Attention-Deficit/Hyperactivity [ Disorder ? ]

 

ADHD is something I am very passionate about as I believe there are too many children being diagnosed with this category when contextual factors that may not have been considered thoroughly.

There are certainly many children who experience attentional difficulties and struggle with focusing on tasks that require sustained mental effort, particularly when engaging in activities that are boring to them. I am personally concerned about the possibility of children who display highly active temperaments being labelled as having ADHD when they are simply being children.

Before I explain further, I would like to share the criteria for ADHD that comes from the Diagnostic and Statistical Manual of Mental Disorders 5th Edition:

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Attention-Deficit/Hyperactivity Disorder

A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by 1 and/or 2:

1. Inattention:

Six or more of the following symptoms have persisted for at least 6 months to a degree that is consistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older) at least five symptoms are required.

A. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work or during other activities (e.g. overlooks or misses details, work is inaccurate).

B. Often has difficulty sustaining attention in tasks or play activities (e.g. has difficulty remaining focused during lectures, conversations or lengthy reading).

C. Often does not seem to listen when spoken to directly (e.g. mind seems elsewhere, even in the absence of any obvious distraction).

D. Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (e.g. starts tasks but quickly loses focus and is easily side-tracked).

E. Often has difficulty organizing tasks and activities (e.g. difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

F. Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (E.g. schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

G. Often loses things necessary for tasks or activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

H. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

I. Is often forgetful in daily activities (e.g. doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

2. Hyperactivity and impulsivity: Six or more of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behaviour, defiance, hostility or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required.

a. Often fidgets with or taps hands or feet or squirms in seat

b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

c. Often runs about or climbs in situations where it is inappropriate. (note: in adolescents or adults may be limited to feeling restless.)

d. Often unable to play or engage in leisure activities quietly.

e. Is often “on the go” acting as if “driven by motor” (e.g. is unable to be or uncomfortable being still for extended time, as in restaurants meetings; may be experienced by others as being restless or difficult to keep up with).

f. Often talks excessively

g. Often blurts out an answer before a question has been completed (e.g. completes peoples sentences; cannot wait for turn in conversation)

h. Often has difficulty waiting his or her turn (e.g. while waiting in line).

i. Often interrupts or intrudes on others (e.g. butts into conversations, games or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g. at home, school or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic or occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g. mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

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Now it's important to note the criteria above are to be considered with regards to severity and contextual factors that may explain a child's presentation before a professional diagnosis is made.  My great concern is that children may be labelled with a diagnosis that does not fully consider:

  • how children behave in differing contexts

  • are children being rewarded (inadvertently receiving secondary gains) for not paying attention, playing up or not following adult instructions

  • what does the family environment look like that may help to explain some reasons for a child being inattentive or hyperactive

  • what is the school environment like

  • what mechanisms are available/not available to adults in the child’s life (i.e., teachers) to guide desired behaviours

  • does the child have a strong temperament towards being active, having lots of ideas, being impulsive, risk-taking

  • what does a child find rewarding, what is the child's currency for reward

  • What is the value of categorising a child to have a mental disorder vs describe the factors that contribute to a child behaving in a certain way

  • how do we define interferes with functioning or development.

  • What is the accuracy of measurement of assessing whether behaviours interfere with functioning or development.

  • are parents/caregivers of children selectively reporting behaviours they don't like

  • how are children disciplined, what are their consequences

  • how are parents/caregivers able to follow through with providing punishments and rewards  

  • how are parents/caregivers able to follow through with removing punishments and rewards

  • how do those around the child request compliance from the child (i.e., authority vs respect)

  • and the list goes on. there are many many factors.

Please don't misunderstand me. There are children with significant attentional difficulties and significant challenges with managing their behaviour that certainly interfere with learning, socialising, development and day to day functioning. This is a fact. I am just worried that diagnosing/misdiagnosing may not be beneficial to children and their families, even those that say they would like a diagnosis.

Maybe we can explore the category of ADHD as children with rapidly shifting attention who are very active/fidgety and don't consider consequences to their actions very much…. just an idea but I think a worthwhile consideration that is more nurturing and compassionate towards children then simply offering a diagnosis.

Additional reading to consider in making your own mind up:

 
String Nikolic