ADHD or Attention Deficit Hyperactivity Disorder is defined in the DSM-5[Diagnostic and Statistical Manual of Mental Disorders-5th edition] as the persistent pattern of inattention, hyperactivity-impulsivity, or both that interferes with normal functioning and development. The manifestations of inattention include wandering of task, being disorganized and the lack of persistence. Hyperactivity includes fidgeting, and talkativeness. Impulsivity is a tendency toward hasty action.
ADHD is one of the most common childhood mental disorders and can persist through adolescence into adulthood. Stimulants are the most commonly used medications to treat this condition, and at the same time, unfortunate stimulant misuse is on the rise within the general population.
International studies have shown that an estimated 5% of children and adolescents have ADHD. Among adults, the prevalence is about half that in children, or about 2.5%, and in the United States, the numbers are climbing fast among diagnosed children and adolescents.
For a long time, experts believed that children and adolescents outgrew ADHD, though it can persist into adulthood, and the most prominent symptoms vary with age and circumstance. The hyperactivity symptoms are usually most noticeable during preschool and early elementary years. Middle school and late elementary school years are when inattention symptoms appear. In adolescence, fidgeting, jitteriness and impatience appears.
Depending upon circumstance, symptoms may wax and wane. A new setting, close supervision, an engrossing activity or frequent rewards for appropriate behavior may make symptoms go away temporarily.
DIAGNOSTIC CRITERIA FOR ADHD[generalized and condensed]
- INATTENTION[6 or more of the following symptoms have persisted for at least 6 months inconsistent with developmental level and impacts social and academic activities]:
- often fails to give close attention to details or careless mistakes in schoolwork
- difficulty sustaining attention in tasks or play
- often doesn’t seem to listen when spoken to directly
- does not follow through on instructions, fails to finish schoolwork or chores
- difficulty organizing tasks and activities
- avoids dislikes or tasks that require sustained mental effort
- loses things necessary for tasks or activities
- easily distracted by extraneous stimuli
- often forgetful in daily activities
2. HYPERACTIVITY and IMPULSIVITY[6 or more of the following symptoms have persisted for at least 6 months within the same parameters as above]:
Note: Symptoms are not solely manifestations of oppositional behavior, defiance, hostility or a failure to understand tasks or instructions. For adolescents and adults[17 and older] at least 5 symptoms are required.
- often fidgets, taps hands, feet or squirms in seat.
- leaves seat in situations when remaining seated is required(leaves place in classroom, or situations expected to stay in place)
- runs or climbs in inappropriate situations
- unable to play or engage in leisure activities quietly
- often on the go, as if driven by a motor(unable to remain still or uncomfortable being still for extended periods of time)
- talks excessively
- blurts out an answer before a question is asked in completion(completes people’s sentences, not waiting for turn in conversations)
- difficulty waiting his/her turn(while waiting in line)
- interrupts or intrudes on others(butts into conversations, activities, and may use others’ belongings without asking)
Appropriate diagnosis of the disorder is of significant concern given the substantial social and economic costs. Children with ADHD are at high risk for problems throughout school, and increased risk for substance use, automobile accidents and other psychiatric conditions. ADHD has potential long-term consequences for education, health and general well-being. Given these potential negative outcomes, it is essential that ADHD is diagnosed and treated to mitigate these risks. There is however, also significant concern for over-diagnosis followed by unnecessary medicating, with associated risk for side effects.
A prominent subject of concern with regards to ADHD is the unfortunate misdiagnosis and particularly the relative age of school-age children. With school start cut-offs, in a kindergarten class one child may have just turned five years of age while another child is almost six years of age, creating an almost 20% age difference at that stage. It has been shown that children who are relatively younger than their peers and are born closest to the school start age cut-off are more frequently diagnosed and treated for ADHD .
In a study involving a large sample of children for whom the school-age cut-off is December 31, it was found that boys born in December were 30% more likely to be diagnosed and 41% more likely to be treated for ADHD than those born in January, and that girls born in December were 70% more likely to be diagnosed and 77% more likely to be treated for ADHD than those born in January.
Children born on the last three days of the year were at significantly higher risk for diagnosis and treatment than those born on the first three days of the new calendar year. This significant difference in risk occurs within a span of six days. Given that ADHD is a neurological condition whose prevalence should not differ significantly based on birth date, this finding indicates a failure to account for the developmental immaturity of a child relative to peers and suggests that diagnoses of ADHD are not solely based on biological factors but rather, on other potentially subjective factors.
While ADHD research involving children has focused largely on school-age children, another concern for relative age and developmental immaturity in ADHD diagnosis is early preschool diagnosis. Much behavior consistent with ADHD, including inattention, impulsivity and over-activity, may be normal for the developmental age of a preschooler. Current screening tools and measures for ADHD are designed for school-age children and investigations of whether ADHD can manifest in preschool children are limited.
Many symptoms in preschoolers are found to be transient, and there is a significant challenge in distinguishing between the majority of preschoolers whose symptoms will pass and the 5% to 10% who will develop persistent ADHD; this has significant implications for the decision to medicate. Findings suggest limited agreement among parents, teachers and clinicians on ratings of ADHD behavior in preschoolers an additional challenge given the need to assess child behavior in multiple settings.
Girls diagnosed with ADHD show less behavioral symptoms compared with boys, with less aggressive, disruptive and hyperactive behavior. In an educational setting (often the origin of suggestion for ADHD assessment), this may at least partially indicate why boys are more frequently diagnosed than girls.
It is hypothesized that boys and the symptoms they present may represent a more prototypical representation of ADHD and more frequently diagnosed. Girls may exhibit less hyperactivity and externalized behaviors and may show greater intellectual impairment than boys.
What is the bottom line? Always demand a 2nd opinion if your child demonstrates persistent symptoms indicative of ADHD, and if a mental health professional or educator assesses or evaluates your child, ensure he or she is fully informed, qualified and without bias.
Question: Have you ever considered that your child may be ‘gifted’-not deficient, but proficient? Similar ‘symptoms’, but identification of exceptional aptitude requires a wider lens!