According to the American Psychiatric Association’s DSM-IV, ADHD is a disorder that first presents in childhood and is usually seen before the age of seven in a child. It is characterized by inappropriate levels for the development of inattention, distractibility, impulsivity and/or hyperactivity. The impairment occurs in one or more major areas of life, typically in the home, classroom, social interactions, occupational settings, or other areas of adaptive functioning. The list of symptoms goes on to describe a variety of interferences that can occur with ADHD that can easily disrupt any child’s performance, learning, and behavior. Interestingly, the description of the symptoms does not specify the amount or severity of the symptoms, with the exception that the interference must exceed normal developmental levels evident in children. As a result, parents and professionals alike face the challenge of distinguishing excessive ADHD symptoms from those that are normal for a child’s specific level of development.
Good practice calls for an ADHD evaluation to include the collection of multiple types of information from a variety of sources. A simultaneous effort must be made to rule out as many alternative disorders that may present with similar attention and performance difficulties. This could include, but is not limited to, impairments seen in learning disabilities, developmental delays in younger children, sensory regulation dysfunction, mood difficulties and depression, anxiety, as well as low basic motivational effort. These alternative interruptions will easily and predictably interfere with the child’s optimal performance and learning in the classroom. However, distinguishing these interferences in the classroom remains a challenge for teachers and professionals, especially when attention deficits are characteristic of a variety of interference disorders.
As a child psychologist, I realize this professional challenge every time I start a new ADHD evaluation for a presenting child. I will then lament the absence of an accurate and objective assessment of ADHD that can effectively distinguish inattention from alternative interfering conditions. From time to time, I will be lucky enough to learn crucial information about the presenting child that I have come to recognize as “Exclusion” from ADHD. While these exclusion factors are not necessarily absolute in her distinctive ability, they generally increase my potential to accurately diagnose ADHD.
The age of onset is one of these differential diagnostic factors. The presence of ADHD can be recognized at least by the age of seven in a child. Typically, at this age, a child has developed in multiple areas, including cognitive, social, emotional, behavioral, and physical, to enable them to meet most of the routine expectations held for that student in the classroom. The same cannot be said for five-year-olds who may still be developing their ability to self-regulate attention and activity level to facilitate learning in the kindergarten classroom. My comfort level in attempting ADHD assessments improves substantially when the identified child is at least six years old. At this chronological age, I can more accurately use my clinical experience and judgment to determine when activity and inattention are seen beyond expected developmental levels.
I use a related exclusion factor whenever I test students who are a little older. I recently evaluated a fifth grade girl who was referred for poor academic performance and difficulty in attending specifically in the area of ​​Mathematics. Her absence of symptoms of inattention or worry from her during the early years of elementary school raised serious questions about a possible ADHD diagnosis. Not only was there an absence of prior ADHD concerns, but this student enjoyed excellent achievement and academic achievement in all previous elementary years. Unfortunately, her math performance began to show a decline as she progressed through the curriculum that involved more abstraction in concepts and problem solving. In my opinion, increased academic challenge will predictably lead to higher levels of inattention and poor task engagement in students and cannot be recognized as the neurological impairment of ADHD.
Exclusion factors are critical when considering any child with ADHD. Specifically, children must show evidence of ADHD by age seven and the symptoms cannot be mistaken for delayed child development. The interference of ADHD symptoms must be recognized without fail by classroom teachers in all elementary grades, and the interference must be evident in all academic areas. This suggests that a student with ADHD will show a certain amount of attention problems in all subjects and activities. And finally, the interference of ADHD will not suddenly appear in fourth or fifth grade according to the increasing demands of the elementary school curriculum. In the current example, a student who demonstrates a developmentally appropriate ability to sustain homework engagement early in elementary school will not lose this ability in later grades. More precisely, learning weaknesses or motivation problems frequently occur in students who struggle with the progressive academic demands in the classroom. These students will almost certainly have trouble staying focused and attentive to their assigned work.
These rule-out factors are certainly helpful in arriving at an accurate diagnosis of ADHD in any child or student. Although such Ruling factors can reasonably rule out the diagnosis of ADHD, such factors are largely suggestive rather than absolute in making this diagnostic determination. The non-specific descriptive criteria for ADHD (DSM-IV) in combination with the lack of objective evidence for ADHD will continue to provide the basis for meaningful clinical judgment contributing to its final diagnosis. While there are numerous factors and indicators that will support an accurate diagnosis of ADHD, there are numerous variant presentations of this disorder that must be considered in diagnosing or ruling out this disorder.