ADHD symptoms can be deceiving

Andrew Schwartz, Ph.D., a Consumer Reports survey research associate and licensed clinical psychologist who assesses children for attention deficit hyperactivity disorder and other learning disabilities, discusses two cases.

An 11-year-old boy I'll call Joseph was brought to my office by his concerned parents. He was throwing fits every morning because he hated to go to school.

As a psychologist with a part-time practice assessing attention and emotional disorders, my first thought was that Joseph's refusal to go to school might be related to either separation anxiety or a behavior disorder. But as I questioned the parents, I learned that Joseph didn't have trouble separating from his parents when it was time for his soccer games or to play with his friends. In general he was a well-behaved, compliant boy who, except for school refusal, showed no signs of defiant behavior.

On further questioning, the father revealed that he himself had some trouble with reading and often lost interest in activities at work. When I asked about Joseph's reading and attention, his parents said they knew he was a smart boy, but the teacher had mentioned that he had been missing details and tended to space out during reading assignments.

After a learning evaluation with a clinical neuropsychologist that included getting feedback from the school, Joseph was diagnosed with a minor reading disability and attention deficit disorder. It turned out that he was avoiding school because he was embarrassed about his declining performance and inability to complete reading assignments as quickly as his peers.

Joseph's parents asked the school to make recommended accommodations, including sessions with a reading specialist, extended time for reading assignments, and moving his seat to the front of the classroom. This helped improve Joseph's performance and attitude. He was soon able to go to school without the morning outburst.

While most people think of children with ADHD as screaming and climbing the walls, a number of children like Joseph suffer primarily from symptoms of inattention, such as missing details, losing things, being forgetful, or avoiding disliked activities. It can be difficult to untangle learning and attention problems from the emotional consequences of experiencing these issues.

The survey team at Consumer Reports Health recently polled 934 parents who had a child diagnosed with ADHD and found that well-established clinical guidelines for making a diagnosis are not always followed. For example, medical screenings and feedback from the schools may not be included in the assessment. This is unfortunate, because without a 360-degree view it's hard to reach the correct diagnosis and implement the right strategies for helping the child.

Consider the case of Ruby, a 9-year-old girl. Her parents complained that she was "in her own world" most of the day and was missing information at school. While assessing her, I, too noticed these symptoms, but observed that Ruby had a nasal tone to her speech and was breathing through her mouth. When I asked if she had a cold, she said, "No, I always breathe like this." I referred her for a sleep test and it turned out that she had sleep apnea, which caused poor sleep at night and left her exhausted during the school day. When Ruby's sleep apnea was treated and she began to get a good night's sleep, her behavior and attention problems gradually resolved themselves.

It's important for parents and professionals alike not to jump to conclusions about what's causing a child's behavior. Our report on ADHD can help guide you through the diagnostic process and learn how to insist that your child get the right kind of evaluation.