This year, I started the process of becoming an ADHD certified rehabilitation services provider (ADHD-RSP). That means a bunch of certification courses on the disorder, the latest research, meds, and management. Let me just say that the lecture content has been quite eye-opening. ADHD is way more complex than I previously thought and it’s generally misunderstood, even with the decades of research and the ever-growing amount of information available these days. So for the next two weeks, I’ll be sharing what I’ve learned and hope that it will shed some light on what ADHD is, how it affects our kids, and effective ways to address it. Today, we’re breaking down the disorder; from its name, misconceptions, and how it’s diagnosed.

ADHD (attention deficit hyperactivity disorder) is a neurobiological developmental disorder characterized by continued patterns of inattention, hyperactivity, and impulsivity that interfere with daily functioning and development. It is an impairment of the brain’s executive functions that involve working memory, cognitive flexibility, and self-control. It has been described as “having a racecar brain outfitted with bicycle breaks.”    

According to the CDC, it is the most commonly diagnosed neurobehavioral condition in children under the age of 18. A 2022 national survey reported an estimated 7 million (11.4%) U.S. children aged 3–17 years have been diagnosed with ADHD.

• About 6 in 10 children have moderate or severe ADHD
• Boys (15%) are more likely to be diagnosed than girls (8%)
• Children with both ADHD and another co-occurring condition (anxiety, depression, learning disability, conduct problems, etc.) more often have severe ADHD than children with ADHD without co-occurring conditions
• At least 50% of children retain ADHD symptoms into adulthood

Even though it is common/mainstream now, ADHD still carries misconceptions that prevent the diagnosis from being taken seriously. For instance, all kids at one point or another are hyper, inattentive, distracted, and highly emotional. If that’s the case, isn’t the ADHD label essentially just classifying childhood? Additionally, who HASN’T tuned out of a conversation, made an impulsive decision, or forgot to do something? Because ADHD describes blips in attention and impulsivity, it doesn’t get much concern or recognition that it truly is a dysfunction that affects every aspect of a person’s life and well-being.

Some misconceptions include:

• You can’t have ADHD if you get good grades. ADHD has nothing to do with intelligence, but everything to do with executive functions that include skills like time management and planning/organizing. So while your child can ace a math quiz without a problem, it may be harder for them to get ready for school in a timely manner or remember to give you a field trip permission slip to sign. Any mom will tell you that this can be just as frustrating as academic performance.
  
  
• People with ADHD are lazy and need to try harder. Symptoms of ADHD may manifest as disinterest, disorganization, or lack of motivation to non-preferred tasks (like cleaning their room or doing homework) that require sustained attention and effort to initiate and complete.
  
  
• Poor parenting causes ADHD. Currently, there is no credible evidence that social factors, such as parenting or screen time, can lead to ADHD. Because the impulsive symptoms of ADHD may present as rude and inappropriate behavior, parents oftentimes shoulder the blame, shame, and judgement of their kid’s actions.
  
  
• Having ADHD isn’t that serious. Sure, it’s not a life-threatening illness, but ADHD can hinder a person’s ability to effectively perform their daily responsibilities. Those everyday struggles can be debilitating, especially for kids and school. Common experiences include difficulty keeping up with their peers academically, frequent reprimands for their behavior, and receiving poor grades for incomplete assignments. These frequent situations can result in having low self-esteem, self-confidence, and anxiety.
  
  
• ADHD isn’t real. Research has found differences between ADHD and typical brains, such as brain structures, neurotransmitter levels, and neural pathways (more on this next post).

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What’s in a Name?

ADHD has had multiple name changes since its first official nomenclature of hyperkinetic reaction of childhood and adolescence in 1968. While the term ADD (attention deficit disorder) is well known to millennials, the current DSM-V label is ADHD and has been since 1987. However, many researchers and experts feel that the name ADHD is no longer an accurate term in describing the disorder and suggest that altering its name will give it more credibility.

Breaking down its current name, “attention deficit” implies that people with ADHD can’t pay attention; that is inaccurate. People with ADHD can pay attention and focus, especially to things they find interesting and enjoyable. The problem arises when that hyperfocus consumes their time to a maladaptive degree. If anything, those with ADHD have trouble regulating their attention to other necessary tasks/activities. An interesting find in 2001 noted that people with ADHD have an active default mode network (a wandering brain) compared to their peers. Typically, this default mode decreases when we are engaged in tasks that require conscious attention; with ADHD, it remains active no matter what. This explains why they seem to drift away into their thoughts or go completely off-topic rather than focus on the task at hand.

Another questionable aspect of the name is lumping “attention deficit” and “hyperactivity” together, suggesting that those diagnosed with ADHD present with both behaviors. While that may be true for some individuals, it doesn’t apply to all that are labeled with the disorder. In other words, many people with inattention do not have hyperactivity and some people with hyperactivity or impulsivity do not have inattention problems.

The Three Faces of ADHD

ADHD has three different presentations that can have varying degrees of severity:

Inattentive

This presentation is typically characterized by difficulties with attention and organization (it’s pretty much the ADD we grew up knowing in the 80s). Digging deeper, the inattention is due to the impairment of executive attention and functioning, the skills needed to plan for and reach future goals. Because their working memory is impaired, those with this type of ADHD are tied to the present moment because their mental representation about time is not strong enough to guide their actions towards the future.

Symptoms of inattentive ADHD involve:

• Poor working memory, resulting in losing items or forgetting to complete a task/assignment
• Inadequate persistence towards goals and tasks; cannot sustain attention/action over time
• Becoming easily distracted, either from their environment or their own thoughts
• Difficulties re-engaging to tasks following disruptions, resulting in messy/disorganized work
• Faulty metacognition, causing difficulties in flexible thinking, problem solving, and self-awareness

Hyperactive/Impulsive

This form of ADHD is known for high-energy, restless, and impulsive behavior. This is due to a deficiency in executive inhibition (self-control). These symptoms include:

• Poor motor inhibition – ex: frequently fidgeting
• Poor verbal inhibition – ex: excessively talking
• Impulsive cognition – not thinking through decisions, chaotic and disorganized thinking
• Impulsive motivation – seeking instant gratification
• Emotional dysregulation – rational behind emotion is appropriate, but the intensity is not; emotionally immature

Combined – the mix of both hyperactive/impulsive and inattentive

It’s important to note that everyone falls along a bell curve of executive functions. ADHD represents one extreme end of that continuum. While these symptoms just sound like kids being kids, it becomes a problem if the behaviors are frequent, persistent for at least for 6 months, and are affecting their function across multiple settings (home, school, community, etc.) So even if your child displays limited attention, is mad talkative, and throws tantrums, it’s not considered a problem if it doesn’t hinder their academic performance, household responsibilities, or extracurriculars. It can for sure be annoying, but it’s not enough to mark it as ADHD.

Over, Under, and Misdiagnosed

Even though the DSM-V outlines the criteria to make an ADHD diagnosis, it doesn’t mean that it’s being followed as intended. A 2021 study of 50 pediatric practices found that only an estimated 50% of doctors used diagnostic guidelines from at least 2 sources and across 2 settings to make their ADHD diagnosis, but 93% prescribed medication to treat the condition. This means that children labeled ADHD may be misdiagnosed and overtreated.

Issues that could affect the accuracy of an ADHD diagnosis include:

• Sleep issues that can affect concentration, recall, and following directions
• Anxiety, as they seem tuned out or preoccupied because they’re distracted by worry
• Depression, having little energy to start or complete tasks
• Trauma/stress, as the symptoms are similar
• Learning difficulties, like dyslexia, dyscalculia, auditory processing disorder, or sensory processing challenges
• Immaturity. Researchers have found that typical immaturity seen in children who are young for their grade level may be misdiagnosed with ADHD; additionally, children who have higher levels of intelligence may also be misdiagnosed because they grow bored in classes that they feel are too easy for them

Despite the notion that ADHD is over-diagnosed in children, girls and children of color are still underdiagnosed. For instance, a 2019 study suggests that girls are more likely to experience inattentive symptoms of ADHD than exhibit hyperactive/impulsive behaviors. Because these behaviors don’t scream “Hi! I have a problem!”, girls fly under the radar until much later. Research has also found that Asian, Black, and Hispanic kids are less likely to receive an ADHD diagnosis compared to their white peers.

ADHD is a real phenomenon, but what causes it and what makes the ADHD brain different from the rest? Stay tuned for part 2.  

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More from our Child(ish) Advice Course Notes series

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