Recognition and Diagnosis of ADHD
Recognizing ADHD can be noticeably clear for some and complex for others, in both children and adults. Parents may have a hard time determining if their child has ADHD or if their behavior is common for their age. There are different types of ADHD and ADHD can vary from person to person. There are signs and symptoms that can be determined to recognize ADHD in both children and adults. There are different factors that contribute to the development of ADHD. The diagnosis process consists of different factors as well.
Mary Solanto, PhD
Dr. Solanto is professor of pediatrics and psychiatry at the Hofstra-Northwell School of Medicine. Prior to joining Hofstra, she was director of the ADHD center in the department of psychiatry at the Mount Sinai School of Medicine, and an associate professor of psychiatry at the NYU School of Medicine. Dr. Solanto’s research on the cognitive and behavioral functioning of children with ADHD, the effects of psychostimulants, and the characteristics of the subtypes of ADHD has been supported by grants from NIMH, NICHD, and NINDS. She developed a novel cognitive-behavioral intervention to target problems of executive self-management in adults with ADHD, which was the focus of an NIMH-sponsored treatment efficacy study and published in the American Journal of Psychiatry. She authored the manual for therapists, Cognitive-Behavioral Treatment of Adult ADHD: Targeting Executive Dysfunction.
Listeners will be able to:
- Identify ADHD symptoms throughout the lifespan.
- Describe the importance of interprofessional collaboration in treatment of ADHD.
Announcer: You are listening to Pocket MD, training on ADHD in children and adults.
Dr. Eugene Arnold: Hello, I am Dr. Eugene Arnold, professor emeritus of psychiatry and behavioral health at Ohio State University and CHADD's resident expert. And we will be talking today about recognition and diagnosis of ADHD. With us today is Dr. Mary Solanto. Mary, would you fill us in on your background?
Dr. Mary Solanto: Sure. I am a clinical and research psychologist. I am a professor of pediatrics and psychiatry at the Hofstra-Northwell School of Medicine. I have devoted my career, essentially, to ADHD as it is manifested in preschoolers, school-aged children, all the way up through adulthood. And I am on the professional advisory board and the public policy committee of CHADD.
Dr. Eugene Arnold: First, talk about what ADHD really is. How would we describe it and define it?
Dr. Mary Solanto: Okay. So, ADHD is a neurodevelopmental disorder and it's characterized by difficulties related to attention, hyperactivity, or impulsivity, or any combination of those. It's manifested early in life, by the criteria, at least by age 12. And we have certain characteristic difficulties in each of those domains.
Dr. Eugene Arnold: Would you go ahead and describe those?
Dr. Mary Solanto: So, with respect to inattention, there are difficulties manifested as failure to listen, short attention span for tasks, poor attention to detail resulting in errors on academic and other tasks, forgetting things, losing things, having a lower tolerance for tasks that require efforts, such as homework. Hyperactivity can manifest as restlessness, fidgetiness or by running around, difficulty remaining seated, often described as being driven by a motor. It is important to note, though, that a child can have ADHD and not necessarily be running around. A child can be considered hyperactive, even if they are primarily fidgety or restless—and this is important, because I think parents and teachers might only identify a child who is literally running around. Impulsivity is manifested by difficulty waiting, taking turns, by interrupting, intruding on other activities. And we may describe this as being impatient as the overarching feature. I would also add that impulsivity is highly correlated with hyperactivity, and so those two are considered to represent a single dimension for purposes of describing the disorder for any individual child.
Dr. Eugene Arnold: So how common is this syndrome among children?
Dr. Mary Solanto: Well, estimates have varied. I think we have some very good estimates from studies done in the 2000s that have examined large-scale birth cohorts of children who were diagnosed—for example, there was a study done in Rochester, Minnesota—and these studies have yielded a rate of 8% for school-aged boys, primarily. More recently, the Centers for Disease Control reported a rate of 11% for boys between seven and 11. But it's important to note that those children were not actually examined by a physician and diagnosed. These numbers come from the response of parents to the simple question, "Has your child ever been diagnosed with ADHD?” So, I think that figure is less reliable than the one that involved examination diagnosis by physicians.
Dr. Eugene Arnold: There is some doubt then about the exact prevalence, but we know it's very common.
Dr. Mary Solanto: It is quite common, and yes, there's variation in the estimates of prevalence.
Dr. Eugene Arnold: Okay. Does this rate decrease or increase or change in any way over the lifespan?
Dr. Mary Solanto: Yeah, it is pretty consistent through adolescence. There may be a decrease of maybe 25% of overall prevalence, and in adulthood it is estimated that maybe that 60% are still experiencing some impairment from the symptoms. So, there is continuity, but there was also some change in maturation, as people get older, that might result in fewer symptoms.
Dr. Eugene Arnold: Okay, well what causes it?
Dr. Mary Solanto: Well, we understand ADHD to be primarily genetic in origin. And I think there's very convincing data from twin studies that have looked at the concordance rate between twins. So, that is the answer to the question, “If one twin has it, what is the likelihood that the other twin will also have it?” And these studies show that for identical twins, which share all the same DNA, the concordance rate is up around 80% or higher. However, for fraternal twins who were non-identical and share as much genetic material as any two siblings, the concordance rate is much lower; it is more like about 33%. So, I think that's very compelling evidence that this disorder is primarily genetic in origin.
Dr. Eugene Arnold: So, does that mean that it is not mainly a problem of the parents not making the children behave?
Dr. Mary Solanto: It is important that parents know that they are not the cause of ADHD. That does not mean to say, however, that their behavior, their response to the child, their management of the child has no impact. What they do can benefit the child, can help ameliorate the disorder, or can make it worse. So, on the positive side, there are parent behavior management training programs that can be very helpful in guiding parents on how to respond helpfully to these behaviors. On the other hand, we know that criticism, over-control, [and] negative feedback can have a deleterious impact.
Dr. Eugene Arnold: Yeah, the children can be rather stressful to the parents so there may be a tendency for parents to react negatively to the child's behavior. But I gather from what you are saying that that would be counterproductive.
Dr. Mary Solanto: It certainly would be, but it is very understandable that parents might resort to that kind of response because they are frustrated and feeling that nothing they do or say is having a significant impact on the child's behavior. But parent behavior training programs aim to endow the parents, if you will, with other strategies that we know are effective that they can use to better manage the child's behavior, help him or her be more attentive, be more compliant, be less impulsive, less intrusive, and so on.
Dr. Eugene Arnold: I think you are making an important point here. The genes are only expressed by interacting with the environment, so that if we say that there is 70% genetic risk for ADHD, that does not mean there's nothing you can do about it.
Dr. Mary Solanto: Absolutely.
Dr. Eugene Arnold: We do not need to give up and fall into genetic determinism.
Dr. Mary Solanto: That is true. That is true. And 70% is less than 100%, so that is the degree of difference between the child's genetic endowment and how it is expressed. And there is where the room for intervention is, behaviorally.
Dr. Eugene Arnold: Yeah, and actually it's more than 30% because if we think of an analogy of PKU, phenylketonuria, it's 100% genetic, it's an inborn error of metabolism, but it's also 100% environmental because it only is manifested in an environment where there's fentanyl alanine in the diet. So, when we say something 70% genetic or 70% heritable that does not mean that the environment is not important.
Dr. Mary Solanto: That is quite true.
Dr. Eugene Arnold: How does ADHD impact youngsters' functioning?
Dr. Mary Solanto: Well, it impacts in several very important ways: academically, socially, emotionally. Beginning with the academic, as one might expect, children who have ADHD have difficulty concentrating and completing seat work at school, completing homework, and pay lower attention to the teacher when she is teaching. So, not unexpectedly, they get lower grades in school. They are more at risk for grade retention. They have lower scores on standardized tests of academic skills. Teachers often described them as "not working to potential." And their poor functioning means that they often receive more penalties and negative feedback from teachers in schools.
Socially, it takes a toll on friendships, and just so in different ways for kids with different combinations of inattention or hyperactivity and restlessness. So, the kids who have not only problems with attention, but also self-control in the form of impulsivity and hyperactivity, as I described, they often endanger their friendships and their relationships with peers because they are more prone to do things that other kids will find objectionable, to say things that are inappropriate, to call names, to hit, to be intrusive, to not wait their turn. And sociometric studies of friendship patterns show that children with this combination of symptoms are more likely to be socially rejected by other children.
Children, on the other hand, whose primary problem is with attention also have difficulties, but they are a somewhat different sort. So, these kids, and we call them the predominantly inattentive subtype, tend to be too quiet, kind of withdrawn, hypoactive, slow to respond. And so, kids do not find that they are able to get much of a response for them and kind of get impatient and lose interest. And these kids are more likely to be socially neglected or ignored, and so, do not have the same quality or frequency of friendships as other kids for that reason.
Dr. Eugene Arnold: What you just said about the inattentive type reminds me of the phrase "sluggish cognitive tempo." Could you comment on that?
Dr. Mary Solanto: So, that has been a description given to this combination of difficulties that I described where the child or even the adult appears withdrawn, doesn't respond immediately, takes time to kind of process information and has difficulty relating to others because they don't respond quickly enough and people kind of lose interest. And this can also affect the way they process tasks, even when interpersonal relatedness is not important. But that is more characteristic of individuals with this predominantly inattentive type of ADHD, as opposed to the combined type, for example, which includes not only inattention, but hyperactivity and/or impulsivity.
Dr. Eugene Arnold: How would one go about diagnosing ADHD? What is the DSM diagnostic criteria?
Dr. Mary Solanto: So, I listed some of the symptoms in each of the domains: attention, hyperactivity, impulsivity. It's important to recognize that what we're looking for here is whether or not these behaviors, these symptoms are exhibited at a rate and frequency that are higher than for other kids of the same gender and the same age. And so, any child, any individual can have trouble with attention, for example. The issue is whether this is more than we would expect for a child at a given level of maturity.
Another characteristic is whether or not the difficulties have persisted for at least six months. So, we don't want to include kids who are adjusting to some major change in their school environment, starting a new class, for example, with a new teacher or in their home environment, birth of a sibling, parent losing a job, any other kind of major stressor that might have an impact on the child. We have to be sure that these behaviors are not simply in response to some event of that sort.
Another criterion is that behaviors be manifested both at home and in school, and that there be some impairment as a result in both of those environments. For adults, we would say that there need to be difficulties at home and at work, for example. Another characteristic is that there needs to have been symptoms with impairment either before age 12 or at age 12. And the final criterion is that these problems are not better accounted for by some other difficulty, by a learning disability, by a sensory problem, by anxiety or depression, all of which could affect a child's ability to pay attention. So, it's important, though, that we rule those out before we conclude that this is a manifestation of ADHD.
Dr. Eugene Arnold: You mentioned the important issue of quantification. This is a diagnosis of quantity, rather than quality. We all have a little bit of inattentiveness, a little bit of hyperactivity. I like the analogy of blood pressure. We all need blood pressure. We could not live without it, but if you have too much of a good thing, then that becomes pathological and it needs to be treated.
Dr. Mary Solanto: That is a great analogy.
Dr. Eugene Arnold: How does this manifest at different ages? Obviously, adults with ADHD are not running around climbing things, acting like we're driven by a motor, although that's the classical stereotype of a child with ADHD. So how do these symptoms manifest differently at different ages?
Dr. Mary Solanto: Right. So, ADHD can be recognized as early as preschool, and giveaway symptoms might be things like has difficulty sitting in the circle, sitting on the rug in a circle, which preschoolers often do while teacher is describing something or telling a story. And they are the ones that cannot stay in that circle. They would get up, start walking around or at the very least are not paying attention. We see difficulties in paying attention, even in other situations like a one-to-one with a parent who is trying to read to them and has them next to him or her, or on his or her lap. We see manifestations when the child does not comply when you ask him to do something or stop doing something, when you ask him or her to stop. We might see interpersonal problems where the child is more intrusive with other children, invades their personal space, or may be aggressive with other kids.
In childhood years, we see the constellation of symptoms that I described at the outset that affect academic [and] social behavior. We also see that they tend to be messy, disorganized. They do not bring home the homework assignment, or they do not bring home the books or papers that they need. And it works in the opposite directions, too. So, they may do the homework, but forget to bring it in. So, we see problems in managing the demands of school, both timewise and organizationally, as well as the difficulties with attention and self-control that I've described.
In adolescents, we come into the manifestation of other difficulties. Typically, these adolescents have difficulty with procrastination, getting started on homework, on studying, on writing papers. Even when they get started, they are easily distracted. So, they may be sitting up there in their room and you think they are working, but really, they're on their cell phone or they're surfing the internet. They also have difficulty managing materials and getting them to the right place. They need coaching and prompting to do these sorts of things, to get started on homework, to get their materials together for the morning, to go to bed on time. So, the late start that they often get often means that then they have to stay up very late to finish and sleep deprivation tends to exacerbate the same cognitive problems that are already vulnerable in ADHD. The pressure from parents, though, and the desire to get them to do what they are supposed to do can lead to conflict. And with parents and stress in the household, not only might they be late for school in the morning, but they may be truant from school. Truancy at school becomes a rather toxic environment for them that they might prefer to avoid. If they use the car, they may not abide by the speed limits or the rules of the road. They have more accidents, more speeding tickets. So, it is important to be aware of that before they are allowed to have the car keys and have penalties for those kinds of behaviors.
In school, teachers complain often that adolescents are not listening, they are talking while the teacher is talking, they are not following along when called on. They may be overtly disrespectful to the teacher. They are typically unprepared for class, and then they are also described by teachers as performing under potential. Socially, the friendship problems that I described for school-age kids may well be exacerbated. In more serious cases, these youth may turn to drugs or alcohol, either to salve their wounds as a result of not doing well in school and not being popular, but also maybe as a result to get in with a different social group or antisocial group. In more serious cases, we may also see things like lying, stealing, and other antisocial behavior.
Dr. Eugene Arnold: This can manifest differently at different times, but I am wondering, some kids are diagnosed very early, maybe even preschool. Others get diagnosed as late as in high school. Can you talk a little bit about the things that make a difference in age? For example, does intelligence level make a difference?
Dr. Mary Solanto: Right. So, it's important to be aware of these potential ameliorating variables. So, kids who are smarter may be able to continue to do well in school for a longer period because they do not have to be using their attention fully in order to learn. Another positive support that may allow the child to function well for a longer period of time is teachers who are supportive, who are good at managing behavior in the classroom, rewarding positive behavior, penalizing or ignoring negative behavior. And the same applies to parents who may be able to just naturally implement these kinds of responses to kids. Schools, even those who are aware that a child needs very specific support, may also help that child function well until such points as the cognitive and emotional demands of the setting exceed the child's ability to respond appropriately.
Dr. Eugene Arnold: Could you elaborate a little bit on the fifth criteria, which in my experience is the most neglected, the one that says that it should not be better explained by another disorder.
Dr. Mary Solanto: Yes, and this means that the person, the physician, the psychologist, or other professional doing the evaluation really has to cast a wide net and look at the functioning of the child and of the family from an emotional perspective, an interactional perspective, to be able to have some insights as to whether other variables are causing this child's problem. And that means some understanding of family function, recent difficulties that may have been present in the home, having testing for learning disabilities, so that can be ruled out before one leap to the conclusion of ADHD. So, there are a number of other things that have to be considered before we can finally conclude that this is not any of these other problems primarily, but it reflects ADHD. Now that does not mean to say that some of these problems can't also be present as well, but the issue is that they are not the primary or initial cause of the child's inattention or difficulties in self-control.
Dr. Eugene Arnold: Is there anything that we have not hit on that you think should be mentioned in terms of recognition and diagnosis?
Dr. Mary Solanto: So, I think it is important to be aware that the symptoms may well persist into adulthood and continue to cause impairment. And for many years, adults were not recognized as being at risk for this, because it was thought that ADHD spontaneously remitted around the time of adolescence. Now that we have had longer-term follow-up studies into middle adulthood, we know that is not the case for many adults. Problems that they may continue to be at risk for include failure in or limited higher education in college or beyond, problems at the workplace resulting in greater unemployment or underemployment as a result of not being able to manage time well, missing deadlines, and could also result from difficulty in interpersonal relationships with the boss or supervising personnel. We also can have difficulty with driving, more accidents. It has been shown that adults with ADHD are more likely to have citations and crashes and ER visits as a result.
They are also more likely to have comorbidity with anxiety and depression. Studies show that as many as half of adults with ADHD have an anxiety disorder and about a third have what we call a comorbid mood disorder. And we can understand this as potentially being the result of a lot of negative feedback and failure experiences that they have accrued in the course of their lifetime from childhood onward. There's also higher rates of alcohol and drug abuse in adults with ADHD.
There is, even now that there is some new data being published and described, a shorter life expectancy for adults with ADHD. So, beginning at about age 27, they are likely or more likely to have an eight-year shorter life span. And this may likely be the result of drug and alcohol abuse, of poor nutrition, obesity, inadequate sleep, inadequate follow-up treatment for things like high blood pressure or high cholesterol. And these difficulties seem to converge around the issue of conscientiousness, which is that issue of self-control, being able to follow through with things and adults with ADHD are, by definition of the condition, less likely to be able to follow through and manage these kinds of risks. And so, they're more likely to have a shorter life span. So, it's important to know that it's so important to treat this condition as early as possible in the lifespan to prevent some of these many negative outcomes.
Dr. Eugene Arnold: Would you like to summarize the key points that you think should be taken from this?
Dr. Mary Solanto: Well, I think it is important to know what the primary characteristics of ADHD are, the difficulties with attention, and for some kids as well, difficulties with hyperactivity and impulsivity. It's not necessary for a child to actually be running around to be able to say that they're hyperactive, but that it's important to rule out some of these other possibilities as primary causes of the child's difficulty, things like anxiety, depression, stress, PTSD, family difficulties, poor management on the part of parents.
But again, stressing that parents do not cause ADHD and that genetics plays an important role in the likelihood that a child has ADHD, but that parents' response to these behaviors can have a crucially important impact on how well the child is managed and how well they develop from that point onward, avoiding negative experiences that lead to higher rates of anxiety and depression in these individuals. And it is important to recognize specifically what difficulties these symptoms produce in the lives of children with ADHD. They do not just affect their academic work, but also their social and emotional functioning.
There are many spinoff effects, and although we will be discussing this more in another podcast, there are very effective treatments, both behavioral and psychopharmacological for this condition. So, there's reason to be very hopeful and have a positive outlook on management of ADHD.
Dr. Eugene Arnold: Thank you, Dr. Solanto.
Dr. Mary Solanto: You're welcome. My pleasure.
Announcer: Pocket MD is brought to you by CHADD, with funding from the US Centers for Disease Control and Prevention and in partnership with the Rainbow Center at Rainbow Babies and Children's Hospital.
- Society for Developmental and Behavioral Pediatrics (SDBP), Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents with Complex Attention-Deficit/Hyperactivity Disorder, Journal of Developmental & Behavioral Pediatrics, January 30, 2020.
- Society for Developmental and Behavioral Pediatrics (SDBP) Complex ADHD Guidelines Executive Summary.
- American Academy of Pediatrics (AAP). Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents, Pediatrics, October 2019
- CHADD National Resource Center on ADHD. About ADHD (fact sheet)
- Solanto, Mary. DSM-5 & ADHD: New Diagnostic Guidelines. CHADD National Resource Center on ADHD’s Ask the Expert Webinar, July 11, 2013.
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