(Click here if you don’t get the reference.)

So summer is over, and your kids are back in school. Hopefully it’s going well so far, but sometimes it doesn’t. It’s a hard adjustment for a lot kids after a summer crammed full of sleeping in–especially if this is your child’s first year in a formal school setting. This is usually the time of year when we begin to see newly-emerging concerns about academic problems (usually coinciding with the first progress reports). When teachers or parents see children that appear to be performing beneath their potential–or preventing the other students from reaching theirs, many of them think of ADHD. But there can be many other causes for poor academic performance, and it can be difficult to distinguish between them.

What is ADHD?

Attention-deficit/hyperactivity disorder is a neuro-behavioral condition that makes it difficult (but not impossible) for an individual to focus on a task, to control impulsive behaviors, and to function in everyday life. It is the most commonly diagnosed (and maybe the most commonly misdiagnosed) psychiatric disorder in childhood.

What is the difference between ADD and ADHD?

20 years. Really. The term “ADD” was retired in 1994, when the disorder was renamed “ADHD.” The now-outdated term “ADD” still makes frequent appearances, and a lot of parents inform me that their child “doesn’t have the ‘H'” (for hyperactivity). What they don’t realize is that ADHD has 3 different subtypes or “presentations.” The presentations are Inattentive, Hyperactive/Impulsive, and Combined. Here are the diagnostic criteria (from the DSM-5, or Diagnostic and Statistical Manual of Mental Disorders, 5th Edition):

Inattentive presentation:

• Fails to give close attention to details or makes careless mistakes.
• Has difficulty sustaining attention.
• Does not appear to listen.
• Struggles to follow through on instructions.
• Has difficulty with organization.
• Avoids or dislikes tasks requiring a lot of thinking.
• Loses things.
• Is easily distracted.
• Is forgetful in daily activities.

Hyperactive-impulsive presentation:

• Fidgets with hands or feet or squirms in chair.
• Has difficulty remaining seated.
• Runs about or climbs excessively in children; extreme restlessness in adults.
• Difficulty engaging in activities quietly.
• Acts as if driven by a motor; adults will often feel inside like they were driven by a motor.
• Talks excessively.
• Blurts out answers before questions have been completed.
• Has difficulty waiting or taking turns.
• Interrupts or intrudes upon others.

Combined presentation: Exhibits symptoms from both categories.

So, you can see, the kids “without the ‘H'” should really be classified as “ADHD, inattentive presentation.” And, unfortunately, they are often the last ones to get diagnosed, because the kid running around the classroom and jumping off the furniture is certain to draw more attention. The squeaky wheel gets the grease.

How do I know if my child has ADHD?

Talk to your pediatrician. Like most other psychiatric or behavioral diagnoses, there is no laboratory test or x-ray to order. ADHD is diagnosed based on your child meeting enough of the criteria above, in two or more settings (i.e., home and school). The best way to diagnose ADHD is to use one of several formal rating scales to obtain input from parents and teachers. If your child meets the criteria, and there isn’t another obvious condition causing the symptoms (see below), he or she will likely be diagnosed with ADHD.

Does ADHD run in families?

What’s a stronger word for “absolutely?” There’s no single gene responsible for ADHD, but kids with a parent or sibling with the disorder are 3-5 times more likely to have it themselves. Try not to blame yourself, though; it’s nearly universally your spouse’s fault.

What else could it be?

Anxiety, depression, bipolar disorder, autism, intellectual disability, learning disabilities, sleep disorders, substance abuse, oppositional-defiant disorder, absence seizures, and even vision or hearing problems can all be mistaken for ADHD. To complicate things further, ADHD co-occurs with at least one of these other diagnoses about 2/3 of the time. And many of these conditions can be worsened by ADHD medications. This is the reason why it is so critical to do a thorough evaluation prior to starting treatment. Your child may need psycho-educational evaluation through the school district to investigate some of these other possible conditions. A “trial of treatment” approach is always inappropriate for ADHD, as the medications used to treat the disorder are the academic equivalent of “performance enhancing drugs” and will help pretty much anyone, whether or not they have ADHD (which explains their street value on college campuses).

How is ADHD treated?

The first-line treatment for ADHD is a stimulant medication. They have some side effects, but are generally well-tolerated. There are two main classes, and several different immediate- or extended-release options within each class. Your pediatrician (and, sadly, your insurance) will help you decide which would be the best choice for your child, and it often take a couple tries to find one that works well. The dose typically increases as your child gets older, and you may be asked to repeat the rating scales to help with dosing decisions.

There are also a few non-stimulant medications used for ADHD. They are generally added when the stimulants just aren’t cutting it, and can be quite useful in certain situations.

But aside from the medications, behavioral interventions can go a long way–remember how I said ADHD makes things difficult but not impossible? It’s important for children to understand this as well; ADHD is an explanation, not an excuse. These interventions are important at home and at school, and can include the following:

• providing frequent reminders (including verbal reminders, smartphone apps, sticky notes, to-do lists, etc.)
• maintaining consistent routines and structure
• having reasonable expectations
• minimizing distractions
• taking frequent breaks
• judicious use of caffeine in older children (it’s a mild stimulant)
• ensuring adequate sleep and exercise
• choosing appropriate seating in school
• requesting a 504 Plan or Individualized Educational Plan (IEP) from the school
• communicating frequently with the teacher about performance and areas for improvement
• utilizing a “silent signal” in school to remind your child to focus without drawing the attention of other students

Will it go away?

I’m of the belief that ADHD never truly goes away. However, by the time many children reach college-age or adulthood, they will have developed good enough coping skills to do quite well without pharmacological help. But relax–your child can go far, even with ADHD. Several of my classmates in medical school carried this diagnosis (and probably many more of us were simply never diagnosed).

But while some people learn to manage their symptoms quite well, the stakes of impulsive decisions increase dramatically with age. People with ADHD struggle not only with school, but also with social relationships and careers. They are far more likely to have automobile accidents, get speeding tickets, abuse drugs, have unplanned pregnancies, get divorced, be fired from a job, suffer accidental injuries, and wind up incarcerated. These serious consequences highlight the necessity of appropriate diagnosis and treatment, with which your child can live a healthy and productive life.

Where can I learn more?

Check out my Recommended Reading page for several great books, and visit the following websites for more information about ADHD and guidance for obtaining services at school:

Children and Adults with Attention Deficit Hyperactivity Disorder

Wright’s Law

And one final note about ADHD: if you made it this far (without a prescription), you probably don’t have it.