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What Are the Factors That Can Rule Out the Presence of ADHD?

According to the American Psychiatric Association’s DSM-IV, ADHD is a disorder that first presents in childhood, usually seen before the age of seven in a child. It is characterized by developmentally inappropriate levels of inattention, distractibility, impulsivity and/or hyperactivity. The impairment is realized in one or more major areas of life, usually at home, in the classroom, in social interactions, in workplaces, or in other areas of adaptive functioning. The list of symptoms then outlines a variety of interferences that can be presented with ADHD that can easily disrupt any child’s performance, learning, and behavior. Curiously, the symptom description does not specify the amount or severity of the symptoms, except that the interference must exceed the normal developmental levels evident in children. As a result, parents and professionals face the challenge of distinguishing excessive ADHD symptoms from those that are normal for a child’s specific developmental level.

It is good practice for an ADHD assessment to include collecting several types of information from a variety of sources. A simultaneous effort should be made to rule out as many alternative disorders that may present with similar attention and performance difficulties. This could include, but is not limited to, impairments seen in learning disabilities, developmental delays in young children, sensory regulation dysfunctions, mood disorders and depression, anxiety , as well as low baseline motivational effort. These alternative disturbances will easily and predictably interfere with a child’s optimal performance and learning in the classroom. However, distinguishing these interferences in the classroom remains a challenge for teachers and professionals, especially when attention deficits are characteristic of a variety of disruptive disorders.

As a child psychologist, I realize this professional challenge every time I undertake a new ADHD assessment for a presented child. I will then lament the lack of an accurate and objective assessment of ADHD that can effectively distinguish inattention from other interfering conditions. Occasionally, I will have the chance to learn crucial information about the presenting child that I have come to recognize as ADHD “outsiders”. Although these exclusion factors are not necessarily absolute in their ability to distinguish, they generally increase my potential for an accurate diagnosis of ADHD.

The age of onset is one of these differential diagnostic factors. The presence of ADHD can be recognized at least by the age of seven in a child. Typically, at this age, a child has developed in several areas, including cognitive, social, emotional, behavioral, and physical, in a way that enables them to meet the majority of routine expectations for that student in the classroom. The same cannot be said for five-year-olds who may still be developing the ability to self-regulate their attention and activity level to facilitate learning in the kindergarten classroom. My comfort level in attempting ADHD assessments is significantly improved when the identified child is at least six years old. At this chronological age, I can more accurately use my clinical expertise and judgment to determine when activity and inattention are observed beyond expected developmental levels.

I use a related exclusion factor whenever I assess slightly older students. Recently I assessed a fifth grade girl who was referred because of her poor academic performance and difficulty in assisting specifically in math. His lack of symptoms of inattention or preoccupation during the early elementary years casts serious doubt on a possible diagnosis of ADHD. Not only were there no previous ADHD issues, but this student also had excellent grades and performance in all previous elementary years. Unfortunately, her performance in mathematics began to deteriorate as she progressed through a program involving greater abstraction in concepts and problem solving. In my view, increased academic challenge will predictably generate higher levels of inattention and low task engagement in students and cannot be recognized as the neurological impairment of ADHD.

Exclusion factors are key when examining a child with ADHD. Specifically, children must show signs of ADHD by the age of seven and the symptoms cannot be confused with a child’s developmental delay. ADHD symptom interference should be recognized by teachers in every elementary grade without fail, and the interference should be highlighted in every school area. This suggests that an ADHD student will show some amount of impaired attention in all subjects and activities. And finally, ADHD interference will not suddenly present itself in fourth or fifth graders corresponding with the increasing demands of the curriculum in elementary school. In the current example, a student who demonstrates a developmentally appropriate ability to maintain engagement in a task early in elementary school will not lose that ability in later grades. Specifically, learning weaknesses or motivational issues are frequently present in students struggling with progressive academic demands in the classroom. These students will almost certainly find it difficult to stay focused and attentive to the work assigned to them.

These exclusion factors are certainly helpful in arriving at an accurate diagnosis of ADHD in any child or student. Although these exclusion factors can reasonably rule out the diagnosis of ADHD, these factors are largely suggestive rather than absolute in making this diagnostic determination. The non-specific descriptive criteria for ADHD (DSM-IV) combined with the absence of objective tests for ADHD will continue to set the stage for meaningful clinical judgment contributing to its final diagnosis. Although there are many factors and indicators that will support an accurate diagnosis of ADHD, there are many presentation variants of this disorder that must be considered in diagnosing or excluding this disorder.

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