Winter 2010

Diagnosis of Attention-Deficit/Hyperactivity Disorder
in the Early Elementary Years

Mary Ann Roberts, PhD Clinical Professor of Pediatrics
University of Iowa Children’s Hospital

Attention-Deficit/Hyperactivity Disorder (ADHD) is a common disorder of school-age children, with prevalence estimates ranging from 3 to 7 percent. Boys are more likely to be diagnosed with ADHD: At the University of Iowa Children’s Hospital Pediatric Psychology Clinic there is a ratio of three boys diagnosed for each girl. In child psychiatry settings the ratio may be as high as nine boys to one girl.

The three symptom dimensions of the diagnosis of ADHD include inattention, overactivity, and impulsivity of greater than six months duration that is outside the normal limits for age and developmental level. (The six-month duration is to exclude disruptions caused by adjustment disorders, family disruption, etc.) Diagnosis of ADHD in the 6- to 9-year-old child can be complicated by a high rate of comorbid learning and behavior disorders. An appointment with the child’s primary care

physician may be the first time a professional outside the sphere of the child’s daily life raises with parents the question of ADHD.

The diagnostic criteria require that the ADHD symptoms be manifest in more than one setting; however, parents may not find symptoms to be as problematic because a child can generally pace his or her own activities at home. It is often helpful to ask parents about homework completion or how long the child can maintain attention to daily reading activities.

Classroom teachers often notice behavioral issues in children and it is helpful prior to a physician referral to have information about these observations. In the 6- to 9-year-old age group, teachers may identify problems with sitting still in the classroom, completing class work, and/or impulsive behavior in the classroom or on the playground. The teacher discusses these observations with parents and additional evaluation may be conducted at school, including classroom observations of the attention of the child and a comparison peer. The teacher may complete a behavior checklist and ask the parent to do the same, rating the child’s behavior at home. If not already available, a physician may ask that this information be collected before proceeding with a diagnosis.

Due to the high rate of comorbid difficulties, it also is helpful to obtain information on the child’s academic achievement, any educational supports being provided (e.g., Title I reading, Reading Recovery, learning disabilities resource support), and other behavior concerns. It also is helpful if the behavior checklists completed can be compared to norms for the child’s age or grade. During an office exam, unfortunately, it is the exception rather than the rule that the child will exhibit any of the behaviors described above. Children with ADHD do best in novel settings; during brief visits; with self-paced tasks; and in situations that provide frequent feedback. This may be the reason these children often have a very long attention span for videogames. It may also be the reason that teachers often are the first to identify possible ADHD symptoms: they work with children in a setting that is more routine than novel, with tasks paced by the teacher. Also, in the general education classroom, children with ADHD often do not get feedback on their performance as often as needed.

For some children, there are physical factors that may exacerbate ADHD symptoms. Children who engage in excessive screen time or sleep poorly (due to having a television on while going to sleep, for example, or who snore due to enlarged tonsils) may benefit from environmental modifications or medical intervention. Children with little routine in their daily environment may benefit from increased structure and organization.

Once the physician has made the diagnosis of ADHD, treatment may be initiated. The child would qualify for a 504 Plan in the general education classroom (i.e., a document agreed upon by school staff and parents to provide accommodations in the regular classroom), which might

include preferential seating near the teacher, a positive behavior system, redirection to task, and/or reminders to take home materials needed for homework. Medication treatment also may be considered as an option.

If ADHD symptoms remain problematic after implementing classroom and home modifications and initiating medication treatment, it may be time to consider a referral to a child psychologist for assessment of possible learning difficulties. There may be psychologists in your community or you may consider referral to the regional Child Health Specialty Clinic. Physicians also may consider referral to one of the clinics at the University of Iowa Children’s Hospital such as the Pediatric Psychology Clinic, the Healy Clinic at the Center for Disabilities and Development, or the Child Psychiatry Clinic. A referral to the Behavioral Pediatrics Clinic at the Center for Disabilities and Development also may be indicated if the child displays oppositional behavior, noncompliance, or aggression. Online resources are available, as well. Children and Adults with Attention Deficit Hyperactivity Disorder (chadd.org) is an excellent resource for parents. Information on local CHADD groups may be available through local schools. The American Academy of Pediatrics (aap.org) provides helpful information to physicians (toolkit for assessment) and parents (information about treatment options).