Is it Actually ADHD?

Assessing the Cause of ADHD Symptoms First

Pat Pernicano

MJ14-CaseStudy-WebAbout 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.

Topic: Parenting | Children/Adolescents

Tags: adhd | adhd child | adhd children | adhd symptoms | attention deficit | attention deficit hyperactivity disorder | counselor | psychotherapy | psychotherapy networker magazine

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3 Comments

Friday, June 27, 2014 4:39:46 PM | posted by First Name Last Name
A developmental model teaches us that presenting symptoms, whether in a child or an adult, have their origin in early experience. From birth onward the infant is acquiring skills from the social environment. If the social environment is chaotic, fragmented, traumatic, and disconnected, the child will acquire a chaotic, fragmented, traumatized, and disconnected way of being in the world, and the behaviors arising from this way of being will be labeled ADHD, Aspergers, or bi-polar. Infants and children given these diagnoses often lack attended, sensitive parents who are primarily preoccupied with the emotional well-being of the child. As a result of this parenting style, the child enters pre-school and kindergarten with deficits in emotion regulation. The causes are often structural, meaning that the caregiver is a single parent and must work or the family requires two incomes to survive. In either case, the child is placed in pre-school and day care where he or she does not receive the attuned, sensitive, primarily pre-occupied attention he or she needs to develop the skills to recognize, tolerate, and regulate a range of emotions. Furthermore, the Self that emerges from this early life experience of deficit is poorly equipped to manage the vicissitudes of life in middle school and high school. The ADHD child can be helped by transmitting the skills to manage a range of emotions, thereby remediating some of the disorganization of Self structure. The family of the ADHD child must be treated as well, because ADHD is a systemic disorder. The human genome has been interrogated, and molecular biologists have determined there is no single gene for ADHD.

Friday, June 27, 2014 3:57:43 PM | posted by Diane Vines
Thank you for calling attention to this! It is appalling how frequently children are misdiagnosed not only with ADHD, but also bi-polar disorder and more recently autism because of their symptom presentation. Even when the clinician takes a history and unearths trauma, they often have virtually no clue about how that trauma has impacted the child's brain organization and development, which subsequently affects the child's behavior. They simply look at the symptoms and give a diagnosis.

Friday, June 27, 2014 2:56:00 PM | posted by Susan Robson
Thank you for this article. As we know, AD/HD is so much more than struggling to pay attention and being overactive - like shifting from one task to another, speeding up on a task, managing behaviors when upset, remembering more than one thing at a time, and connecting actions and consequences. And there are many factors that can lead a child to be distracted and fidgety. This is why, even though it is within my scope of practice to diagnose AD/HD and I feel that I can accurately identify it in people, I suggest that my patients seek evaluation by a Neuropsychologist who is familiar with the diagnosis and will thoroughly assess for all possible cognitive issues. Since we also know that most folks who have AD/HD have co-occurring issues - anxiety, learning disorder, sleep issues, etc - a complete evaluation by a Neuropsychologist will identify other concerns along with AD/HD if they are there. I am aware that there are regional differences in the way AD/HD is identified and treated, so this may be more about my city, but it's too often that I see people who have been diagnosed with AD/HD by their family doctor who then prescribes medication and sends them on their way with no information about what AD/HD is, what other forms of treatment are available, or what other things the family should be doing to assist the person with the diagnosis. This after having asked 5 or 6 questions about behaviors rather than sending out questionnaires or speaking to more than one person about the behaviors. All this said, I wonder about the impact of titles like "Is it actually AD/HD" when there are already so many stories in the media questioning the validity of the disorder. For the people who have AD/HD, I promise you it is actually a real thing.