Ask an Expert: Active or ADHD – What’s the Difference?
Q: What’s the difference between a very active, inquisitive child and a child with ADHD? Well-meaning people have told me that I should have my daughter evaluated for the disorder, but I’m not so sure.
Answer from Eugene Borkan, M.D., child/adolescent psychiatry, Providence Portland Medical Center: I’m glad to hear that you have an active, inquisitive child — that certainly doesn’t worry me. Every child is born with a different spectrum of activity levels, and having an active child is no cause for concern.
When questions arise about ADHD — attention deficit hyperactivity disorder — it’s usually because somebody has become concerned about the way a child is functioning when away from the home environment. A day care provider or school teacher may mention, “I’m having trouble managing your child’s behavior,” or, “Your child is getting into other kids’ faces” or “having trouble settling down.” A child who seems fine at home may have problems surface in more structured environments that require her to sit still, to control her behavior, to listen or to focus attention on a project. It’s in these types of environments that the differences between an inquisitive, active youngster and a child with ADHD may first become noticeable.
Three differences that may suggest a problem
The signs of an ADHD disorder fall into three main categories of behavior: inattention, hyperactivity and impulsivity. I’ll give you some examples of each, but keep in mind that simply noticing some of these behaviors does not necessarily mean that your child has ADHD:
Inattention: This has to do with being unable to sustain attention on a task. For a child with ADHD, focusing attention is especially hard when there are other distractions, such as noise, talking, other kids doing things, or people coming and going. The youngster may do well at home, but when she goes out into a more stimulating social situation, she may appear more inattentive. In school, a child with ADHD may show inattention by not listening or by having difficulty organizing information. As she progresses academically, inattention may result in making careless mistakes, losing things or being forgetful.
Hyperactivity: Signs of hyperactivity may include squirming, inability to sit still, fidgeting, getting in and out of an assigned seat, difficulty playing quietly, getting into other people’s business, always being on the go, talking a lot, and expressing feelings of restlessness — just having to move.
Impulsivity: A child may show impulsive behavior by blurting out answers in class, keeping his hand raised, being unable to wait until the teacher calls on him, having difficulty waiting his turn, interrupting, intruding, and doing things without thinking about the consequences — like mouthing off to a teacher.
Again, any one of these things may be a normal part of human behavior; the disorder has to do with a collection of problems that occur when a child has difficulty adapting to an environment.
An evaluation opens the door for support
Some parents are afraid to have their children evaluated because of the stigma surrounding ADHD. But I try to remind them that everybody is different — ADHD is just one of millions of human differences. If you can identify ADHD early and give a youngster the support she needs from an earlier age, then you make it easier for her to minimize problems throughout her life and to focus, instead, on exploring her own unique talents.
If your daughter is diagnosed with ADHD, your support will be very important. ADHD, in and of itself, is just a phenomenon. But youngsters who grow up with ADHD can end up having other associated problems. We call these “co-morbid” problems — they aren’t part of the disorder itself, but they often go along with it. It’s these co-morbid problems that pose the biggest hurdles — far more than the disorder itself — for a youngster as she struggles to grow up and learn and be happy.
One co-morbid problem, for example, is that kids with ADHD tend to have trouble adapting to educational environments. Because of that, they may not do well in school, even though they may be very bright. They tend to get in trouble, because they’re in and out of their seat a lot. They may generate negative perceptions: for example, classmates may think of them as annoying, or inexperienced teachers may perceive them as purposely challenging their authority. Along with these educational challenges, there’s also a higher prevalence of absolute learning disorders among people with ADHD. So school can be tough for them.
As these kids get older, they may be less and less successful. By high school, kids with ADHD have a higher than average dropout rate. As they grow older, they have a higher risk of impulsive disorders, so they may do things without using good judgment, like sticking a candy bar in their pocket at the store, or experimenting with tobacco, drugs and alcohol at an earlier age. They have a higher tendency to develop drug problems.
Because other kids don’t always understand or tolerate their differences, their self-esteem may suffer, which can lead to challenges with social relationships and a higher rate of depression. Depending on which study you look at, approximately 25 to 50 percent of kids with ADHD have co-morbid depressive disorders. That doesn’t mean they are suicidal, but they can be pretty unhappy.
I want to underline the word “may” in all of the above. None of these problems is automatic. But they do occur more often in kids with ADHD, and studies show that they begin very early — you can identify kids who are struggling with ADHD-related problems as early as their kindergarten year. This just emphasizes the importance of identifying the disorder early in life.
What’s involved in an evaluation
A thorough evaluation of your daughter will involve the following:
A clinical interview of the child by a trained professional
A complete family history, because ADHD tends to run in families
A thorough history of your daughter’s health
A full physical examination to rule out any other disorder that could be causing changes in her attention and behavior
Selective laboratory evaluation
Observing your daughter in more than one environment — either directly, such as watching her in school for a while, or indirectly, by talking to a teacher or a coach — to get a clear, composite picture of her behavior
I want to underscore a couple of things. First, at this time, there is no blood test or brain scan that can diagnose this disorder. That’s a common and very expensive misconception.
Second, it’s important to understand that diagnosing problems with children is an imperfect science. Kids grow and change, and they can surprise us down the road.
Living with the diagnosis
Kids with ADHD do face certain challenges, but everybody has challenges of one sort or another — this is just one set of challenges. ADHD does not generate a bad prognosis. It just means that, to be able to provide for your youngster, you have to be able to support her fully. That’s the challenge. It’s really just a question of understanding your child.
Because so many of the challenges of ADHD manifest in the classroom, one of the most important things a parent can do is to work closely with the child’s school. Make sure that her teachers understand her learning style. Get involved each year in planning her classroom placement and teacher choices. The school environment can pose some of the toughest and most painful struggles, both socially and academically, for children with ADHD; a parent’s early and continual advocacy can make a big difference.
If I can close with a pitch, it’s this: Look into Providence Health & Services’s Gately Academy. Gately is a wonderful, supportive school for youngsters (grades 5–8) with ADHD and learning challenges. It is probably the best school of its kind in the nation. I heartily encourage families whose kids are struggling in school to look into this program.
I hope you’ll consider an evaluation for your daughter if it seems appropriate. If the results show that she doesn’t have ADHD, what have you lost? Regardless of the outcome, you will have gained a better understanding of your daughter — and it’s always good to know as much as we can about our kids.
