DEFICIT HYPERACTIVITY DISORDER
Part IV of
VII Getting Help
In third grade, Mark's teacher threw up her hands and
said, "Enough!" In one morning, Mark had jumped out of his seat to sharpen his
pencil six times, each time accidentally charging into other children's desks and toppling
books and papers. He was finally sent to the principal's office when he began kicking a
desk he had overturned. In sheer frustration, his teacher called a meeting with his
parents and the school psychologist.
But even after they developed a plan for managing Mark's
behavior in class, Mark showed little improvement. Finally, after an extensive assessment,
they found that Mark had an attention deficit that included hyperactivity. He was put on a
medication called Ritalin to control the hyperactivity during school hours. Although
Ritalin failed to help, another drug called Dexedrine did. With a psychologist's help, his
parents learned to reward desirable behaviors, and to have Mark take "time out"
when he became too disruptive. Soon Mark was able to sit still and focus on learning.
Because Lisa wasn't disruptive in class, it took a long
time for teachers to notice her problem. Lisa was first referred to the school evaluation
team when her teacher realized that she was a bright girl with failing grades. The team
ruled out a learning disability but determined that she had an attention deficit, ADHD
without hyperactivity. The school psychologist recognized that Lisa was also dealing with
Lisa's teachers and the school psychologist developed a
treatment plan that included participation in a program to increase her attention span and
develop her social skills. They also recommended that Lisa receive counseling to help her
recognize her strengths and overcome her depression.
When Henry's son entered kindergarten, it was clear that
he was going to have problems sitting quietly and concentrating. After several disruptive
incidents, the school called and suggested that his son be evaluated for ADHD. As the boy
was assessed, Henry realized that he had grown up with the same symptoms that specialists
were now finding in his son. Fortunately, the psychologist knew that ADHD can persist in
adults. She suggested that Henry be evaluated by a professional who worked with adults.
For the first time, Henry was correctly diagnosed and given Ritalin to aid his
concentration. What a relief! All the years that he had been unable to concentrate were
due to a disorder that could be identified, and above all, treated.
How Is ADHD Identified and Diagnosed?
Many parents see signs of an attention deficit in
toddlers long before the child enters school. For example, as a 3-year-old, Henry's son
already displayed some signs of hyperactivity. He seemed to lose interest and dart off
even during his favorite TV shows or while playing games. Once, during a game of
"catch," he left the game before the ball even reached him!
Like Henry's son, a child may be unable to focus long
enough to play a simple game. Or, like Mark, the child may be tearing around out of
control. But because children mature at different rates, and are very different in
personality, temperament, and energy level, it's useful to get an expert's opinion of
whether the behaviors are appropriate for the child's age. Parents can ask their
pediatrician, or a child psychologist or psychiatrist to assess whether their toddler has
an attention disorder or is just immature, has hyperactivity or is just exuberant.
Seeing a child as "a chip off the old block"
or "just like his dad" can blind parents to the need for help. Parents may find
it hard to see their child's behavior as a problem when it so closely resembles their own.
In fact, like Henry, many parents first recognize their own disorder only when their
children are diagnosed.
In many cases, the teacher is the first to recognize
that a child is hyperactive or inattentive and may 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 like Lisa who are quiet and
Types of Professionals Who Make the Diagnosis
School-age and preschool children are often evaluated by
a school psychologist or a team made up of the school psychologist and other specialists.
But if the school doesn't believe the student has a problem, or if the family wants
another opinion, a family may need to see a specialist in private practice. In such cases,
who can the family turn to? What kinds of specialists do they need?
The family can start by talking with the child's
pediatrician or their family doctor. Some pediatricians may do the assessment themselves,
but more often they refer the family to an appropriate 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 in the back of this [series], can help identify an
Knowing the differences in qualifications and services
can help the family choose someone who can best meet their needs. Besides school
psychologists, 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. Adults who think they may have ADHD can also
seek a psychologist, psychiatrist, or neurologist. But at present, not all specialists are
skilled in identifying or treating ADHD in adults.
Within each specialty, individual doctors and mental
health professionals differ in their experience with ADHD. So in selecting a specialist,
it's important to find someone with specific training and experience in diagnosing and
treating the disorder.
Steps In Making a Diagnosis
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. In ruling out other causes, the specialist checks the child's school and medical
records. The specialist tries to sense whether the home and classroom environments are
stressful or chaotic, and how the child's parents and teachers deal with the child. They
may have a doctor look for such problems as emotional disorders, undetectable (petit mal)
seizures, and poor vision or hearing. Most schools automatically screen for vision and
hearing, so this information is often already on record. A doctor may also look for
allergies or nutrition problems like chronic "caffeine highs" that might make
the child seem overly active.
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 (Diagnostic and Statistical Manual of Mental Disorders). This
involves talking with the child and if possible, observing the child in class and in other
The child's teachers, past and present, are asked to
rate their observations of the child's behavior on standardized evaluation forms to
compare the childs behaviors to those of other children the same age. Of course,
rating scales are subjectivethey only capture the teacher's personal perception of
the child. Even so, because teachers get to know so many children, their judgment of how a
child compares to others is usually accurate.
The specialist interviews the child's teachers, parents,
and other people who know the child well, such as school staff and 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 some cases, the child may be checked 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 disabilities are in all or
only certain parts of the school curriculum.
In looking at the data, the specialist pays special
attention to the child's behavior during noisy or unstructured situations, like 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 well.
The specialist then pieces together a profile of the
child's behavior. Which ADHD-like behaviors listed in the 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 behaviors seriously interfering with the child's
friendships, school activities, or home life? 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.
Adults are diagnosed for ADHD based on their performance
at home and at work. When possible, their parents are asked to rate the person's behavior
as a child. A spouse or roommate can help rate and evaluate current behaviors. But for the
most part, adults are asked to describe their own experiences. One symptom is a sense of
frustration. Since people with ADHD are often bright and creative, they often report
feeling frustrated that they're not living up to their potential. Many also feel restless
and are easily bored. Some say they need to seek novelty and excitement to help channel
the whirlwind in their minds. Although it may be impossible to document when these
behaviors first started, most adults with ADHD can give examples of being inattentive,
impulsive, overly active, impatient, and disorganized most of their lives.
Until recent years, adults were not thought to have
ADHD, so many adults with ongoing symptoms have never been diagnosed. People like Henry go
for decades knowing that something is wrong, but not knowing what it is. Psychotherapy and
medication for anxiety, depression, or manic-depression fail to help much, simply because
the ADHD itself is not being addressed. Yet half the children with ADHD continue to have
symptoms through adulthood. The recent awareness of adult ADHD means that many people can
finally be correctly diagnosed and treated.
A correct diagnosis lets people move forward in their
lives. Once the disorder is known, they can begin to receive whatever combination of
educational, medical, and emotional help they need.
An effective treatment plan helps people with ADHD and
their families at many levels. For adults with ADHD, the treatment plan may include
medication, along with practical and emotional support. For children and adolescents, it
may include providing an appropriate classroom setting, the right medication, and helping
parents to manage their child's behavior.
NIH Publication No. 94-3572