Attention Deficit Disorder
Often Misdiagnosed and Misunderstood 

Washington Parent Magazine, July 2000
Kay Kosak Abrams, Ph.D.

"Could my child have ADD? Is there a test for it?" These questions are posed more often than any others to those working with school-aged children exhibiting distractibility or poor self-regulation. The wish for a label is often a wish for a "fix", and there are plenty of parents and professionals who fall prey to "quick fix" thinking. especially within today's managed care mental health arena.

When a child is required to sit behind a desk and listen or complete a worksheet, but is unable to sustain attention, any number of factors may influence his ability to be attentive and productive. These factors include stress or fatigue, restlessness or boredom, and/or learning inefficiencies. When social or academic functioning seems impaired, professional assessment is in order.

Is it "ADD?"

Consistent inability to sustain concentration and complete work across various environmental settings may substantiate a diagnosis of the now infamous syndrome known as Attention Deficit Disorder (ADD). When an individual exhibits poor frustration tolerance, impulsivity and/or significant hyperactivity (motor-driven behavior), a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) may be substantiated.

Why is ADD So Prevalent?

Restless, hyperactive or inattentive students have always been present in schools. In the past, these students were identified as being "delinquent," "underachieving" or as having "minimal brain damage." Ironically, many such individuals are exceedingly bright and creative, often attending to too many stimuli at once. Their on-the-edge energy and multitask talent may fuel their success as adult entrepreneurs, but such a temperament is not appropriate in primary and secondary school. As adults, we can be selective about our endeavors and even delegate executive functioning tasks to a secretary or spouse. In contrast, children are required to attend and be productive across neurological domains.

Psychiatric diagnostic systems have evolved, and mental health intervention has improved. Medication is given today where hyperactive or poorly regulated students of the past may have resorted to substances such as cigarettes, alcohol or street drugs at worst, and tutoring, boarding school or the military, at best.

Regardless of current labels, the necessity for intervention is determined by limitation in functioning both socially and academically. Limitations in functioning are determined by both internal biogenetic factors and external environmental factors. When behavior can be managed by adjusting situational factors, such as increased structure at home and in school, medication may be unnecessary.

How is a Diagnosis Determined?

While psychiatric diagnostics is not an exact science, psychiatrists and psychologists can - and should - engage in a thorough assessment procedure, including taking a careful history, giving psychological tests and administering standardized behavioral questionnaires in order to determine which factors are impacting negatively upon attention and productivity.

A substantial amount of data needs to be collected from more than one source, i.e. parent, teacher, or doctor, to confirm an accurate diagnosis. Situational factors that influence social, behavioral and academic functioning must be accounted for. Often when families respond by adjusting work schedules, stress loads, marital discord and/or parenting styles, children who appear to have attention deficits become more attentive and demonstrate age-appropriate self-regulation.

True Attention Deficit Disorders have a biogenetic base, and so symptoms manifest early and generally override environmental factors, even in the most controlled consistent settings. Parents and students who have been blaming themselves are greatly relieved when medication enhances self-regulation, resulting in renewed hope and a sense of mastery.

Misunderstood ADD

'When standardized measurements and observations do not consistently point to a cluster of symptoms that designate a diagnosis of ADD/ADHD, there are several alternative explanations for the presence of attention deficits, and/or poor self-regulation. The most common syndromes that mock ADD/ADHD involve anxiety, adjustment problems or sensory dysfunction.


Many children, adolescents and adults who present with difficulties in attention or productivity are primarily experiencing anxiety. Anxiety is a feeling of restlessness and tension and may be present for a number of reasons. Anxiety disorders are largely inherited but can also be environmentally induced. Distressful or unpredictable events can result in symptoms of anxiety, such as heart palpitations, shortness of breath, sleep difficulties, distractibility and general feelings of nervousness. Experiencing anxiety is not only common, it is inevitable for most of us. But when anxiety is ongoing and elevated to the point of interfering with social, academic or occupational functioning, intervention is in order. Intervention may involve exercising, practicing deep relaxation techniques, psychotherapy, and/or medication.

Needs for Adjustment

Many of us take for granted or minimize the significant impact of change on our physical and emotional well-being. Change could involve starting or ending a relationship, transformation of work demands, a move or even a developmental challenge. Regardless, change results in certain physiological and emotional reactions that may undermine our ability to attend or invest ourselves mentally or emotionally. Motivation and openness to learning may be temporarily lost due to the fact that we must shift our energies in order to adjust.

Extreme and significant change, such as adjusting to new demands or to a divorce, naturally interferes with alertness, motivation and productivity. Yet, there are some students who may thrive on the classroom structure and immerse themselves in schoolwork as they cope with outside changes in their lives. Regardless of individual differences in temperament, we all have a limited amount of energy to invest in coping with the demands of daily living. In the face of needs for adjustment, attention and productivity are often compromised in school.

Sensory Dysfunction

Some individuals are born with hypersensitive sensory systems, resulting in heightened sensitivity and reactivity to sounds, sights, smell or touch. In addition to the possibility of sensory dysfunction, vision or hearing problems may diminish a child's ability to cope. Students with such difficulties may react aggressively or may withdraw when under-or over-stimulated. The uninformed observer may wrongly interpret such behavior as defiant. While indeed the child does not feel like cooperating, progress is contingent upon addressing sensory deficits rather than focusing solely on behavioral management techniques. Skills in focusing attention, processing information and increasing productivity are restored or enhanced when the sensory system is better regulated. This intervention requires the expertise of an occupational therapist (OT).

Learning Differences

Learning disabilities, inefficiencies or discrepancies, as they are called, are a common correlate of attention deficit disorders. Uneven developmental and cognitive abilities are often present for the inattentive, restless and often frustrated ADD or ADHD child. A bright student with either limited handwriting or leading fluency shows subsequent inconsistency in his ability to attend.

When a child is required to sit behind a desk and listen or complete a worksheet, but is unable to sustain attention, any number of factors may influence his ability to be attentive and productive.

Such children, who are often verbally astute yet unable to perform, are sometimes misunderstood. Most teachers are not trained to recognize a learning disability and may understandably feel the child is simply not "trying hard enough."

Calm Your Anxiety 
Enhance Your Attention Skills

There are no quick fixes for ADD/ADHD. There are many internal and external adjustments and accommodations that enhance a person's ability to attend, inhibit and produce. The process of intervention is complex and taxing for all who are closely involved. Anxious parents who fear for the child who 'may have ADD" need information and support. Information yields understanding and acceptance. Greater acceptance yields hopefulness, which yields greater capacity for problem solving. It is the professional's job to inspire hopefulness and facilitate progress by modeling careful attention, tolerance for the process of assessment and productive follow-through.

Copyright 2002 - Dr. Kay Abrams