Homework time. For many children and families, it is a dreaded part of the day, particularly for children who struggle. It’s just like the day before and the day before that, ever since the second week of school. You guide your child to the kitchen table or the desk in their room or some other prearranged quiet spot in the house. Not more than a few minutes go by and before you know it, they are at your side asking for a snack or maybe they snuck outside to play with the dog, ride the bike or is that a video game you hear? In short time, patience has worn thin and you find yourself yelling at them to get back to work. Your thoughts immediately go to the teacher’s comments the week before about work not being finished on time, incomplete assignments and even the occasional outburst when time to work. There is a long school year left and the thought of doing this for another six months is heartbreaking.
It should be intuitive and it would be reasonable to suspect that this is a clear-cut Attention Deficit Hyperactivity Disorder (ADHD). At your wit’s end, you resolve to call the pediatrician in the morning to address this once and for all. Most pediatricians will recognize the well-defined signs and symptoms of ADHD and will even use checklists or inventories for parents and teachers to ascertain the behaviors and settings in which they are observed. For many children, this will be sufficient for an accurate diagnosis and recommended courses of treatment.
However, for a subset of children, the situation may be more complicated for there are many other conditions and situations that may result in ADHD-like behaviors, none of which would be treated with often-prescribed stimulant-class medications. In fact, a 2010 Michigan State University study estimates that almost one million children per year are incorrectly diagnosed with ADHD. In those situations, only a more careful and broader assessment may shed light on the true source of the concerning behaviors.
One area which has gained considerable attention in recent years has been the effect of poor sleep. Sleep disorders are a common source of attention problems during the day. Who hasn’t had that occasional bad night’s sleep and just felt “off” the whole day after? However, when that poor sleep is part of a more habitual pattern, then the problems during the day appear to be more enduring and constant. Parents and teachers will see difficulties focusing attention, low stamina for school work, and inconsistent performance throughout the day – all behaviors that could be consistent with ADHD. However, by addressing the sleep issues, sometimes, as simple as adjusting sleep hygiene, such as bedtimes and nighttime routine, can ameliorate many of the concerns. Careful interview and specifically questioning sleep habits and routines would shed light on this situation. While simple behavioral modifications could be sufficient, as noted, referral to a sleep specialist for more elaborate assessment may be necessary.
For some children, a mood disorder will explain inattentive behaviors. For example, children may manifest depression differently and inattention may be one of the main signs. Similarly, anxiety can produce similar behaviors. In both situations, a child may be vulnerable to a pattern of distracting thoughts that will interfere with their ability to fully engage with their environment and affect their availability to learn in the classroom. Again, these are situations that would require careful interview and sometimes, psychological assessment.
Environmental and situational factors should also be considered. Illness of a parent, divorcing or divorced parents, financial struggles or other socioeconomic factors can result in challenges to a child’s still-developing coping resources and their ability to function well throughout their day. While there is little that can be done to change those circumstances for children in those situations, providing support and building their coping resources will often be necessary.
Other conditions may also present along with ADHD. For example, it is estimated that 20 percent to 30 percent of children with ADHD also have a specific learning disability. Learning disabilities also present with symptoms of ADHD. In fact, the ADHD behaviors may often be the first sign of the learning struggle. Again, in the absence of more detailed assessment or analysis, a key aspect of a child’s struggles may go unaddressed for longer than it should. Other conditions that can present with ADHD symptoms include Tourette’s Syndrome, endocrine disorders, developmental disabilities, autism spectrum disorders, allergies and asthma, and the list goes on.
Again, for most children, the straight forward clinical diagnosis based on presenting behaviors alone will be sufficient to put together a solid course of treatment and management. However, for those situations where there is either no or very slow improvement, a different approach should be considered both in terms of diagnosis and treatment. The rule of thumb for many years has been conjoint therapy of medication and psychotherapy/behavior management approaches. As the situation becomes more complex or resistant to traditional approaches, a more comprehensive analysis of cognitive functioning and behavior is warranted. Neuropsychological assessment, while in and of itself not necessary for the diagnosis of ADHD, it can certainly clarify the underlying sources, both cognitive and behavioral, of the presenting challenges. It may also lead to more targeted medical assessment, if necessary. In the end, a more accurate diagnosis that takes into account all elements can lead to more effective treatment and management approaches.