When parents suspect their child may have ADHD and bring that child into my office there are two questions they want answered: What is wrong? What can be done about it?
The first step in the treatment of any medical or psychological disorder is to get an accurate diagnosis. The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) has become more prevalent in the past decade, both in children and adults. One of the challenges in diagnosing ADHD in young children is the fact that young children are naturally full of energy. For this reason, diagnosing a young child as hyperactive is difficult in the same way that it is difficult to diagnose naturally moody adolescents as clinically depressed. This is why it is important to diagnose each child on an individual basis and understand the diagnostic criteria of ADHD within the context of each child’s unique, subjective personality and temperament.
Nobody knows a child like their parents and parents can tell when something is wrong. Teachers can also often tell when something is amiss and other children are excellent natural barometers of whether a child is having trouble “fitting in.” Making a diagnosis is part art, part science. Information must be gleaned from every possible source and then the objective criteria of ADHD as described in the DSM (Diagnostic and Statistical Manual) must be applied to subjective situations. Professionally, this is known as “clinical sense” and it cannot be taught. It is a combination of knowledge, experience and natural intuition.
There are two main types of ADHD. One is the “hyperactive” type, which is the one we usually think of when thinking about ADHD. The other is the “inattentive” type, which is less well known. One of the characteristics of the “inattentive” type is a “daydreaming” quality on the part of the child. Many children daydream so one cannot diagnose based solely on the presence of this characteristic. A complete ADHD “diagnostic picture” has to present itself in order to make an accurate diagnosis. An accurate diagnosis is important for many reasons. We do not want to treat a child for something they do not have and you cannot treat if you don’t know what you are treating.
Other childhood conditions, such as mood or anxiety disorders can look like the hyperactive or inattentive Type of ADHD. A depressed child might have trouble focusing, be irritable, appear unmotivated, and often seem to be elsewhere or daydreaming. What looks like the hyperactivity of ADHD can be the anxiety of an anxiety disorder or the anxiety that is almost always a part of clinical depression.
Further, it is not uncommon that ADHD presents with another disorder simultaneously. Children with ADHD often have damaged self-esteem and depressive and anxious symptoms can result. Conversely, depression and anxiety alone make it difficult to focus and this can be misinterpreted as the poor concentration that is part of ADHD.
Being aware that ADHD can mimic or disguise other disorders is important when deciding on medication. When a child has a mix of ADHD and depressive type symptoms one often medicates the depression first. If treated effectively, the depression lifts, the child’s grades and behavior improve and the ADHD “goes away.” The ADHD “goes away” because it was never there.
Educated, well-meaning parents sometimes use their familiarity with ADHD to shield themselves from realizing that their child has a different condition which can be more or less serious. In these cases, one has to inform the parents that their child has a diagnosis that is different from what they assumed, in order that the proper treatment can begin as soon as possible. In some of these cases, psychotherapy is inappropriate or must be modified or combined with other modalities.
It is important to get a diagnosis from an experienced child psychotherapist. What school of thought they follow, whether Freudian, Jungian or otherwise, is not particularly important. Neither is whether the therapist is a social worker, psychologist or psychiatrist. Cost is likewise irrelevant. Paying a lot does not mean one will get a more accurate diagnosis or better treatment. Diagnostic skill, which is different from the skills needed to be an effective treating clinician, is the most important factor when looking for an accurate diagnosis.
Many parents are wary about giving their children medication. This concern is understandable. Medication does not have to be a first choice but should not be eliminated as a choice altogether. Medications can always be stopped and dosages can be changed. Concern regarding the possible side effects of medication should be weighed against the probable long-term effects of not using medications.
It is important when observing and diagnosing behavior in children to differentiate between aggression and hyperactivity. Hyperactivity is not synonymous with being oppositional or aggressive. Hyperactivity is a defining feature of ADHD but aggression is not. Similarly, in Oppositional Defiant Disorder (ODD), a child is oppositional with rules at home and/or in school but they are not physically aggressive. There are disorders where aggression is a defining feature or an inherent part of how we conceptualize the disorder.
For example, one way to understand depression is that it is the result of aggression being directed toward the self. Sometimes aggression is not buried deep beneath the surface as in depression but percolates just below the surface and erupts periodically. This is the case with the impulse control disorders where the person cannot resist the urge to express an aggressive impulse that is harmful to the person or others. The DSM lists five impulse control disorders: kleptomania; 2) trichotillomania; 3) pyromania; 4) compulsive gambling and 5) Intermittent Explosive Disorder (IED).
IED is a disorder where a child will react to a stimulus with an explosive, aggressive act that is completely out of proportion to the stimulus. For example, a child may be told that they cannot have a toy and as a result they have severe tantrums that include kicking, biting, yelling, turning over desks, throwing chairs, and destruction of property. During these episodes, some children will run out of school and off school property, in any direction, so they can burn off the energy they are experiencing. After these intense discharges of energy some children become exhausted and fall asleep. These explosions are not intentional and many children do not remember what they did while in this state, so they have difficulty expressing remorse.
Other children will remember what they did and may or may not express remorse. Children with this disorder are usually described by their parents as sweet and considerate and they often have many friends. These children cannot predict or control the explosions of anger and aggression that they experience.
If left untreated, impulse control disorders usually get worse as the child matures, especially with boys who get older and stronger and can become more destructive. Once children become adults, the law will not accept the explanation that they could not control their urges. Consequently, these disorders must be treated as soon as they are recognized.
A family history often reveals that other people in the family have impulse control issues. These traits are described as familial, because it is unclear how much of the behavior is genetically determined and how much is learned. Like many personality traits, parents often notice these aggressive traits in their children at a very young age, even as toddlers. They may report that when angry their toddler banged their head against the wall or floor. Parents may have been uncomfortable leaving their more aggressive child with their other children. Sometimes, relatives of the child have a mood disorder where extreme shifts in energy levels can lead to irritability, anger and displays of aggression.
Impulse control disorders can be treated with psychotherapy and medications such as antidepressants and anti-anxiety medications. Medications that are usually prescribed for mood disorders or psychotic disorders may be prescribed in low doses for impulse control disorders because of their effectiveness in stabilizing mood and aggression, not because the child actually has a mood or psychotic disorder.
Jonathan Bellin, LCSW, has a teletherapy practice and is accepting new patients. He treats anxiety, mood disorders, trauma, relationship and work issues. Jonathan received his MSW from Yeshiva University in 1993 and is certified in Supervision and Field Instruction by Columbia University. He is a member of NEFESH and the New York State Society of Clinical Social Work. You can reach him at [email protected].
