Diagnosing ADHD in Kids

We are seeing an increase in requests for kids to be evaluated for ADHD. I'm getting asked about diagnosing a child about once a week or more, and they're usually requests by parents and they're usually at well-visits.

Limitations of Well-visits for ADHD Evaluations

Well, for starters, it should be mentioned that I cannot do an ADHD evaluation at a well-visit. That's a whole different appointment that requires a lot of paperwork to be completed ahead of time.

Some parents think I can just tell them right then and start treatment. Nope. Although I've reviewed medical records where some other providers do, that's not ideal or in the best interests of the child.

The Complexity of ADHD Diagnosis in Children

There's actually a lot that goes into evaluating a patient for ADHD. ADHD isn't a simple diagnosis, especially in kids, because many things present like hyperactivity or focus issues in kids, but they don't actually meet the criteria for ADHD.

For example, I have parents of 2- and 3-year-olds wanting me to diagnose their kids as having ADHD. All toddlers and preschoolers seem to have ADHD. It's because their brains are still developing and they are very busy little people to begin with.

Diagnostic Criteria for ADHD in Children

A true diagnosis of ADHD requires symptoms to be present after age 6 for at least six months. Those questionnaires we have parents and teachers fill out are standardized for kids ages 7 and up. There is no way that a child aged 2 or 3 should be diagnosed with ADHD. They can be labeled as hyperactive, but there are lots of reasons kids that age are hyperactive.

Parents will often say that the teacher has asked them to have their child evaluated for ADHD. Again, there are specific criteria, and one of those is that symptoms need to be present in more than one setting, usually both at home and at school.

I have a lot of patients come in and they behave great at home, but they act out at school. Often, I find that it's more oppositional behavior because they don't like their teacher, or they could be getting bullied, or they have a learning disorder that's not been diagnosed. And so instead of trying to get the work done, they goof off because they don't understand the information and they don't want to try because they know they won't get it, and that causes other behavior issues.

I've had some kids where the teachers are concerned about focus issues because the kids just space out. Some of those have actually turned out to be seizure disorders, and some end up being anxiety.

Similarly, I have a lot of patients who are angels and great students at school, but Tasmanian devils at home. My boys, for example. Home is their safe place and they let loose there, but they don't have ADHD because their behavior issues are only in one setting.

One thing I'm learning while doing a lot of ADHD evaluations is that there are a lot of kids who don't meet the criteria for ADHD but do for anxiety and oppositional defiant disorder. Those two go together a lot actually, and they're best managed by therapy.

So when parents or even teachers question why I'm not giving the child ADHD medications, I explain why those medications won't help with the behaviors that that child has. They work on different neurotransmitters in the brain and it's not appropriate for me to prescribe medications in those cases.

Influence of Electronic Devices on Children's Behavior

Another interesting finding is there's actually something that is becoming more prevalent and it's due to electronic devices that even babies are being exposed to. There is research coming out showing that kids are being conditioned to want immediate feedback in response to a behavior.

Think about it. I have kids as young as 9 months old who start crying in my office, and what do the parents do? They pull out their phones and they put on a video for the baby to watch.

The babies then develop connections in their brains that say, "Hey, when I cry, I get a reward of watching a video," and their brains start to rewire so that when they do a certain behavior, they want that reward. When they don't get it, they ramp up their behavior.

Kids will have full-on temper tantrums because they want that reward and they won't stop until they get it.

Executive Function Disorder

There's also emerging evidence for something called executive function disorder. It's not a full diagnosis yet, but it is a component of many issues that kids and adults have with not being able to plan out activities and regulate their emotions.

Basically, in childhood, even starting in the first year of life, kids learn how to work towards goals, adapt to new situations, and ultimately develop the ability to do abstract thinking and planning. These executive functions aren't fully developed until early adulthood, but the foundations are laid in early childhood.

Kids who have executive function disorder struggle with the ability to organize their thoughts and follow through on activities they've started, and this also causes issues with hyperactivity and distractibility.

There are theories out there right now that all of the immediate feedback from video games and electronic time that kids are having is leading to an increase in this executive function disorder.

Seeking Diagnosis and Management for ADHD

The good news is that researchers are finding that certain types of cognitive therapies can help to rewire the brain and to help learn some of the skills that people didn't learn earlier in life.

The bottom line is if you think your child has ADHD, usually your pediatrician can help with the diagnosis or can refer you to someone who can help with the diagnosis and management.

However, not everything that looks like ADHD is ADHD. If it isn't ADHD, then your child's pediatrician can help you with the next steps to getting your child the help they need from a behavioral specialist or a therapist.