According to the American Psychiatric Association’s DSM-IV, ADHD is a disorder that first presents in childhood usually observed before the age of seven years in a child. It is characterized by developmentally inappropriate levels of inattention, distractibility, impulsivity, and/or hyperactivity. Impairment is realized in one or more major life areas typically in the home, in the classroom, in social interactions, in occupational settings, or other areas of adaptive functioning. The symptom list goes on to describe a variety of interferences that can be presented with ADHD that can easily disrupt performance, learning, and behavior in any child. Curiously, the symptom description fails to specify the amount or severity of symptoms with the exception that the interference must exceed normal developmental levels evident in children. As a result, parents and professionals alike are left with the challenge of distinguishing excessive ADHD symptoms from those that are normal for a child’s specific level of development.
Good practice demands that an ADHD evaluation include the gathering of multiple types of information from a variety of sources. A simultaneous effort must be made to rule out as many alternative disorders that can present with similar attention and performance difficulties. This could include but not be limited to the impairments observed in learning disabilities, developmental delays in younger children, sensory regulation dysfunction, mood difficulties and depression, anxiety, as well as basic low motivational effort. These alternative disruptions will easily and predictably interfere with a child’s optimal performance and learning in the classroom. However, distinguishing these interferences in the classroom remains a challenge for teachers and professionals especially when attention deficits are characteristic of a variety of interfering disorders.
As a child psychologist, I realize this professional challenge every time I begin a new ADHD evaluation for a presented child. I will then lament the absence of an accurate and objective evaluation for ADHD that can effectively distinguish inattention from alternative interfering conditions. On occasion, I will be fortunate to learn crucial information about the presenting child that I have come to recognize as “Rule Outs” of ADHD. While these Rule Out factors are not necessarily absolute in their distinguishing ability, they usually increase my potential of accurately diagnosing ADHD.
Age of onset is one of these differential diagnostic factors. The presence of ADHD can be recognized at least by the age of seven in a child. Generally by this age, a child has developed in multiple areas including cognitive, social, emotional, behavioral, and physical so as to allow them to meet the majority of routine expectations held for that student in the classroom. The same cannot be said for five year old children who may still be developing their ability to self regulate attention and activity level so as to facilitate learning in the kindergarten classroom. My comfort level in attempting ADHD evaluations is substantially improved when the identified child is at least six years of age. By this chronological age, I can more accurately use my clinical expertise and judgment to determine when activity and inattention is observed beyond expected developmental levels.
I use a related Rule Out factor whenever I evaluate students who are somewhat older in age. Recently, I evaluated a fifth grade girl referred due to her lower academic achievement and difficulty attending specifically in the area of Math. Her absence of inattentive symptoms or concerns during earlier elementary years cast serious doubt on a possible ADHD diagnostic. Not only was there an absence of earlier ADHD concerns, but this student enjoyed excellent academic achievement and performance in all prior elementary years. Unfortunately, her math performance began to show degradation as she progressed in curriculum involving higher abstraction in concepts and problem solving. In my opinion, increased academic challenge will predictably generate higher levels of inattention and poor task engagement in students and cannot be recognized as the neurological impairment of ADHD.
Rule Out factors are critical when considering any child for ADHD. Specifically, children should show evidence of ADHD by age seven and the symptoms can not be confused with delayed child development. ADHD symptom interference should be recognized by classroom teachers in every elementary grade without fail, and the interference should be evidenced in every academic area. This suggests that an ADHD student will show some amount of impaired attention in all subjects and activities. And finally, ADHD interference will not suddenly present in fourth or fifth grade correspondent with the increasing curriculum demands in elementary school. In the current example, a student who demonstrates developmentally appropriate ability to sustain task engagement early in elementary school will not lose this ability in later grades. More accurately, learning weaknesses or motivational problems frequently present in students struggling with the progressive academic demands in the classroom. These students will almost certainly have trouble keeping focused and attentive to their assigned work.
These Rule Out factors are certainly useful in arriving at an accurate diagnosis of ADHD in any child or student. Although such Rule Out factors can reasonably dismiss the diagnosis of ADHD, such factors are largely suggestive rather than absolute in making this diagnostic determination. The non-specific descriptive criteria of ADHD (DSM-IV) in combination with the lack of objective ADHD testing will continue to set the stage for significant clinical judgment contributing to its final diagnosis. While there are numerous factors and indicators that will support an accurate diagnosis of ADHD, there are numerous variant presentations of this disorder that must be considered either to diagnose or rule out this disorder.