Author: Dr. Andy Woodall

As a clinician, one of the most common presenting concerns I hear from clients across all ages (especially with children) is that they have a difficult time focusing, concentrating, and sustaining an adequate amount of attention to complete the tasks they are faced with in their everyday lives. Despite their expressed efforts, they just can’t seem to focus in school, complete their homework, or endure the length of time it takes to devote their attention to a project that is necessary to achieve their goals. For example, parents may report that, “My child seems to make careless mistakes on his homework,” or that, “They seem so forgetful about following the simplest instructions.” On top of all of that, parents often report that their children often seem fidgety, can’t sit still, or appear “hyperactive,” which only makes redirection to a task seem more difficult.

The question that most often accompanies these concerns is “Does my child have ADHD?” The answer may not be as straight forward as you think. That is because inattention and psycho-motor agitation (e.g. heightened motor activity such as pacing, tapping feet, or rapid talking) are symptoms of a large variety of neurodevelopmental, mood, and trauma disorders. In a similar way that a cough or sore throat may signal one of many underlying illnesses, inattention and heightened motor activity may also manifest in response to a number of different underlying issues. Unfortunately, many clinicians may make a hasty diagnosis without conducting a thorough and comprehensive psychological evaluation. A comprehensive psychological evaluation takes emotional functioning into account beyond performance on measures of executive functioning (e.g. sustaining attention, memory, organizing, planning, self-monitoring, task fluency, and impulse inhibition). The lack of comprehensive psychological evaluations for these presenting concerns has often led to the over- or mis-diagnosis of ADHD. In fact, a recent meta-analysis of research suggests that, “Approximately 1.1 million children received an inappropriate diagnosis [of ADHD] and over 800,000 received stimulant medication due only to relative [im]maturity.” (1) Consequentially, this often leads to ineffective treatment approaches. For example, a child might be prescribed a medication, such as Adderall, when instead they may be better treated by a professional who helps them process and work through potential performance anxiety that flares up every time they are faced with a challenging homework assignment.

Furthermore, there is a wealth of research that indicates a strong relationship between attentional control and emotion regulation. In fact, the connection between attentional control and emotional regulation is part of why mindfulness meditation practices are believed to be so effective in treating a wide range of disorders (2). In brief, people have a tendency to seek relief and avoid discomfort, which is not only reflected in their physical actions, but in their mental efforts as well. This means it might feel better to daydream about your favorite video game than it does to focus on your homework. Let us return to the child in the classroom who struggles with performance anxiety. If anywhere they direct their attention represents a potential failure, rejection, or catastrophe, then focusing attention can feel as strenuous as trying to avoid setting off an explosion. It is no coincidence that parents may report their child also has meltdowns or frequent angry and tearful outbursts at home or at school. Inattention in this case may reflect your child’s best efforts at emotional regulation by mentally maneuvering through a minefield rather than being suggestive of a neurodevelopmental condition, such as ADHD. Unfortunately, the redirection of attention in the hopes to achieve relief can also heighten emotional distress as children start to miss out on vital information which can ultimately hinder their functioning or academic achievement.

It is also important to note that struggles with inattention or the appearance of “hyperactivity” can have a powerful impact on a child’s life. Whether the child is, in fact, diagnosed with ADHD and/or another disorder, they often find themselves regularly being called out or corrected at home or in class (which often evokes shame and may affect self-esteem), and their performance in school may not be accurately reflecting their true talents and abilities. It is understandable, then, that children who often wonder if they are inadequate or behind in comparison to their peers may also develop an aversion to engaging in school or other tasks that are associated with such emotional distress.

To provide some additional guidance, below is a list of 3 things that may indicate that inattention is due to something other than ADHD:

1) Late Onset

Attention Deficit Hyperactivity Disorder is a neurodevelopmental disorder, which suggests that the symptoms are due to brain development rather than in response to social-emotional or environmental stressors. For a diagnosis of ADHD, inattentive and hyperactive-impulse symptoms must be present from an early age across multiple contexts such as home, school, or work. In other words, if you have only recently started experiencing difficulty with concentration and attention, it could be in response to a major life event or emotional stressor in your life.

2) Worry and Anxiety

Individuals with ADHD are inattentive because of their attraction to external stimuli, new activities, or preoccupation with enjoyable activities. This is distinguished from the inattention due to worry and rumination seen in anxiety disorders. Restlessness might also be seen in anxiety disorders (3).

3) Boredom or Lack of Challenge

Sometimes it is the case that inattention and hyperactivity is not due to any disorder at all. In fact, some children/adolescents and adults who are cognitively gifted may simply lose interest in tasks that are too easy or not stimulating enough. Adults or children may report inattention and hyperactivity, when instead they’re really just bored! Unfortunately, lack of interest and engagement may consequentially impact their school or work performance which still raises concerns. In these cases providing individuals with the appropriate amount of challenge for growth may be just enough to engage them.

While this article intends to point out that inattention can reflect issues other than ADHD, such as mood or anxiety concerns, this is not to say that these diagnoses are mutually exclusive. As eluded to earlier in the article, many of those who experience symptoms of ADHD consequentially struggle with emotion regulation and mood due to associated challenges with the diagnosis. Thus, it is important to consult a clinician and ask about the benefits of conducting a comprehensive psychological evaluation to gain a clearer picture of the cause of inattention and difficulty concentrating.

For further information on the importance of conducting thorough evaluations, click here.  If you would like to learn more about the history and overview of ADHD, click here. For ways that SVPS can help clarify a diagnoses, give us a call or click here to learn about the different psychological and neuropsychological evaluation services we offer!

References

1) Merten, E. C., Cwik, J. C., Margraf, J., and Schneider, S. (2017). “Overdiagnosis of mental disorders in children and adolescents (in developed countries).” Child and Adolescent Psychiatry and Mental Health 11:1.

2) Chambers, R., Gullone, E., & Allen, N.B. (2009). Mindful emotion regulation: An integrative review. Clinical Psychology Review, 29, 560-572.

3) American Psychiatric Association, DSM-5 Task Force. (2013). Diagnostic and statistical manual of mental disorders: DSM-5™ (5th ed.). Arlington, VA, US: American Psychiatric Publishing, Inc.
http://dx.doi.org/10.1176/appi.books.9780890425596