Attention Problems: Is it ADHD or something else?
The majority of children referred for an evaluation have some form of attention problems. This might include difficulty with any of the following:
- Paying attention when bored or challenged (but not when they do things they enjoy)
- Listening to directions
- Daydreaming or mind wandering
- Following multi-step directions
- Staying on task independently
- Sustaining effort or persisting with tasks or work
- Being easily distracted
Some also have trouble with behavior regulation, such as with the following:
- Sitting still when needed, fidgeting, squirming
- Making careless errors or rushing
- Being messy or disorganized, and easily losing things
- Interrupting others, talking too much or at the wrong time
- High activity level, running or climbing when not appropriate
At first glance, any combination of these symptoms can suggest the possibility of an attention deficit hyperactivity disorder or ADHD, with or without hyperactivity/impulsivity. In fact, children commonly get referred for an ADHD evaluation, rather than the symptoms themselves. This can be a problem because ADHD is not the only reason for attention problems.
The CDC reports that 2% of children ages 2-5 years, 10% of children 6-11 years, and 13% of teens 12-17 years are diagnosed with ADHD in the United States. Read more at: https://www.cdc.gov/ncbddd/adhd/data.html
ADHD is even more common in children with a medical diagnosis that affects the developing brain, such as epilepsy, cerebral palsy, congenital heart disease, genetic disorders, and others.
BUT problems regulating attention can occur for other reasons.
Some of the following can cause or contribute to problems with attention:
- Academics or learning difficulties
- Bullying or peer relationships
- Abuse, neglect, or trauma
- Language delays
- Hearing problems
- Disrupted or poor sleep
Let me explain with a few fictitious patient examples:
Attention and Reading Problems
Harry is a 4th grade student who hates to read. He feels embarrassed and frustrated that school is so hard. Harry does not currently receive any extra help at school. Reading comprehension issues are now affecting math, especially word problems. And he does not understand the information he must read for Science and History classes. Harry thinks he is “stupid”, and he doesn’t want anyone to know reading is so difficult. So he gives up and doesn’t do his work. It’s easier to not try than to try and fail. He is off task during class and easily distracted. His teacher notices that he has incomplete work and missing assignments. Harry is falling behind. Paying attention is getting more challenging.
Harry is referred for an evaluation by his pediatrician because he is not paying attention in class, he is not doing his work, and he is acting out. His teachers and family believe that if he would pay attention, do his work, and try harder, reading would be okay.
A neuropsychological evaluation reveals that Harry has Dyslexia, also called a learning disability with impairments in reading. After he receives this diagnosis, a plan is put into place at school and he starts to receive small group help in reading. He also starts tutoring. Attention and effort problems nearly resolve within a year. Harry does not have ADHD.
Attention and Language Problems
Sam is a 5 year old girl who is repeating Pre-Kindergarten due to slow learning. She was adopted at 6 months old and her early medical/family history is unknown. Her teachers are complaining that she is daydreaming, zoning out, has trouble following directions, and she is very shy with peers. Her parents describe her as a sensitive and introverted girl. She is referred for an evaluation by her school team.
Neuropsychological testing reveals that Sam has a language disorder and she needs speech/language therapy services. She also has a lot of anxiety, especially in groups or when she must talk to strangers. As her language improves, Sam’s attention problems improve. Her parents start working with a therapist to help build coping strategies for the anxiety. Sam does not have ADHD.
Attention and Sleep Problems
Kathy is a 12 year old girl with a long history of sleep problems. She has always struggled to fall asleep at night, and she is irritable and moody upon waking for school. She snores in her sleep. Kathy was also born with congenital heart disease that required surgery as an infant. She has a long history of respiratory illnesses. Kathy gets very tired during the day and often takes a short nap after school. Sometimes she falls asleep while riding in the car. Her teachers and family have noticed that she cannot follow directions that include more than one step. She is easily distracted and needs redirection to stay on task. Kathy struggles to complete her homework. She is referred by an evaluation by her cardiologist.
Neuropsychological testing reveals a high level of attention and executive functioning problems, along with concerns about memory. However, the neuropsychologist knows that it’s possible that these concerns are related to inadequate sleep. Before these symptoms can be fully understood, we need to address sleep issues.
Kathy is referred for a sleep study and she is diagnosed with sleep apnea, as well as enlarged tonsils and adenoids. Kathy requires surgery to remove her tonsils and adenoids and this improves her sleep significantly. Her attention also improves. But problems do not entirely resolve. Mild attention issues persist at school and with homework despite extra help. A follow up neuropsychological evaluation shows that she does meet criteria for mild ADHD, inattentive subtype.
In summary, attention problems can be a symptom of other things. A clinician must thoroughly consider causes and related factors before giving a diagnosis and recommending treatment.
As a parallel, think of headaches as a symptom with many causes. Headaches can occur for a lot of reasons: stress, dehydration, hunger, poor sleep, allergies, sinus infections, and in rare cases, a medical diagnosis that needs to be treated. Headaches that occur rarely are not a concern. But headaches that occur often need to be explored by the medical team, and that includes consideration of multiple causes before treatment is prescribed.
Attention Problems Can Overlap with Other Symptoms
A final note about attention problems is that overlapping or co-occurring symptoms can create more complexity for diagnosis and treatment. Attention problems rarely occur by themselves.
Children with a diagnosis of ADHD also tend to meet criteria for other diagnoses. According to the CDC, 52% of children with ADHD are also diagnosed with a behavior or conduct problem, 33% with anxiety, 17% with depression, 14% with autism, and 1% with Tourette Syndrome: https://www.cdc.gov/ncbddd/adhd/data.html Another trusted resource reports that among those diagnosed with ADHD, 12% have speech problems and 45% have a learning disability: https://chadd.org/about-adhd/co-occuring-conditions/
If your child is exhibiting attention problems, and ESPECIALLY IF YOUR CHILD HAS A MEDICAL DIAGNOSIS, ask your pediatrician, medical specialist, or school team for a referral to complete a full evaluation of your child.
Sometimes it is recommended to complete only teacher and parent rating scales. But this really isn’t sufficient for some children. The clinician who evaluates your child needs to measure the extent of the attention problems, across which settings they occur, which areas they may be affecting (e.g., memory, math, reading), whether other areas are a concern (e.g., executive functioning, academics), and if there are potential causes that should be addressed first.
IF YOU THINK YOUR CHILD WOULD BENEFIT FROM A NEURODEVELOPMENTAL EVALUATION DUE TO CONCERNS ABOUT ATTENTION PROBLEMS, CONTACT US TO LEARN MORE: https://pedneurocenter.com/contact/
