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Case Study

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Rush to Judgment: Beware of the ADHD diagnosis

By Pat Pernicano

About once a month, a teacher, school counselor, or pediatrician refers a child to me for evaluation and treatment of attention deficit hyperactivity disorder (ADHD). Often someone has administered a Conners teacher or parent rating scale that presumably justifies the diagnosis, or the child has already been diagnosed with ADHD and has taken medication without symptom improvement. Such children commonly exhibit troublesome symptoms, including agitation, moodiness, hyperactivity, and distractibility, so I understand why they were referred to me. But what I can’t understand—and have become increasingly emphatic about pursuing—is why professionals diagnose and treat ADHD symptoms without first trying to understand the causes of those symptoms.

In my view, there’s an epidemic of misdiagnosis of ADHD in young children. Yes, school personnel are overwhelmed by the number of children whose poor concentration make it difficult for them to learn, and a number of likely explanations have been offered for the apparent increase in hyperactivity and inattention in children. Class sizes are bigger than they once were. Music, art, recess, and physical education—activities that used to provide a break from routine—have nearly been eliminated in many school systems. Children spend too many hours on video games to the exclusion of creative, unstructured play, and they don’t get the amount of physical exercise that contributes to healthy brain development. Lack of adequate sleep also contributes to poor mood and focus, as do the challenges faced by children of substance-abusing or addicted parents.

Schools and physicians are aware of some of the above, but they don’t seem to understand the ways in which trauma leads to symptoms that resemble ADHD. Thus, we all need to ask the right questions and dig a little deeper in creative ways to find out what may be troubling the child so that our treatment is effective and not just a surface remedy for a misdiagnosis. In other words, it’s crucial to figure out why a child is tuning out, having trouble concentrating, and being moody and hyperactive. A child living in dangerous chaos, for example, has to find ways to cope and adapt, and the resulting stress-based behavior can sometimes mirror ADHD symptoms. To complicate matters, many children referred for suspected ADHD are in preschool, kindergarten, or early elementary school and are so young they don’t yet have the verbal and conceptual skills to tell us what’s going on in their lives. Thus, therapists need to get a thorough family history, engage the child in play activities (e.g., art, stories, puppets, sand play, and dollhouse), and observe the child’s play for clues about the cause of the symptoms. Only then can we form a plausible hypothesis, develop a plan of care, and match interventions to a child’s issues.

Getting to Know Ella

Five-year-old Ella, who’d just started kindergarten, was brought to my outpatient treatment office by her mother at the request of her first-grade teacher. At school, Ella would talk out of turn, get out of her seat without permission, and boss other children around.

“Her teacher thinks Ella has ADHD and should be on medication. He says she’s behind the other children and can’t pay attention,” her mother told me. “I don’t know what to think.”

To start, I began collecting a life-and-developmental history to help me rule out ADHD. In other words, if Ella actually had ADHD, there’d be no other factors to account for trouble sleeping, difficulty completing or following tasks in school or at home, impulsivity, and hyperactivity. I also wanted to rule out conditions that include ADHD symptoms, such as autism spectrum, depressive disorder, post-traumatic stress, complex stress, anxiety, and adjustment disorders.

I started by inviting Ella to play with the toys and puppets in my office so she could stay occupied while I spoke with her mother. Our conversation revealed that she was tired of Ella’s “bad attitude,” yet concerned about her daughter’s nightmares, fear of sleeping in her own bed, waking during the night, and frequent tearful and angry outbursts. She found her daughter’s high-intensity behavior exhausting and gave up quickly when Ella didn’t listen to her. I wondered if her lack of energy might indicate depression, especially since children of depressed mothers have to work so hard to get their mothers’ attention that they can show symptoms of anxiety and ADHD. If that proved to be the case, I’d refer the mother for treatment of her own.

Meanwhile, Ella offered a constant commentary on her exploration of the office toys; however, when she felt excluded from my conversation with her mother, she became provocative, intrusive, and pouty. She answered questions I directed to her mother about Ella’s sleep behavior, school performance, and noncompliance with chores and rules. I suspected that this little girl wanted to be in charge, in control, and independent. I wondered what in her life might have led her to mistrust and ignore her mother’s directions. Ella’s behavior mimicked some symptoms of ADHD, but she seemed too attentive and intentional in her actions for the diagnosis to fit.

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1 Comment

  • Comment Link Wednesday, 11 June 2014 09:38 posted by Jessica M. Newland, Psy.D.

    Thank you for publishing Dr. Pernicano's case study and discussion of issues relevant to the differential diagnosis of ADHD and trauma in young children. I know Dr. Pernicano from my years at Spalding (she was on my dissertation committee) and from the awesome reputation she has in the KYANA area. It is articles like this that continue to inspire and help my own practice of psychology in working with young children. I will likely use this article as an introduction to assessment and therapy for parents who suspect their child has ADHD. I think it might be useful for the pediatricians and school counselors I receive referrals from to read as well.