ADHD: The Great Imposter

If I had kept record over the many years I have been in practice, I would imagine that something over 50% of the children being referred were sent to me for neuropsychological evaluation with a question of potential Attention-Deficit/Hyperactivity Disorder (ADHD). Truly, many of us can cite instances of poor focus, distractibility, restlessness, and even impulsivity. On our best days, these may not be problematic, but on days in which we are a bit under the weather, overly tired, or stressed out by a particular circumstance, symptoms that appear consistent with ADHD may be quite apparent. That said, there are many reasons children, adolescents, and even adults may display symptoms that are seemingly characteristic of ADHD, but are actually due to other issues, including medical or psychiatric causes.

Problematic sleep is one of the most basic culprits leading to challenges with attention and behavioral regulation. In fact, there has been research completed with children and adolescents previously diagnosed with ADHD, some of which were found to have sleep-related breathing disorders (i.e., sleep apnea). A large number of those children who were then treated for their sleep-related breathing disorders no longer met criteria for ADHD. Chances are, we can all think back to a time in which sleep evaded us for any number of reasons, after which we were not likely on top of our game. That said, addressing sleep hygiene should be the first thing to address as a potential contributor to ADHD-like symptoms.

Much more rare than sleep-related issues, children with a particular type of seizure may also appear inattentive and unfocused, when in fact their “daydreaming” or “staring off into space” is actually a generalized seizure known as an absence seizure. These are more difficult to identify and may often go unnoticed for some time, perhaps even into middle to later elementary school years when the child is able to identify that they seem to be missing brief chunks of instruction or activity. Therefore, if parents or teachers are noticing periods of time in which a child is unresponsive and does not alert to their name being called or even startling noises for a period usually less than a minute, then additional conversation with a pediatrician (to start), and perhaps a neurologist, may be warranted.

Learning-related difficulties and psychiatric disorders may also manifest as ADHD. Children who struggle with academic subjects may cease to engage during instruction, group work, or independent tasks given their difficulty with the respective material. Consider this scenario: you are asked to sit in on an advanced graduate level course covering a topic that is completely foreign to you. You try for some time to make sense of the material, but as the professor continues to demand more and your fellow students are apparently making sense of the information and completing tasks with ease, you realize that you are unable to do so. How long would you keep trying? Would you ask for help, or would you perhaps start to check out just because you do not see the value in continuing to try? This happens for many children who have a learning disorder but who have not yet been properly identified. While they may also have ADHD (learning disorders and ADHD commonly occur together), treating the child as if they have a singular diagnosis of ADHD is not going to address the root of their learning issue.

Finally, many parents do not recognize the level of internal distress, frustration, or anxiety their child in experiencing. This occurs primarily because the externalizing behaviors of inattention, poor concentration, difficulty making decisions, restlessness, and fatigue are so easily attributable to what seems to be ADHD. However, the above noted symptoms are also symptomatic of anxiety and/or depression. Because the popular notion of depression is that of someone who appears tremendously sad all the time, depression may be missed in children and adolescents; in fact, irritability is actually the more common manifestation of depression, especially for those under 18 years of age. Additionally, children with anxiety may be hypervigilant to their surroundings, have repetitive and bothersome thoughts streaming through their mind, and be excessively restless; from an observer’s perspective, this appears quite like ADHD. That said, only a thorough neuropsychological evaluation can really tease out the etiology for such similar symptoms.

While the availability of information through internet resources and even social media usually assists individuals in seeking appropriate medical or mental health care, it may also route them in the wrong direction and thus delay intervention. That said, a comprehensive neuropsychological evaluation, which will screen for all of these issues and refer to the appropriate medical provider (when appropriate), will likely result in identifying the core issues and providing the most applicable recommendations for intervention. Early identification and intervention is best, but correct identification at any age can still provide opportunities for development and change in the positive direction.


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