ADHD Diagnoses in Children

There is nothing harder in parenting than being told there is something of concern with our child. A health concern, a developmental concern, a socioemotional concern. We want the path for our children to be as smooth as possible. Of course, it isn’t always smooth. When the bumps appear, sometimes it’s clear how to deal with them. We have a sense of what to do when our kids are sick with normal childhood illness, for example. But there are other cases in which the struggles of these concerns are compounded by a feeling that we do not know how to handle them. One clear example of this, for me, is the diagnosis of attention-deficit/hyperactivity disorder (ADHD) or attention deficit disorder (ADD). Many parents write to me about this. Their questions are often similar: My child’s teacher said they are worried about ADHD; how worried should I be? Or My child was diagnosed with ADHD — what do we do? I’m overwhelmed by the treatment options. This problem is hard, in part because our data is fairly limited. One thing we know clearly is that diagnoses of ADD/ADHD have increased over the past several decades — from 6.1% in 1997-1998 to 10.2% by 2016. To see this in more granular detail, I pulled data from the CDC’s National Health Interview Survey for 2010, 2016, and 2021 and graphed ADD/ADHD diagnoses (they are combined in the data) by age. There is some evidence of an increase in the more recent years here, largely in the older age groups. Diagnoses among younger children are still quite uncommon. So diagnoses have increased over time. What is less clear is why. It seems very likely that at least some — possibly all — of the increase is driven by changes in diagnosis. This doesn’t necessarily mean overdiagnosis; greater awareness could lead to more diagnosis because a condition was previously underdiagnosed. It is also possible that some aspect of the environment has increased the prevalence of the condition. Heritability is thought to be about 75%, leaving some share of variation to be due to possibly modifiable factors. (For example: as I have discussed elsewhere, ADHD diagnoses are more likely in kids who are younger for their grade. I’ve also written about the question of Tylenol in pregnancy and this diagnosis or others.) Even more complex is the question of what to do, as a parent, in response to this diagnosis, or a suggestion of a diagnosis. There isn’t an obvious data-oriented path. Instead, the right path requires a thoughtful, probably slow, approach to figuring out what works for your family. I wanted to give a sense of how to approach these discussions, but it is very much outside my wheelhouse. So I’m delighted that Erin O’Connor agreed to weigh in on this topic, framed by a few specific questions from you. Reader questions on ADHD Erin O’Connor is a developmental psychologist, a professor in teaching and learning at New York University’s Steinhardt School of Culture, Education, and Human Development, and the program leader for Early Childhood Education. She is also the co-host of the parenting podcast Parenting Understood, and chief of education at the parenting advisory company Cooper. Her research focuses on development within the context of social interactions. My child is being tested for ADHD, and I’m worried about her being put on medication. I know it could help, but I also worry about side effects. Is this something that gets overdiagnosed and overmedicated? What questions should we be asking to ensure she’s being treated well? I worry it will change her personality and her spirit, but I also struggle with all the behavior challenges we consistently come up against. Do I just need to try harder as a parent? Is this something we could have solved by being stricter or something else? I worry that it’s a reflection on bad parenting as much as I worry about my child. Thanks so much. —Seeking the Best for My Kid Erin: A common theme among all parents, and especially those of children with ADD/ADHD, is concern that their parenting caused their children to experience challenges. While there is no valid research showing that parenting in any way causes ADHD, there is extensive research that ADHD is a neurological condition and that children with ADHD can benefit immensely from environmental support. For example, studies using the gold-standard research design of a randomized control trial have found that children with ADD/ADHD whose parents receive education around how to support them with their executive functioning skills showed lower levels of behavior challenges than those whose parents did not. Asking questions of your child’s teacher and physician is very important as you determine the best ways to support her. An effective diagnosis of ADD/ADHD involves compiling a complete picture of the child in the home and school settings. For a child to be diagnosed with ADD/ADHD they have to show symptomatic behaviors, such as difficulty completing tasks and/or hyperactivity, across both settings. Therefore, when thinking about questions to ask, it would be helpful to check in with your child’s teacher and see if the observed behavior is similar to what you’re observing at home. You’ll also want to ask if the behavior is consistent throughout the day or if it’s more prevalent at certain times of day (for example, in the afternoon when your child is tired) and whether the behavior seems more extreme than that of their peers. Questions for your child’s physician may focus more on examining other factors that may be at the root of some of your child’s behaviors. Some medical conditions can cause symptoms similar to ADD/ADHD, such as hyperthyroidism. So you may want to ask your physician if they have explored other potential sources for some of your child’s behavior. You will also want to ask your physician what type of medication they are thinking of prescribing and whether your child will be taking it every day. Some children benefit from taking some stimulants, for example, only during the school day, while other children benefit from more frequent and longer-lasting medications. Diagnosis of ADD/ADHD also requires standardized testing around attention and behavior, usually conducted by a neuropsychologist. When meeting with a neuropsychologist, ask them what tests they are conducting and in what setting. An important point to note in regard to testing is that many children with ADD/ADHD often perform well on tests in new settings, as the stimulus of a new environment can help them focus. You may, therefore, ask if they will also be observing your child at school or another more familiar setting if testing is conducted in their office. In addition to asking your child’s teacher and physician questions, you will want to put together some information from your interactions with your child. Diagnosis requires that there is a history of behaviors over time. Compiling a list for yourself of behaviors that concern you, when you first noticed them, and where and how often they occur is an important part of the process. Many parents report that one of the more challenging parts of supporting their child with ADD/ADHD is the decision around whether or not to medicate. Medication has been proven very safe and effective in the treatment of ADD/ADHD symptoms. There are multiple medications that can be used, but a commonality among all of them is that they help with focusing. As Edward Hallowell and John Ratey note in their well-known book on ADD/ADHD, Driven to Distraction, medication acts as “internal eyeglasses,” helping the brain filter out competing stimuli or distractions and focus on one task at a time. Research does not show that medications change a child’s personality and interests. However, they can have some side effects. You can discuss and manage these in partnership with your doctor and child. You raise another important question regarding the prevalence of diagnosis and whether ADD/ADHD is potentially being overdiagnosed. As Emily noted at the top, rates of diagnosis, especially in North America, have gone up precipitously in the past two decades. Such an increase has led many people to question whether some of this may reflect misdiagnosis. While that is always a possibility, as we learn more about ADD/ADHD and how children (and adults) respond to treatment, and the often high co-occurrence of ADD/ADHD with learning differences, experts are beginning to think it may actually be underdiagnosed. Underdiagnosis may be of special concern among girls and children of color. My daughter is in pre-K. At our last check-in with her teachers, they suggested that she is somewhat behind her peers in being able to complete multi-step processes, pay attention during circle time, and keep track of her belongings. They did agree that there’s huge variation in kids at this stage, but they also noted that this is an area of her development to closely watch. I’m left wondering how young is too young to start thinking about learning differences. On one hand, 4 seems very young to know if a kid needs support or is just a bit immature (or maybe constitutionally absent-minded, like at least one of her parents). On the other hand, if there are early interventions that can help if she could use it, and wouldn’t hurt or create other future challenges if she doesn’t, then it seems like trying those as early as possible would make sense. —Katie Erin: Getting feedback around behaviors like these, which involve such wide variation at a young age, is tricky. As you note, you want to support your child but also don’t want to jump to any conclusions too quickly. A note before we delve more into your questions. We often think of ADD/ADHD as a learning difference. But ADD/ADHD is a neurological condition, in which rates of learning differences are higher than among the general population. ADD can occur without hyperactivity (ADD) or with hyperactivity (ADHD), as well as primarily involve inattentive (difficulty completing tasks, loses things) and/or hyperactive/impulsive behaviors (fidgeting, extremely active). Generally, learning and many neurological differences, especially ADD/ADHD, are not diagnosed until a child has been in school for a few years. Early on there can be some signs of learning differences, including communicating less often or differently than their same-age peers, early fine or gross motor differences, thinking through and solving problems in ways that vary from their peers, and challenges interacting with peers. That being said, so much of what you’re describing in your pre-K daughter is common, and that’s because at this age, it can be hard to decipher between developing executive functioning skills and other factors (like learning differences). Before considering whether your daughter does, in fact, have a learning difference, let’s lay out what executive function skills are and why they’re important. Executive function skills are skills housed in your prefrontal cortex and consist of three components: cognitive flexibility, working memory, and inhibitory control. In other words, executive function skills allow us to successfully get things done in life (focus our attention on something, think flexibly, remember rules, etc.). Despite being such important skills, we aren’t born with these. Rather, they develop over time. That’s why a case like your daughter’s isn’t clear-cut, because while your daughter could have a learning difference, she’s also at an age where her executive function skills are developing, and some children (and adults) have trouble with executive function skills. This looks different in everyone. In fact, the signs of executive function challenges can present very similarly to ADD/ADHD (which makes sense, because ADHD is directly related to issues with executive function). All this is to say, if your child does have issues with executive function, it does not necessarily mean your child has a learning difference or ADHD. Regardless of an ADD/ADHD or learning difference diagnosis, as a parent, you can support executive function skills at home. These recommendations are relevant for all parents, regardless of learning differences, especially as these skills are continuing to develop in young children. You can help your child stay on task by using timers to support them. For younger kids (under 7), make sure to use a visual timer, as their understanding of time isn’t solidified yet. If you’re giving multi-step directions, be as detailed as possible. Instead of “Get ready for school,” you can break the task up into detailed and manageable steps. For example, “First, brush your teeth. Next, pick out your clothes.” You can also ask your child to repeat directions as you list them. Routines can also be critical for children. Their brains are wired to detect patterns, so if they know what to expect, they’re more likely to be able to get it done. Consider establishing a strong routine around going to sleep and getting ready for school. Aside from understanding that there’s a ton of development happening at this age (brain development is fast-tracked in the first five years of life), there are questions you can ask and steps you can take before beginning the evaluation process. Check in with your daughter’s teacher. As much information as you can gather is helpful. Is her focus and ability to complete multi-step directions consistent throughout the day and across specialties (for example, is this behavior seen in gym too)? Regarding her belongings, can you ask for concrete examples? Make sure to ask your daughter’s teacher what interventions they’ve put in place to support your child in the classroom around organization and multi-step directions. For example, is there a visual to go along with the directions? How you respond to your child’s challenges has a lot to do with you and your temperament. Of course you want to support your child in the best possible way, but the way in which you act is related to your temperament too. If you find yourself antsy for answers, you may be likely to search for those earlier through interventions. If you’re more comfortable with a waiting game, there can be value in waiting and watching. My 5½-year-old was just diagnosed with ADD, and I’m terrified of making the wrong decision on medicating him or not. —Caitlin Erin: Unfortunately, there is no clear-cut answer as to when the best age is to start medication for ADD/ADHD. The American Academy of Pediatrics recommends that a child with ADD over 5 should start taking medication and receive behavioral support as soon as they are diagnosed, while a child under 5 should start with behavioral supports before taking medication. Medication is often part of the treatment plan, but education, behavioral modification, and coaching are all important and necessary parts of supporting children and adults with ADD/ADHD as well.

ADHD Diagnoses in Children

Answering your questions with Erin O’Connor, EdD

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