Attention Deficit Hyperactivity Disorder - Predominantly Inattentive Type A Diagnostic Dilemma

Attention Deficit Hyperactivity Disorder (ADHD) is a common mental disorder in children that adversely affects adequate attention, acceptable levels of activity and imposes an impulsive behaviorial style. For children the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), a publication of the American Psychiatric Association, breaks ADHD into four categories:
ADHD - Predominantly Inattentive Type
ADHD - Predominantly Hyperactive/Impulsive Type
ADHD - Combined Type
ADHD - Not Otherwise Specified

For the most part, ADHD Hyperactive/Impulsive and Combined types have highly visible characteristics that bring the child to the attention of medical providers at an early age. On the other hand, ADHD Inattentive Type (ADD) may be overlooked until the affected child is found to be struggling in school or showing signs of a mood or anxiety disorder.

At this point the picture may be less clear and many questions will arise. Is the academic underachievement due to the under focused behavioral style of ADD? Perhaps it is confused with internalized and over focused behaviors seen in children with a compulsive or pervasive developmental disorder? Might it be because the child has a learning or language disorder (LDD)? Maybe, for many reasons, the child is depressed or anxious and cannot concentrate.

The answer is that ADD can be confused with or be associated with any or all of the above. This is the reason for the dilemma that many mental health care providers face when evaluating the child for problems that have not been recognized in the early grades or when there are coexisting conditions in the same child.

Inconsistency of early academic performance is the key to early detection of simple or isolated ADD. Generally speaking, when a child performs well in all phases of academics some of the time but struggles the rest of the time, ADD should be a prime diagnostic consideration. Once ADD has been diagnosed and properly treated, the erratic learning style will be corrected and the child with the disorder should progress at or near full ability. This is especially true when the diagnosis is made before academically imposed stressors come into play.

A real diagnostic puzzle for the caregiver is to identify conditions that are frequently coentities with ADD or those same conditions that can, of themselves, cause inattention. One should always consider evaluating a child for LDD when a child with ADD continues to have academic difficulty after appropriate management has been in place. By the same token, children who are clearly learning disabled but struggle with productivity should be highly suspect for ADD. (About 50% of children with LDD have ADD and about 30% of children with ADHD have LDD).

Another puzzle is the over focused child who is often misdiagnosed as ADD. A key difficulty for this child is one of dealing with transition. The over focused child finds it difficult to leave one school subject and turn attention to another. This problem is often thought to be an attention deficit, when, in reality, it is quite the opposite. This problem requires very different strategies for behavioral and academic intervention.

Other mental disorders can interfere with attention: juvenile mania, depression and anxiety, to name a few. Each and every condition that is seen with ADHD should be considered and ruled out. So too, should environmental, familial, health, behavioral and other risk factors be inventoried and evaluated for potential problems that could alter attention.

Again, early intervention and treatment of ADD can be very rewarding as there are behavioral and educational strategies as well as medications that, when used appropriately, can prevent the problems seen in chronic school failure often associated with ADD.

For more information about the conditions or terms used, visit www.abledev.com and the ABLE Glossary.