Why it might not be ADHD

Difficulties with a child’s attention or ability to sit still are significant concerns for a lot of parents who come to my office. They hope to find answers, and at the same time avoid over-pathologize their child. However, psychiatric diagnostics is a complex concept, and even if there is significant difficulty paying attention or holding still, it may not be Attention Deficit Hyperactivity Disorder, or ADHD. There may be something else going on.

I hope to provide a little clarity on the intricacies of psychological diagnoses, and how difficulty concentrating doesn’t always lead to a diagnosis of ADHD.

Every mental health provider in the country uses the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as the official basis of their diagnoses. This next part is really important: every single diagnosis is a collection of different symptoms. There are a lot of overlaps in diagnostic symptoms because no one symptom defines any single diagnosis, or they might not be severe enough to warrant a diagnosis. Being sad doesn’t necessarily mean that a person is depressed. Being nervous in large groups doesn’t necessarily mean a person has an anxiety disorder.

Likewise, difficulty paying attention is a symptom, not a diagnosis, and there are many diagnoses that can affect attention. Coupled with the way kids express distress, this is why I’ve only diagnosed ADHD once or twice.

Diagnosis by elimination

Rule out everything else that could interfere with attention. This might include stressful events to which children might react. Symptom overlap is so significant that most DSM-5 diagnoses I commonly encounter affect attention in some way.

• Post-traumatic stress disorder can result in a need to constantly scan one’s environment for danger.

• To a differing degree, other forms of anxiety can cause distraction from preoccupation with the source of anxiety.

• Distractibility is overtly a symptom of bipolar disorder.

• Major depressive disorder can result in slowed cognition and impaired concentration, and can even manifest as a secondary reaction to other diagnoses, complicating things further.

When young kids are in emotional pain, they tend to act out (especially boys) instead of being able to talk it out. Kids often look like they have ADHD, whether it’s true or not.

Autism and attention

Impairment in concentration, distractibility and hyperactivity are all extremely common in those who carry an autism spectrum disorder (ASD) diagnosis. I generally expect to see these symptoms. Additionally, the DSM-5 makes it clear that both ASD and ADHD diagnoses are supposed to take into consideration a child’s developmental (not chronological) age.

What does this mean for those with ASD? It means that a combo diagnosis of ASD/ADHD should be fairly uncommon. But why?

“Stevie” and autism

Let’s say that 10-year-old “Stevie” has a diagnosis of ASD. Stevie is likely going to have some difficulties with attention and with social skills. Based on his symptoms and behavior, we estimate that he has the social/developmental age of a typical 6-year-old. Comparing the attention span of a typical 6-year-old to a typical 10-year-old (Stevie’s chronological age), you’ll see a big difference. However, because Stevie has an ASD diagnosis we can’t make that comparison in order to give him an ADHD diagnosis. We expect him to act like a typical 6-year-old, so that’s where the measuring stick needs to be used for his attention level.

It’s only when Stevie’s concentration and attention is significantly impaired compared to a typical 6-year-old that we can start to consider an ADHD diagnosis as a possibility.

I could write a lot more about this, but what I hope you take away is that sometimes a label (or additional label) isn’t needed. There are many reasons someone’s attention can be affected, and those still might warrant clinical attention, regardless of diagnosis. The problems are what they are.

If you’re concerned about someone in your life, consult a local mental health professional. In the meantime, I hope this brings some clarity to a potentially confusing and stressful situation.

R. Boccamazzo, PsyD, LMHCA

Dr. Boccamazzo is a doctor of clinical psychology and social skills coach with Aspiring Youth. In addition, he is the clinical director of TakeThis.org, a national nonprofit focused on mental health and the gamer community, runs a private psychology practice in Bellevue offering individual therapy and psychological assessment to adolescents and adults, and provides parent and clinician trainings on technology in psychology. Much of his work focuses on high functioning autism, problematic technology usage, social anxiety, trauma and games. In his spare time, he enjoys acting, cooking, board games and video games.

Photo credit: ADHD