When is it ADHD and when is it just normal attention issues?

[Anonymous]

My son what I'd describe as a pretty typical 4.5 yo boy - very energetic, very active, loves superheroes/Ben 10 (and knows all the dozens of characters by name) - but seems to have some problems with his focus. His pre-school teachers recently brought up that they were concerned that he seems distracted easily and over focussed on things like Ben 10 aliens. My 4.5 yo has been evaluated by Child Find and scored in the average/advanced range for everything (expressive language, etc.) but has some speech (mostly pronunciation) issues. The comments by the pre-school teachers though have me worried.

I find that my son focusses just fine when he wants to (e.g., when doing an interesting art project, playing video games - I know, not ideal, but they certainly get his attention, doing a fun puzzle). It isn't like he can't finish ANY projects. The teachers are also worried that he doesn't seem to know all his classmates by name. Part of me feels like this is actually a school issue (both my son and my nanny, who volunteers there every now and again when they need help) have mentioned that it is boring.

But I don't want to brush aside a real issue if there is one.

I would appreciate anybody's insight as to whether this appears normal or whether he does seem to have some ADHD qualities. For what it is worth, my MIL always talks about how my DH was the exact same in school. Teachers always thought he had a hearing problem b/c he would get so focussed on something that he would tune out everything else. My son definitely seems to do this...

TIA

[Anonymous]

Ask your pediatrician for the Conners and/or the Vanderbilt. These are the assessments that are used by pediatricians and schools to diagnose ADHD in young kids. They are (long) questionnaires filled out by the parents and the teachers.

[Anonymous]

Have your child evaluated by a developmental pediatrician. That is really the only way to know. There are some red flags there, but without a professional evaluation, you really don't know. At best, you can have your concerns alleviated. But if he does have something going on, you can learn how to help him.

If the mom is concerned and the school is concerned, its worth checking out.

[Anonymous]

NP here, but with similar concerns. It's about time to check our DC out for ADHD, as suggested by other therapists and teachers, etc., but my question is this: once you start down this road, is there no turning back? Once the developmental pediatricians have DC in their fold, are they ever going to say, no, DC does NOT have ADHD? Or are they always going to find something that needs treating, regardless?

[Anonymous]

Of course if they are any good (and there are excellent developmental peds around here) they aren't going to fabricate something that isn't there. I have seen more children whose parents were told their children did not have ADHD and then, several years and continuing problems down the road, have gotten another opinion and told they did have it. I know of no family for whom this dynamic has worked in reverse (though obviously its possibly). In other words, I think a false negative is much more common than a false positive.

I hope you don't take this the wrong way, 14:18, but you make it sound like a religious conversion. "In the fold." Either your child has ADHD or not -- and the best you can do is seek an evaluation with the best person you can find. Most people feel comfortable with the diagnosis once they try meds and their child responds -- its like an "aha" moment.

[Anonymous]

OP here - I appreciate everybody's insight. Can anybody recommend a development pediatrician for me to bring DS to for an evaluation?

Thanks again.

[Anonymous]

We had our son evaluated as part of an NIMH ADHD study. It's free, you get in very fast, they are doing the cutting edge research on ADHD - so they know their stuff, and it's not a treatment study - so there is no particular push for any type of treatment - just a lot of information that you can share with your peditrician, school, etc. They also make recommendations for further testing you may want to pursue. We had a wonderful experience.

http://intramural.nimh.nih.gov/chp/adhd/index.html

[Anonymous]

May I ask the name of the preschool? There are a few known to be hypervigilant or known to over-refer for evals. The vast majority of preschools however have teachers who have seen enough kids and know what's what.

Unfortunately it's not so clear cut to diagnose even with an expert. There's a continuum and the line where you go from normal to ADHD and how you judge how much an issue impairs a child can be a little different based on who you speak with. If you have a preschool teacher who tends to over-refer or who is green she/he will fill out the Conners in such a way your child will present as ADHD. Of course for the dx you need info from multiple settings and people, sometimes clinicians will observe as well. At 4.5 it sometimes isn't so clear. Sometimes it's not until academic and behavioral demands increase that is becomes glaringly obvious.

[Anonymous]

PP - could you share the names of the schools that are hyper vigilant and quick to refer (and mention if you have personal experience) ...I'm the OP of the thread about the 4 year old who is behind socially and one of my concerns which I didn't mention is that I think his preschool is one of those schools. That's okay to some extent but I need to know how to factor that into my assessment of information I get from them and also to assess whether he'd really be better off elsewhere. I don't want genuine issues ignored, but, on the other hand, my concern about this school is that referring becomes a way for them avoiding any outside the box thinking about how to deal with a child who may just march to his own drummer a little bit.

[Anonymous]

The not calling classmates by their names is possibly an ASD thing, but you don't mention anything else that sounds like a red flag for that.

[Anonymous]

Anonymous wrote:We had our son evaluated as part of an NIMH ADHD study. It's free, you get in very fast, they are doing the cutting edge research on ADHD - so they know their stuff, and it's not a treatment study - so there is no particular push for any type of treatment - just a lot of information that you can share with your peditrician, school, etc. They also make recommendations for further testing you may want to pursue. We had a wonderful experience.

http://intramural.nimh.nih.gov/chp/adhd/index.html

I'm not the only NIMH lady! We, too, participate in that study and our experience was very positive. We chose to continue on to the second part of the study (absolutely no pressure to do so) and did the brain MRI. It was fascinating and we really learned a lot about brain development and ADHD.

I agree with the PP that false negatives are likely more common than false positives. Our experience is that if the child isn't noticeably hyperactive, it can be hard to get a definitive diagnosis at the younger ages. When the kids go to school and the demands/expectations increase it often becomes more easy to diagnose. For some kids, that's early elementary, for others, it can be middle school. Their natural intelligence can take them a long way. Also, what can be difficult to understand is that having ADHD doesn't mean a person can't focus, it's not being able to maintain and regulate attention. We all find it difficult to attend to boring, routine things. The difference is that those of us who are "normal", can bring our attention back around. People with ADHD often can't - or can't sustain it. On the other hand, when it's something they're really into, they have can have problems with hyperfocus. It's hard for them to get their mind off the thing of interest and on to something else.

[Anonymous]

Hi there, NIMH ladies! I apologize if this is hijacking, but could you please tell me more about the studies? My son was just diagnosed with ADHD by a reputable psychologist; however, I remain in need of education (at best) or skeptical (at worst) because he doesn't meet my stereotypical, uninformed notion of ADHD. I'd like to participate in something that can help me learn more, though I'm wary of putting my son through more testing (which he hated). So all info welcome. Thank you!

[Anonymous]

20:57 here. I first have to tell you that my DS didn't seem to fit what I thought ADHD was - that was before I learned more about it and now I can see he's a classic non-hyperactive type. I think it's great that you want to learn more about it to see if you think that's what it is. It wouldn't be the first time someone got a wrong diagnosis.

DS was 6.5 when we started the study and had been diagnosed with ADHD about 6 months prior to that. We were interested in the study, not just because we think this kind of research is important, but because we had done other studies where we learned a lot more about what was going on with our kids. The researchers also suggested areas we might focus on in order to help DS (ie, focus on exercised improving executive functioning, books to read, websites, etc.).

When we arrived at NIMH for this particular study, DS went with one group of researchers and I went with another. They interviewed me and took a detailed history. For DS, they gave him a number of tests, mostly on the computer. They realize that these tests can be very boring and it can be hard to keep the kids engaged to complete them. To help motivate the kids to get through it, they provide "prizes" for completing portions of the tests. My DS was very motivated to earn those prizes. The team that worked with my DS was great. They were very engaging, interactive and my normally loathe to separate DS was more than happy to go with them. They also gave him snacks that he liked (they checked with me in the beginning to see if there was anything off limits).

DS did not join me for the debrief (he was happy to play video games with one of the staffers). The team was very sensitive to the fact that it's not easy to hear your child has challenges. They also explained the tests, the results and the interpretations. One of them was an intelltigence test and my DS scored very low. They were quick to point out that this wasn't an accurate measure of his intelligence but was part of the ADHD. The test was boring, DS was sometimes inattentive and didn't really hear the question (and gave a wrong answer) and that he sometimes forgot which button he was supposed to push and kept pushing the wrong button even though he knew the correct answer. But, he was motivated to get through the test in order to earn the prizes.

I don't know what kind of testing the psychologist did to arrive at an ADHD diagnosis for your DS but our initial ADHD eval was done by a neurodevelopmental pediatrician and it was very interactive. I've heard some testing is mostly computer based and that it can be pretty boring. I don't have any experience with that kind but I do think if this team diagnoses ADHD, it's accurate. They've obvsioulsy seen all types of kids and their goal is to make sure their participants do, in fact, have ADHD so that their study is valid. They have every reason to screen out normal or borderline cases because it would skew their results. The report they sent me a few weeks later was well written and has been of great benefit to us in the IEP process. We continued on to the second part of the study (brain MRI) but we were given every opportunity to opt out. When I told DS that we were going back, he was very excited to see them again (and earn prizes). DS also has sensory issues and I was very surprised that with we were able to persuade him to go into the MRI machine. Prior to going, we'd listened to MRI sounds in headphones so he knew what noises to expect. He had some resistance to laying down in the machine initially but when he requested headphones (in addition to earplugs), the staff jumped to get them. Once he got in, he was fine, especially when they started showing March of the Penguins. We were able to see images of his brain there and they emailed the pictures to me later. Using his pictures, they also explained what their research to date was showing about brain development and ADHD. Very interesting stuff.

[Anonymous]

"Unfortunately it's not so clear cut to diagnose even with an expert. There's a continuum and the line where you go from normal to ADHD and how you judge how much an issue impairs a child can be a little different based on who you speak with. If you have a preschool teacher who tends to over-refer or who is green she/he will fill out the Conners in such a way your child will present as ADHD. Of course for the dx you need info from multiple settings and people, sometimes clinicians will observe as well. At 4.5 it sometimes isn't so clear. Sometimes it's not until academic and behavioral demands increase that is becomes glaringly obvious. "

I agree with this. Diagnosing development or other special needs issues is not an exact science. The observers, reporters, evaluator and even the parents inject bias by nature. Like other areas in medicine and psychology there is a spectrum of approachs from a more conservative (wait and see) to a more interventionist (why not therapy can't hurt anyway) depending on who you go to and their personality.

You can even see a more extreme perspective among parents. I've noticed on this board that people will post some vague descriptions that in no way would determine whether a child had an issue or not (no fault of the poster who is just seeking some advice). You will see two camps jump in. Some will assert the child is perfectly normal when they have no basis to say this. Some will assert that the child needs an evaluation and sounds like they have condition XXX, also something they have no basis to say. Its just as common for parents to seek out a diagnosis as it is for parents to avoid one.

You may want to first think about where you tend to fall. If you prefer a more wait and see, you could try working through the issues with the teacher or maybe even get some books about approaches for ADHD. Some of the behavorial approaches for things are not revolutionary at all but good for all kids. If you prefer a more interventionist approach then go forward to a development ped and evaluation.

I don't know you child or you so I can't recommend which course is better.

[Anonymous]

I recommend Dr. Gersh at Children's. Very experienced Dev Ped. We really liked him, but he was just the first little step in the journey.
And as for the notion of getting stuck with the diagnosis... so what? My DS has very severe ADHD, and at age 3 was diagnosed. His teachers, care givers, anyone ever in contact with him knew it. I have had a lot of people tell me that there is no way a 3 year old can have that, etc.- but I assure you it is possible in certain individuals. On the other hand, I was not diagnosed until I was in my 30s. From experience I would give up anything to have had a mild case that was treated than to have to have gone through the decades of being in a fog. The extra support and guidance that might come from an overly cautious diagnosis would not be detrimental in any way that I could possible imagine.
Fixating on objects can be the result of many things- ASD, OCD, ADHD, really liking something (innocuous). In my son's case it was locks and door knobs, but it turned out to just be part of his ADHD hyperfixation. There was no real "test" but time to tease that aspect of his personality out. Three years of locks and door knobs later and we are into a medication/ therapy combo where he is no longer hyperfocusing on the object and moving into understanding how they work by reading manuals and diagrams. But this started with him taking apart his first door knob at 18 months (to escape his room), so it was precipitated by a pleasurable but discrepant event that seems to have just "stuck". We might never know why! But it took that amount of time to understand that he wasn't ASD, OCD or anything else because there isn't a precise way to tell. At this age the testing relies VERY heavily on the parent interview and questionnaires and it therefore subject to a great deal of variability. No scans, blood tests or certain test is fool proof.
If you are curious or in doubt go get tested. the only real red-flag you talk of is the family history of tune-out issues. ADHD/ ADD runs in families, but the inattentive kind was nearly always brushed aside until recently. Think of it this way- if your child isn't getting all of the information in school he is not getting the best education that he can get. Typically teachers will not reach out as much to "day dreamers" as they will kids with a diagnosed need.