but at a low level, or the symptoms may be caused by
another disorder, it is important that the child receive a thorough examination
and appropriate diagnosis by a well-qualified professional.
Symptoms of ADHD will
appear over the course of many months, often with the symptoms of impulsiveness
and hyperactivity preceding those of inattention, which may not emerge for a
year or more. Different symptoms may appear in different settings, depending on
the demands the situation may pose for the child’s self-control. A child who
“can’t sit still” or is otherwise disruptive will be noticeable in school, but
the inattentive daydreamer may be overlooked. The impulsive child who acts
before thinking may be considered just a “discipline problem,” while the child
who is passive or sluggish may be viewed as merely unmotivated. Yet both may
have different types of ADHD. All children are sometimes restless, sometimes act
without thinking, sometimes daydream the time away. When the child’s
hyperactivity, distractibility, poor concentration, or impulsivity begin to
affect performance in school, social relationships with other children, or
behavior at home, ADHD may be suspected. But because the symptoms vary so much
across settings, ADHD is not easy to diagnose. This is especially true when
inattentiveness is the primary symptom.
According to the most
recent version of the
Diagnostic and Statistical Manual of Mental Disorders2
(DSM-IV-TR), there are three patterns of behavior that indicate ADHD. People
with ADHD may show several signs of being consistently inattentive. They may
have a pattern of being hyperactive and impulsive far more than others of their
age. Or they may show all three types of behavior. This means that there are
three subtypes of ADHD recognized by professionals. These are the
(that does not show significant inattention); the
(that does not show significant hyperactive-impulsive behavior) sometimes called
ADD—an outdated term for this entire disorder; and the
(that displays both inattentive and hyperactive-impulsive symptoms).
children always seem to be “on the go” or constantly in motion. They dash around
touching or playing with whatever is in sight, or talk incessantly. Sitting
still at dinner or during a school lesson or story can be a difficult task. They
squirm and fidget in their seats or roam around the room. Or they may wiggle
their feet, touch everything, or noisily tap their pencil. Hyperactive teenagers
or adults may feel internally restless. They often report needing to stay busy
and may try to do several things at once.
children seem unable to curb their immediate reactions or think before they act.
They will often blurt out inappropriate comments, display their emotions without
restraint, and act without regard for the later consequences of their conduct.
Their impulsivity may make it hard for them to wait for things they want or to
take their turn in games. They may grab a toy from another child or hit when
they’re upset. Even as teenagers or adults, they may impulsively choose to do
things that have an immediate but small payoff rather than engage in activities
that may take more effort yet provide much greater but delayed rewards.
Some signs of
restless, often fidgeting with hands or feet, or squirming while seated
climbing, or leaving a seat in situations where sitting or quiet behavior is
answers before hearing the whole question
difficulty waiting in line or taking turns.
Children who are
inattentive have a hard time keeping their minds on any one thing and may get
bored with a task after only a few minutes. If they are doing something they
really enjoy, they have no trouble paying attention. But focusing deliberate,
conscious attention to organizing and completing a task or learning something
new is difficult.
Homework is particularly
hard for these children. They will forget to write down an assignment, or leave
it at school. They will forget to bring a book home, or bring the wrong one. The
homework, if finally finished, is full of errors and erasures. Homework is often
accompanied by frustration for both parent and child.
The DSM-IV-TR gives these
becoming easily distracted by irrelevant sights and sounds
failing to pay attention to details and making careless mistakes
following instructions carefully and completely losing or forgetting things like
toys, or pencils, books, and tools needed for a task
skipping from one uncompleted activity to another.
Children diagnosed with
the Predominantly Inattentive Type of ADHD are seldom impulsive or hyperactive,
yet they have significant problems paying attention. They appear to be
daydreaming, “spacey,” easily confused, slow moving, and lethargic. They may
have difficulty processing information as quickly and accurately as other
children. When the teacher gives oral or even written instructions, this child
has a hard time understanding what he or she is supposed to do and makes
frequent mistakes. Yet the child may sit quietly, unobtrusively, and even appear
to be working but not fully attending to or understanding the task and the
These children don’t show
significant problems with impulsivity and overactivity in the classroom, on the
school ground, or at home. They may get along better with other children than
the more impulsive and hyperactive types of ADHD, and they may not have the same
sorts of social problems so common with the combined type of ADHD. So often
their problems with inattention are overlooked. But they need help just as much
as children with other types of ADHD, who cause more obvious problems in the
Is It Really ADHD?
Because everyone shows
some of these behaviors at times, the diagnosis requires that such behavior be
demonstrated to a degree that is inappropriate for the person’s age. The
diagnostic guidelines also contain specific requirements for determining when
the symptoms indicate ADHD. The behaviors must appear early in life, before age
7, and continue for at least 6 months. Above all, the behaviors must create a
real handicap in at least two areas of a person’s life such as in the
schoolroom, on the playground, at home, in the community, or in social settings.
So someone who shows some symptoms but whose schoolwork or friendships are not
impaired by these behaviors would not be diagnosed with ADHD. Nor would a child
who seems overly active on the playground but functions well elsewhere receive
an ADHD diagnosis.
To assess whether a child
has ADHD, specialists consider several critical questions: Are these behaviors
excessive, long-term, and pervasive? That is, do they occur more often than in
other children the same age? Are they a continuous problem, not just a response
to a temporary situation? Do the behaviors occur in several settings or only in
one specific place like the playground or in the schoolroom? The person’s
pattern of behavior is compared against a set of criteria and characteristics of
the disorder as listed in the DSM-IV-TR.
is estimated that
characteristics of ADHD, inattention,
children always seem to be constantly in motion or talk incessantly.
who are inattentive have no trouble paying attention if they are doing something
they really enjoy, but focusing deliberate, conscious attention to organizing
and completing a task or learning something new is difficult.
the three characteristics that could appear in an ADHD child the impulsive child
could be the least disruptive in the classroom.
The diagnostic guidelines for ADHD require the behaviors must create a real
handicap in at least two areas of a person’s life such as in the schoolroom, on
the playground, at home, in the community, or in social settings.
Some parents see signs of
inattention, hyperactivity, and impulsivity in their toddler long before the
child enters school. The child may lose interest in playing a game or watching a
TV show, or may run around completely out of control. But because children
mature at different rates and are very different in personality, temperament,
and energy levels, it’s useful to get an expert’s opinion of whether the
behavior is appropriate for the child’s age. Parents can ask their child’s
pediatrician, or a child psychologist or psychiatrist, to assess whether their
toddler has an attention deficit hyperactivity disorder or is, more likely at
this age, just immature or unusually exuberant.
ADHD may be suspected by a
parent or caretaker or may go unnoticed until the child runs into problems at
school. Given that ADHD tends to affect functioning most strongly in school,
sometimes the teacher is the first to recognize that a child is hyperactive or
inattentive and may point it out to the parents and/or consult with the school
psychologist. Because teachers work with many children, they come to know how
“average” children behave in learning situations that require attention and
self-control. However, teachers sometimes fail to notice the needs of children
who may be more inattentive and passive yet who are quiet and cooperative, such
as those with the predominantly inattentive form of ADHD.
Professionals Who Make
If ADHD is suspected, to
whom can the family turn? What kinds of specialists do they need?
Ideally, the diagnosis
should be made by a professional in your area with training in ADHD or in the
diagnosis of mental disorders. Child psychiatrists and psychologists,
developmental/behavioral pediatricians, or behavioral neurologists are those
most often trained in differential diagnosis. Clinical social workers may also
have such training.
The family can start by
talking with the child’s pediatrician or their family doctor. Some pediatricians
may do the assessment themselves, but often they refer the family to an
appropriate mental health specialist they know and trust. In addition, state and
local agencies that serve families and children, as well as some of the
volunteer organizations listed at the end of this document, can help identify
Can Diagnose ADHD
Can prescribe medication,
Provides counseling or
Pediatricians or Family
Clinical Social workers
* As of October 2006,
Louisiana and New Mexico laws and regulations allow psychologists who have
completed specific training and meet other requirements to prescribe
psychotropic medications. The other 48 states and the District of Columbia allow
only physicians to prescribe medications.
Knowing the differences in
qualifications and services can help the family choose someone who can best meet
their needs. There are several types of specialists qualified to diagnose and
treat ADHD. Child psychiatrists are doctors who specialize in diagnosing and
treating childhood mental and behavioral disorders. A psychiatrist can provide
therapy and prescribe any needed medications. Child psychologists are also
qualified to diagnose and treat ADHD. They can provide therapy for the child and
help the family develop ways to deal with the disorder. But psychologists are
not medical doctors and must rely on the child’s physician to do medical exams
and prescribe medication. Neurologists, doctors who work with disorders of the
brain and nervous system, can also diagnose ADHD and prescribe medicines. But
unlike psychiatrists and psychologists, neurologists usually do not provide
therapy for the emotional aspects of the disorder.
Within each specialty,
individual doctors and mental health professionals differ in their experiences
with ADHD. So in selecting a specialist, it’s important to find someone with
specific training and experience in diagnosing and treating the disorder.
Whatever the specialist’s
expertise, his or her first task is to gather information that will rule out
other possible reasons for the child’s behavior. Among possible causes of
ADHD-like behavior are the following:
change in the child’s life—the death of a parent or grandparent; parents’
divorce; a parent’s job loss
seizures, such as in petit mal or temporal lobe seizures
A middle ear
infection that causes intermittent hearing problems
disorders that may affect brain functioning
Underachievement caused by learning disability
Ideally, in ruling out
other causes, the specialist checks the child’s school and medical records.
There may be a school record of hearing or vision problems, since most schools
automatically screen for these. The specialist tries to determine whether the
home and classroom environments are unusually stressful or chaotic, and how the
child’s parents and teachers deal with the child.
Next the specialist
gathers information on the child’s ongoing behavior in order to compare these
behaviors to the symptoms and diagnostic criteria listed in the DSM-IV-TR. This
also involves talking with the child and, if possible, observing the child in
class and other settings.
The child’s teachers, past
and present, are asked to rate their observations of the child’s behavior on
standardized evaluation forms, known as behavior rating scales, to compare the
child’s behavior to that of other children the same age. While rating scales
might seem overly subjective, teachers often get to know so many children that
their judgment of how a child compares to others is usually a reliable and valid
The specialist interviews
the child’s teachers and parents, and may contact other people who know the
child well, such as coaches or baby-sitters. Parents are asked to describe their
child’s behavior in a variety of situations. They may also fill out a rating
scale to indicate how severe and frequent the behaviors seem to be.
In most cases, the child
will be evaluated for social adjustment and mental health. Tests of intelligence
and learning achievement may be given to see if the child has a learning
disability and whether the disability is in one or more subjects.
In looking at the results
of these various sources of information, the specialist pays special attention
to the child’s behavior during situations that are the most demanding of
self-control, as well as noisy or unstructured situations such as parties, or
during tasks that require sustained attention, like reading, working math
problems, or playing a board game. Behavior during free play or while getting
individual attention is given less importance in the evaluation. In such
situations, most children with ADHD are able to control their behavior and
perform better than in more restrictive situations.
The specialist then pieces
together a profile of the child’s behavior. Which ADHD-like behaviors listed in
the most recent DSM does the child show? How often? In what situations? How long
has the child been doing them? How old was the child when the problem started?
Are the behavior problems relatively chronic or enduring or are they periodic in
nature? Are the behaviors seriously interfering with the child’s friendships,
school activities, home life, or participation in community activities? Does the
child have any other related problems? The answers to these questions help
identify whether the child’s hyperactivity, impulsivity, and inattention are
significant and long-standing. If so, the child may be diagnosed with ADHD.
A correct diagnosis often
resolves confusion about the reasons for the child’s problems that lets parents
and child move forward in their lives with more accurate information on what is
wrong and what can be done to help. Once the disorder is diagnosed, the child
and family can begin to receive whatever combination of educational, medical,
and emotional help they need. This may include providing recommendations to
school staff, seeking out a more appropriate classroom setting, selecting the
right medication, and helping parents to manage their child’s behavior.
Given that ADHD tends to affect functioning most strongly in school, sometimes
the teacher is the first to recognize that a child is hyperactive or
are considered Mental Health Specialist capable of diagnosing ADHD.
ADHD symptoms can never be mistaken for other problems, such as anxiety or
Diagnosis of ADHD is usually a simple and quick process.
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