Understanding the ADHD Diagnosis
Mark Beidelman, PsyD
Pediatric Neuropsychologist at Stanford Children’s Health
What is ADHD
Attention-deficit/hyperactivity disorder or ADHD is a relatively new diagnosis, but the clusters of symptoms that make up this diagnosis have been identified and categorized under different names dating back to at least 1798 (Crichton 1798). What we now know of as ADHD first appeared in the second edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-II) in 1968. Through the various iterations of DSM-III (1980), DSM-IV (1994), and DSM-5 (2013) there have been subtle changes to the classification of these symptoms as a unified condition. As a professional or as a parent, it’s important to not get overly focused on the diagnostic criteria or the changes over time, but instead to think about what aspects of functioning are impaired in this diagnosis and what steps can be taken to make functional improvements.
Currently in DSM-5 ADHD is defined as “A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by Inattention and/or Hyperactivity and Impulsivity.”
Inattention:
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
Often loses things necessary for tasks or activities
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Hyperactivity and impulsivity:
Often fidgets with or taps hands or feet or squirms in seat
Often leaves seat in situations when remaining seated is expected
Often runs about or climbs in situations where it is inappropriate
Often unable to play or engage in leisure activities quietly
Is often “on the go,” acting as if “driven by a motor”
Often talks excessively
Often blurts out an answer before a question has been completed
Often has difficulty waiting his or her turn
Often interrupts or intrudes on others
Now, you might be thinking that you have a hard time sustaining attention on tasks, or everyone is reluctant to engage in tasks that require effort…or something like that. This might be true, but the individual symptoms of ADHD are best thought of as part of the grey scale of personal differences, or what makes us who we are. It is only when we see these symptoms clustered in a way that meets a certain severity and frequency threshold and see functional impairments in multiple settings that we consider ADHD.
One more thing about diagnosis before we move on.
There are three “types” of ADHD, which are:
Predominantly Inattentive Presentation
Predominantly Hyperactive/Impulsive Presentation
Combined Presentation
So, ADD is no more! Now ADD is called ADHD, predominantly inattentive presentation, and I suspect ADHD hyperactive/impulsive presentation and ADHD combined presentation explain themselves (i.e., more hyperactive symptoms for hyperactive/impulsive presentation, and a mixture of inattention and hyperactive/impulsive symptoms for combined presentation).
So, if I have explained the content in the above paragraph well enough, we can now understand you could have attention-deficit/hyperactivity disorder, while simultaneously being the least hyperactive person on the planet (so long as you are inattentive enough). Another consideration is that attention is not an all or nothing concept.
A comment I frequently hear from families is something along the lines of, “While we agree our child has difficulty attending to certain things (e.g., school, chores, books), they can attend or even hyper-focus on things they enjoy (e.g., sports, activities, video games), so how could this be ADHD?” To answer this, it is best to think about ADHD as not a pure deficit of attention, but instead as a difficulty regulating attention effectively. Meaning people with ADHD might have difficulty sustaining attention, ignoring impulses, shifting attention/transitioning appropriately, estimating time, organizing, etc.
ADHD, Executive Functions, and Emotions
Continuing this line of thinking from above, some would argue that ADHD is really a deficit of executive functioning. Executive functioning is a term used to describe an array of cognitive skills that include but are not limited to inhibitory control, working memory, cognitive flexibility, reasoning, problem-solving, planning, etc. My simplified definition of executive functioning is coordinating two mental or cognitive skills to solve one task/problem. Given the breadth of content around executive functions and how those executive functions might play out in daily life, let’s just focus on how attention could impact executive functioning and some of the additional consequences of ADHD.
ADHD and executive functioning are somewhat of a blurry line, in fact, some people even consider control of attention and impulse control as part of executive functioning. For our purpose on this much larger topic, let’s just say that difficulties with regulating attention and impulses will make it difficult to successfully coordinate multiple cognitive skills in an organized fashion.
ADHD and emotions are also complex. Emotion regulation difficulties are also common in individuals with ADHD, but not inherently part of the ADHD diagnosis. Symptoms of anxiety and depression have a higher than chance co-occurrence in people with ADHD.
The reasons for these emotional difficulties are likely multifactorial and could even be explained by different mechanisms in the same person. We will list a few relationships between ADHD and emotion regulation, anxiety, and depression. There can be impulsive behaviors that lead to interpersonal, academic, occupational, or relationships difficulties. Poor attention can make people feel lost or behind at school, work, or activities, which can increase anxiety. Difficulties with academic or work functioning can impact esteem/mood and lead to symptoms of depression. This is not an inclusive list, but it is important to realize that ADHD is not just about attention. A better way to think about ADHD might be to realize how these clusters of systems impact the whole person in academic, interpersonal, occupational, and introspective ways.
The good news is there are successful evidenced based therapies (behavioral therapy, cognitive behavioral therapy, acceptance and commitment therapy, to name a few), behaviors/techniques (mindfulness practice, meditation, exercise, sufficient sleep), and medications (even with individuals with congenital heart disease) that can make lasting changes on attention, executive functioning, and emotional functioning.
There is a lot more to unpack about all this, including the connection between ADHD and Congenital Heart Defects. In the next few articles, this series aims to provide a deeper dive into this connection and what therapies and management strategies are available to parents today.
Dr. Mark Beidelman
Dr. Beidelman is a pediatric neuropsychologist at Stanford Children’s Health. He has studied neuropsychological functioning through the lifespan, but currently focuses on pediatric populations. He currently splits his time between various clinics that include: Developmental Behavioral Pediatrics, Single Ventricle Program, Cardiovascular Connective Tissue Disorders Program, Spina Bifida Clinic, Stroke Team, and the Center for Interdisciplinary Brain Sciences Research. He also has a pug.