Is it Actually ADHD?

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.

Schools and physicians are aware of some of this, 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.

For example, when five-year-old Ella was brought to my outpatient treatment office at the request of her first-grade teacher I noticed—as I collected a life-and-developmental history from her mother while Ella played—that she was more watchful than most ADHD children. At this point, I began wondering about the source of her vigilance. I also noticed that she’d stare off or the tune out when we said anything about her biological father, who was divorced from her mother and in jail. The subject of her father seemed to increase Ella’s level of physiological and emotional arousal. I suspected that Ella’s inattention and high arousal might actually be dissociation or avoidance related to her father.

When I finished my interview with the mother, I turned to Ella to ask why she thought she was coming in. Without hesitation, she said, “I’m bad at school and I don’t like my teacher. I won’t sleep in my own bed, and mommy says I have a bad attitude. My daddy is in jail for hurting mommy and me.” She paused and added, “Dr. Pat, my daddy lied to me. He took me away, and he wouldn’t let me go home to my mommy.”

Aha! There it was—a clear clue as to why Ella felt so powerless and needed to take charge.

Read a case study from Pat Pernicano’s work with child suspected of having ADHD in the May/June 2014 issue of Psychotherapy Networker magazine.