Overdiagnosis is a major problem with ADHD

How can a parent tell if a child has attention deficit hyperactivity disorder (ADHD)? A child who is in constant motion and cannot settle down to pay more than fleeting attention to any task should be evaluated, as should a child who always seems restless, fidgety or too easily distracted.

One telltale sign -- especially if the condition has persisted unrecognized and untreated -- is that the child no longer feels accepted, either by peers, at school or even at home.

Overdiagnosis is a major problem with ADHD. Many children go through periods of overactivity. Anxious children are likely to be hyperactive and to have short attention spans. Sometimes, children who have become anxious after being traumatized are misdiagnosed with the disorder.

About 5 percent of children may suffer from ADHD. Boys are affected four times as often as girls.

Attention problems are the major symptom. In some cases, the child can't pay attention long enough to accomplish tasks that he could otherwise reasonably be expected to accomplish.

For other children, the problem lies in the quality of their attention and their control over it. They may not be able to call up and sustain their attention. Or they may need to focus so intently on a task that they can't take in anything else at the same time.

For example, some children with ADHD may rivet themselves to a video game because it elicits the kind of "overfocus" they need if they are going to be able to pay attention at all. But this overfocusing does not allow the child to take in other information at the same time -- such as the voice of a parent saying it's time to stop playing.

Hyperactivity may be a response to an easily overloaded, hypersensitive nervous system. Activity becomes a way to discharge the tension. Many of these children are hypersensitive to sights, sounds and even touches. Such hypersensitivity not only interferes with a child's ability to pay attention and concentrate, it is likely to lead to poor impulse control.

When these children are overloaded by things they can't screen out, they fall apart easily. Such children have greater difficulty handling frustration because they are using so much of their energy to manage their environment.

For the same reasons, children with ADHD have trouble with change and transitions. Once they've succeeded -- with great effort -- in managing the sights and sounds of one situation, they're not likely to feel ready to move on to a new one.

Their rhythms of sleep and waking are also easily disrupted, with resulting sleep and discipline problems. Poor sleep can further impair attention and concentration, setting up a vicious cycle. (For more information about this, see our new book "Sleep -- The Brazelton Way," Perseus, 2003].)

These children are not intentionally provocative. Yet because they appear to "behave badly," they are often punished. In turn, they quickly develop a poor self-image and begin to expect to get into trouble.

Because their nervous systems easily become overloaded in noisy or busy places, they often seem intent on misbehaving as soon as they enter a crowded or noisy room.

I have used a simple screening test to identify some of these children. A child who is hypersensitive can't shut out a stimulus that is repeated several times -- even when that stimulus clearly offers him no new, useful information.

If I clap my hands (when he's not paying attention), any small child jumps and reacts the first two or three times. But a child with a normal nervous system quickly shuts out the disturbing sounds. By the third or fourth clap, he no longer pays attention.

A child with the hypersensitivity often seen with ADHD (although each can also occur separately) responds each time. He may try to divert his attention to another task, but he will continue to react with a startle and/or an accelerated heart rate each time I clap.

A young child (from 3 to 6) with ADHD will become overstimulated and resort to activity so that he can better handle the buildup of distress in his nervous system.

Learning how to handle the impulsiveness caused by overstimulation can be a long-term project, but it is crucial for future learning. The child can and should understand that this is an achievable goal.

Because children with ADHD often act before they think, they have trouble waiting their turn, compromising, negotiating and solving problems. This makes it difficult for them to get along with others. Parents and teachers need to realize that the child is not acting this way on purpose.

In some cases, children benefit from medication such as Ritalin. Too many medicated children, however, do not receive the other forms of help they need if they are to become aware of their difficulties and learn to compensate for them.

Behavior modification administered by an understanding therapist can help, especially if he or she can enlist the child's desire to overcome his poor controls.

When medication is advised, be sure the child understands its purpose and recognizes its effect on his symptoms. This can give him hope that he is now able to master his poor impulse control and feelings of being overloaded. But he won't feel that way if the medicine is given all the credit for the improvement.

Even a 4-year-old can learn to notice overstimulation when he feels it coming on, turn to a sympathetic adult for help, reorganize and go on with his learning. This is a major achievement and one that deserves high praise.

Dr. T. Berry Brazelton heads the Brazelton Foundation, which encourages and supports education and training programs that implement preventive health-care practices for children and families. For more information, visit www.brazelton.org or write to: Brazelton Foundation, 4031 University Drive, Suite 200, Fairfax, VA 22030

Dr. Joshua Sparrow, a child psychiatrist, is co-author of "Touchpoints Three to Six" and associate director of the Brazelton Touchpoints Center. Learn more about the Center at www.touchpoints.org

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