Attention Deficit / Hyperactivity Disorder (ADHD) is a condition, beginning in childhood, in which the person has difficulties with attention, impulsivity, and/or hyperactivity.

Inattention

• Poor focus and concentration.
• Distractibility.
• Misses important information (e.g. “There’s a test today?! When did the teacher say that?”).
• Neglects details (e.g. ignores the sign in math, forgets to put a period at the end of the sentence, fills in the wrong bubble on scantrons, writes down the wrong page numbers when copying homework assignments).
• Loses track of what s/he is doing in the middle of it and veers off course (e.g. forgets the directions, forgets the solution s/he was executing or what his or her point was).
• Difficulty following multi-step directions.
• Experiences information overload – has trouble keeping track of a lot of information at once (e.g. the names of people and countries during a history lesson).
• Gets easily sidetracked (e.g. goes upstairs to get his or her shoes and coat and winds up getting involved in another activity and forgetting why s/he went up there in the first place).
• Doesn’t seem to listen (e.g. “Wait, what?”)
• Forgetful (e.g. does homework assignment but forgets to hand it in).
• Poor organization (e.g. has a messy backpack with papers shoved everywhere, can’t find what s/he needs to start an assignment).
• Misplaces or loses things (e.g. homework assignments, gloves, jacket, eyeglasses, phone, books).

Hyperactivity

• Always moving.
• Fidgety, can’t sit still.
• Does everything fast (e.g. homework, eating, etc.).
• Feels very restless and antsy, even if s/he is not actually moving around (this is a common way hyperactivity is experienced by adolescents).
• Trouble staying seated.
• Runs around the house.
• Jumps on furniture.
• Goes from one activity to the next, without sticking with one activity for more than a brief moment.
• Has trouble doing quiet activities.
• Talks too much.

Impulsivity

• Acts without thinking of the consequences.
• Takes chances, leaps before s/he looks (e.g. acts dangerously on the playground).
• Interrupts frequently.
• Has no filter, says things without thinking.
• Takes shortcuts when doing schoolwork.
• Guesses at answers instead of reflecting on and thinking through the question or problem.

Associated Features

Associated features of ADHD are behaviors that are not part of the “official” symptoms of ADHD, but are frequent characteristics of people who have ADHD. They include:

• Inconsistency.
• Easily frustrated.
• Moodiness.
• Brief emotional outbursts.
• Behave too forcefully (e.g. greeting a peer with a friendly slap on the back that is too hard, being too rough with the family pet or with toys).
• Rejection by peers.
• Low self-esteem.

People with and without attention problems often can pay attention to what they like. It usually does not take effort to pay attention to something that one likes, is interested in, or is stimulated by. When we like something, it grabs our attention for us – we do not have to “try” to pay attention to things we find interesting. On the other hand, when an individual must do something he or she does not like, it requires more control over-attention to “force” oneself to focus. This is the very ability the person with ADHD is lacking – the ability to “turn on” his or her attention when s/he needs to, not just when s/he wants to. For this reason, the true test of whether or not someone has an attention problem is his or her ability to focus when s/he is doing something s/he does not like. It is also for this reason that a child’s ability to focus on things s/he likes by itself does not contradict a diagnosis of ADHD.

Inconsistency is one of the hallmark characteristics of attention dysregulation. To control one’s attention means to be able to turn on one’s attention when and where one needs it for as long as one needs it. Because attention dysregulation involves a lack of control over attention, it causes inconsistency, as the person’s attention “comes and goes” from one occasion to the next. For this reason, students with ADHD can have widely fluctuating grades from test to test and subject to subject.

ADHD is simply the newer term for what we used to call “ADD” (although some people still say “ADD” instead of “ADHD”). ADD stands for “Attention Deficit Disorder” and refers to problems paying attention. However, this term is misleading because some people have problems primarily with attention, some people have problems primarily with hyperactivity and impulsivity, and some people have problems with both. Therefore, the term was changed to Attention Deficit / Hyperactivity Disorder (ADHD), which has three categories to reflect the above distinctions: ADHD, Predominately inattentive presentation, ADHD, Predominantly hyperactive / impulsive presentation, and ADHD, Combined presentation. What used to be referred to as Attention Deficit Disorder, is now referred to ADHD, Predominately inattentive presentation.

ADHD is only properly diagnosed by a qualified professional, usually a psychologist, psychiatrist, developmental pediatrician, or pediatric neurologist. It is important to remember that almost everyone has moments of inattention, restlessness, and impulsivity. What makes these behaviors “ADHD” is based on the number of these symptoms, how frequently they occur, how severe they are, and how disruptive they are to a person’s functioning at school, socially, and/or on the job. In addition, some forms of ADHD may not be visible to the outside observer (e.g. a child who tries, is well behaved, is not hyper or impulsive, but who is constantly daydreaming) and certain behaviors may look like ADHD, but really reflect other problems (e.g. anxiety, OCD, depression, all of which also can cause inattentiveness). This assessment and determination requires the expertise, training, and experience of a qualified mental health or medical professional.

ADHD is properly diagnosed through a comprehensive, multi-modal assessment, which includes gathering information from multiple sources. ADHD is not properly diagnosed through cursory methods (e.g. eyeballing a child for a few minutes).

Many professionals diagnose ADHD based on interviewing the child’s parent about the child’s behavior as well as interviewing and observing the child directly. Parents may also be asked to complete a rating scale, asking the parent how frequently he or she observes the child to engage in certain behaviors. It is also imperative to obtain observations of the child’s behavior at school from teachers or other school staff. This can come in the form of having teachers complete questionnaires as well as reviewing report cards. In the elementary school years, on most Districts’ report cards, students are graded on a number of “Work and Study Habits,” or a similarly termed category, that often contains a number of behaviors related to attention regulation (e.g. Listens attentively, Follows directions, Organizes his or her work space, etc.). Teacher comments on report cards also can be very helpful.

Regarding the use of rating scales, given common misconceptions, it is important to know that scores and rating scales do not diagnose ADHD, qualified clinicians do. Like any type of diagnostic measure, rating scales can have false positives and false negatives. This means a person could score high on rating scales of ADHD but not have ADHD and a person could score low on ADHD rating scales and have ADHD. Rating scales provide a source of information that a qualified professional needs to interpret and integrate with multiple other sources of information in order to arrive at a diagnostic conclusion. In addition, rating scales are only one (of multiple) ways of collecting observations about a child’s behavior.

A neuropsychological evaluation incorporates all of the above, but takes things a step further. A proper neuropsychological evaluation will include interviewing the child’s parent, interviewing and observing the child directly, and collecting teacher / school staff observations about a child’s behavior. However, neuropsychological testing goes beyond this by directly measuring the child’s abilities in key areas involved in ADHD. Neuropsychological testing literally “puts the child’s brain to the test” and objectively measures the child’s ability to focus, concentrate, mentally juggle information, plan, organize his or her thoughts, etc., areas that are impaired in ADHD.

Neuropsychological testing provides an objective way of measuring these areas. It is analogous to how, if I wanted to know how well you play tennis, I could ask you (and others) to talk about and describe your tennis game. This information would be helpful, but limited and subjective. Alternatively, we could actually go on the tennis court and measure the miles per hour of your serve, the percentage of backhands you hit over the net, etc.

Because it is more comprehensive, neuropsychological testing can offer a more reliable diagnosis, which can be especially important when making treatment decisions, such as whether or not to put your child on medication. Many parents find peace of mind in using a neuropsychological evaluation to make a data driven decision about whether or not to put their child on medication.

However, much more important than using a neuropsychological evaluation for making medication decisions, in my opinion, is the fact that a neuropsychological evaluation can be very helpful in devising behavioral strategies for parents and teachers to manage ADHD and promote the child’s development.

There are many different forms ADHD can take, well beyond the three official diagnostic categories of ADHD (i.e. Predominately inattentive presentation, Predominantly hyperactive / impulsive presentation, and Combined presentation). Some children with ADHD need to be stimulated and challenged to command their attention. Some children with ADHD need the opposite – to be less stimulated, to have information shortened and simplified in order for them to register it. Some children with ADHD begin tasks focused but then their attention fades. Some children with ADHD are the opposite – they have trouble locking on to tasks and need a warm up period after which they are able to focus. And so on, and so on. If your child has ADHD, a proper neuropsychological evaluation can help elucidate the particular ways in which s/he has trouble paying attention so that behavioral and instructional strategies can be individualized for your child.

Central Auditory Processing Disorder (CAPD) is a condition in which the person’s brain has trouble processing sound. Symptoms of Central Auditory Processing Disorder include a tendency to mishear words (e.g. someone says “pencil” and the person hears it as “stencil”), difficulty filtering out background noise and thus trouble listening in a noisy environment, and other symptoms. Because children with Central Auditory Processing Disorder have trouble registering information in the above ways, it sometimes can look like they are not paying attention when they really are – they didn’t catch what the teacher said because have trouble accurately hearing what the teacher said, not because they were not paying attention.

So, if a child has trouble paying attention, the question becomes, “How do you know it’s ADHD and not Central Auditory Processing Disorder?” The answer is:

• Children with ADHD have trouble paying attention to visual and auditory information. So, if a child only has trouble paying attention to auditory information and does not have trouble paying attention to visual information, then it is not ADHD. Conversely, if a child has trouble paying attention to visual and auditory information, it cannot be only CAPD, as CAPD involves difficulty processing auditory information, not visual information.
• Children with ADHD often have trouble organizing and keeping track of information in their mind even when they did hear it correctly. So, if you can verify that the child did in fact hear you correctly in the first place, such as by asking the child repeat back what you said, but then the child still goes on to lose track of the information (e.g. forgets details, makes careless errors, etc.), that would be consistent with ADHD, not CAPD.

Realize also that a child of course can have both ADHD and CAPD. In this case, the child would have the symptoms that define CAPD and shows signs of inattention, including in the ways mentioned above (e.g. inattention when processing auditory and visual information, losing track of information even when s/he heard it correctly, etc.).

There are many, many interventions for ADHD. Below is just a sampling.

• Instructional modifications as well as classroom and test accommodations that are provided on Individualized Education Programs (IEP’s) and Section 504 Accommodation Plans. Examples include preferential seating close to the teacher, information and directions repeated, frequent breaks and opportunities for physical movement throughout the day, prompts to refocus, checks to make sure the child was paying attention and understands the directions, extended time on tests, having the child write the letter of his or her answer for tests on the test booklet instead of having to fill in the tiny scantron bubbles, and many, many others. At the college level, some students with ADHD may qualify for priority registration in order to schedule classes in a way that reduces demands for prolonged concentration (e.g. scheduling classes that are shorter and meet more frequently as opposed to classes that are longer and meet less frequently, scheduling classes with breaks in between as opposed to having hours of classes scheduled back to back because no other sections were open, etc.).
• Teaching strategies to help a student catch important details. One example of this is an “advanced organizer,” which refers to giving the student a “head’s up” about what to look for (e.g. “This passage talks about a communication problem a person had and how she used technology to solve that problem. Be listening for the problem, the technology, and the solution.”
• “Chunking,” which refers to consolidating multiple pieces of information into one unit of information (like putting multiple pieces of paper into one file). This makes information more manageable and can help a student better keep track of details and organize information. There are many ways to “chunk” information. Examples include making ample use of bullet points and tables to summarize large amounts of information or teaching students how to summarize paragraphs in a brief phrase or two. Another way of chunking is to create a visual image that contains multiple details in that one image. For example, a student might imagine Harriet Tubman on a subway, in a nurses uniform, holding a voting ballet to remember that Tubman worked on the Underground Railroad, was a nurse, and advocated for women’s right to vote. A visual like this is a way of packing those separate, multiple details into a single image. Graphic organizers can be another way to chunk large amounts of information.
• Behavioral Intervention Plans (BIP). Some students with ADHD benefit from BIP’s, which basically refer to a plan of using rewards to increase target behaviors. For example, a child might be rewarded with x minutes of time doing a preferred activity, such as time on the computer, for spending a certain amount of time on task.
• Medication. There are stimulant and non-stimulant medications that can help students with ADHD focus and concentrate as well as reduce hyperactivity and impulsivity. As with any medication, there are risks and benefits to medication for ADHD, which you should discuss with your child’s prescribing physician if you go that route.