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Attention Deficit Hyperactivity Disorder

ADHD Diagnosis

07/06/2005

Question:

My son is nearly 5 yrs old. He was a very easy baby & toddler. When he began preschool at 2, he had a classmate who picked my son as a "target" for hitting, hair-pulling, etc. As time passed, my son also became aggressive, & "hyperactive." Realizing the problems between the 2 boys, they were placed in separate 3 yr old classes. For an entire yr I received great progress reports on his behavior & attention span. There was a brief period of negativity before winter break, which resolved during the break & never recurred, at home or school. When that class was over, the next class included the problem boy again. My son`s behavior at school went downhill from Day 1! He was with this child from June til the child left the school in Dec. His behavior problems did not totally resolve, the teacher hinted at ADHD, & my suspicion that he`d been quite affected by the other child was discounted. His current summer teacher, who will also be his teacher in the fall, is pushing me to have him evaluated for ADHD. I`m not against the evaluation, but because the behavior she describes isn`t present to any great degree outside of school, I`m very hesitant to label him as ADHD. He just finished his 1st yr of t-ball, & after a rocky beginning (attributed by the others as just being his 1st time to participate in something like that), by mid-season he was indistinguishable from the other boys. One of his coaches was surprised he had any trouble at school, because he was always so responsive to direction & never disrespectful. I should mention my son is extremely bright, yet has never had comments on a progress report related to "underperforming" - quite the opposite. He retains info very quickly. He learns things without effort or my "pushing" him. For example, in the 3 yr old class, they were learning letters & colors (which he knew at 2). The teacher couldn`t think of a "y" object, so she told them just to draw something yellow. He drew a yellow yo-yo, which floored her! We had a picture of a yo-yo on a card at home, & he immediately thought of it. He loves school, but his teacher is frustrated because he is sometimes defiant & will throw things (like markers the other day). She (like his previous teacher)reminds him of the rules, puts him in a 2-3 min timeout, & sometimes after several incidents will get him to talk to the director. I feel that for him, this is like getting away with it. I`ve tried using the ticket system but the teacher is skeptical & basically refuses to use it. It works at home, if we`re having a problem. He doesn`t throw things at home, act aggressively towards dog or baby sister (1 yr), or have trouble eating or sleeping. He goes to bed easily & sleeps all night. His dr will talk to us at his 5 yr checkup, but the nurse & an LCSW we know suspect he is active but not ADHD, & needs firm behavior mgmt at school. The teacher totally disagrees. After this extra-long description (I apologize), what`s your opinion?

Answer:

No apologies necessary for the long description. History is usually our best tool in medicine and we should make more thorough use of it more often than we do, even for disorders not associated with behavior or mood.

Of course, there is no way to diagnose your son over the net. And five year olds are often incredibly difficult to diagnose even face-to-face. However, let me comment on a few points you bring up that help sort things out a little.

First, you are certainly right to be wary if, in fact, your son's initial behavioral problems were defined only in relation to one bully. None of us should underestimate the power of a bully. On the other hand, I have seen many children walk into a situation with bullying who are able to walk right away unscathed. Although the major concern in his early years may have been the bully, his responses may have indicated early impulsivity in spite of a kind nature. I can't tell from your description and you may have no way of knowing because it was so long ago.

Behavior only being present to an extreme within school does not rule out ADHD. It depends on many variables including activity level, discipline, expectations, temperament, and general stress factors. Even many adults would be more able to deal with a safe home environment where little is expected of us other than to pick up our "toys", mind our manners and do a few minimal chores than with sitting in chairs for hours on end and make decisions throughout the day about how to appropriately deal with positive and negative interactions with 20-30 others in one large room.

Being responsive in sports is not surprising. Although many children with ADHD are better team players on stimulants, for many, the chemical changes inherent in physical activity are the fuel they need for heightened attention. Physical activity is wonderful for many reasons but it is particularly helpful for brain health.

High intelligence has nothing to say for or against an ADHD diagnosis. It could, however, help explain why a five year old could often mask signs of ADHD. Intellect and creativity has a way of helping all of us make up for our weaknesses and ADHD is no exception.

On the other hand, whether or not your son has ADHD, pre-ADHD, or whatever label one might want to give what a five year old might have if his impulsivity, inattention and/or hyperactivity is causing him major problems in school, a strong, loving, positive but highly structured environment may well be key. I am not sure what you mean by "ticket system" but if it involves this with positive reinforcement, I agree.

Also, I have great respect for our hard working school teachers and would certainly urge you to consider an evaluation. If your son does need extra help and it could be solved by a different classroom setting or medication or class adjustments or a different school, you'll want to know ASAP.

If he has a developmental disorder like ADHD it means he is not developmentally at the same point most five year olds are for certain things. In this case, it might mean he does not process between action and reaction (throws things) like a three year old. And expecting him to do so, even after a hundred time-outs or a thousand tickets would be like expecting a 15 month year old to be able to ride a bicycle because her legs fit the pedals.  If the neurocircuits are not there to process the information, it won't happen! And that's important for all concerned to learn.

Then again, it also would be great to learn your son is just "going through a stage" and is likely to get his behavior under control over this next year. An evaluation may show that as well.

The best of luck to you both.

For more information:

Go to the Attention Deficit Hyperactivity Disorder health topic, where you can:

Response by:

Susan Louisa Montauk, MD
Formerly Professor of Family Medicine
University of Cincinnati