The most common complaints teachers have about children and teenagers in classroom settings has to do with restless, impulsive and inattentive behaviors. Do all of these children have ADHD? No, they do not. In fact, the most common complaints of parents and teachers, particularly about young children, relates to restless, impulsive and inattentive behavior. Just as not every sneeze is indicative of a cold, so too not every restless, impulsive and inattentive behavior is indicative of ADHD. When these problems are indicative of ADHD they are chronic, pervasive, occur across multiple situations, are not easily modified by behavior management or environmental manipulation and most importantly, cause significant day in and day out impairment. In this month’s article, I will briefly elaborate on this important issue.
Although ten years ago the diagnostic process used for ADHD did not require significant impairment for a diagnosis to be made, the current diagnostic protocol developed by the American Psychiatric Association requires that not only are symptoms present but that these symptoms cause clinically impairing problems in comparison to the general population in two or more major life domains. It is exactly for this reason that a thorough assessment beyond just a symptom count is essential when ADHD is suspected. When in fact simple symptom counts are used as an initial screening for ADHD, researchers have found that nearly one out of five children in the community may meet symptom count in large, general populations. However, when more careful assessment is completed with these “at risk” children particularly focusing on the chronic nature of these problems, symptom severity and impairment in general life, the numbers of those that meet the diagnostic criteria for ADHD reduces significantly. In carefully controlled studies the incidence of ADHD is well under 10% with a 3% to 5% figure reasonably representing children experiencing impairing symptoms sufficient to warrant a full syndrome diagnosis.
ADHD is a very common condition, effecting nearly one out of twenty children to a significantly impairing degree. However, recognizing the commonality of the condition must be accompanied by a responsibility to avoid over- identification or diagnosis. It is rare that a child demonstrating hyperactive, impulsive, and inattentive problems is not thought to experience ADHD. The problem then is false positives rather than false negatives.
The more specific we can be in identifying the signs of symptoms, behaviors and achievement problems children with ADHD experience in the classroom, the better prepared teachers will be able to identify those children at-risk and make appropriate referrals for assessment. Before a child at-risk for receiving a diagnosis of ADHD enters an organized school setting, his or her temperament exerts a significant influence on life experience and interaction with children and adults. These children enter school with a number of misperceptions concerning themselves and their environment. Within school settings they are often victims of their temperament, making it difficult for them to persist with repetitive, uninteresting activities and victims of their learning history which often reinforces them for beginning but not completing tasks. Teachers tend to focus on misbehavior rather than on its termination. This often further disrupts the classroom by having a disinhibitory effect on other children.
In school settings, children with ADHD demonstrate a normal range of intellectual ability. Thus 2% of the population of children receiving a diagnosis of ADHD suffer from sub-borderline intellectual ability with 2% demonstrating gifted intellect. The more intelligent child with ADHD often manages to survive during the elementary school years and may not be referred for problems until academic and organizational demands increase dramatically in junior high school. At that point even bright children with ADHD begin to experience problems which interfere with school performance.
Children with ADHD often underperform in academic subjects requiring practice for proficiency. Thus absent any specific type of learning disability, they often struggle with the non-phonetic aspects of spelling, attention to detail in mathematics, and the execution (punctuation, spelling, etc.) of written language. The majority of children with ADHD do not suffer from a learning disability. Only approximately 20 to 30% may experience a specific skill weakness in addition to ADHD which causes them to fall further behind academically.
It is also important for parents and teachers to understand that regardless of family, socioeconomic status, age, or gender, the limited self-control of children with ADHD exerts a strong negative effect on achievement, attitude toward school, general behavior in school and social relations. Children with ADHD are rarely chosen by peers as best friends, partners in activities, or seat mates. In the early elementary school years they may be oblivious to their struggles but by middle school years tend to develop a rather helpless approach to school. In classroom settings, they tend to exhibit more negative verbalization and physical activity than their classmates.
By understanding these issues and carefully following diagnostic criteria, false positive diagnoses for ADHD can be avoided. I frequently remind my students, however, that not meeting diagnostic criteria for any condition should never be used to deny children and their families assistance and support when needed.
