What is ADHD? When should parents worry?
What is ADHD, and how is it diagnosed? With Back to School, parents have a lot of questions about ADHD (attention deficit hyperactivity disorder). Children with ADHD have features that are restless and/or inattentive that lead to functional impairment affecting their ability to make academic, cognitive or social gains. For every feature that I’m going to say, most parents will say that at least some of the time my child does this thing; this is NORMAL for all kids to do these things sometimes! For these behaviors to be considered ADHD, they need to occur often, across multiple settings (like home, school, and with a babysitter), last at least six months, be more than excessive for that child’s developmental level (a 4 year old is going to have more forgetful with multistep tasks, for example, than a 7 year old), and again impair function. There are two main types in children – hyperactivity/impulsivity which can start around age 4yo and peaks by age 7-8yo; after age 8, the restlessness is less obvious but the often more concerning impulsive behaviors can get worse – like risky behaviors in adolescence. This subtype involves fidgeting, difficulty remaining seated, difficulty playing quietly, always “on the go”, excessive talking, can’t take turns, blurts out answers too quickly, and interruption. The second subtype is inattention, which shows up around age 8 or 9 in reduced ability to focus attention where kids seems to be daydreaming, to act slowly and to be off task. This is characterized by careless mistakes, difficulty maintaining attention in play, home AND school, difficulty listening, failure to follow through, difficulty organizing, loses objects frequently, easily distracted, and forgetfulness in routine activities. Some children actually fall into both categories. The very youngest this can be diagnosed is 4 years old, but trying to diagnose too early can be a challenge because it is developmentally normal for many 4 year olds to do many of these things. ADHD diagnosis is usually led by a pediatrician who will work with families to gather data across from home, school and other sources where the child spends a significant amount of time.
ADHD diagnosis:
Impulsivity, inattention, restlessness = functional impairment that affects cognitive, academic, behavioral emotional and social functioning
Difficulty with executive function
Emotional dysregulation
hyperactivity/impulsivity subtype – fidgetiness, difficulty remaining seated, difficulty playing quietly, always “on the go”, excessive talking, can’t take turns, blurt out answers too quickly, interruption – starts around age 4, peaks by age 7-8; restlessness settles down by age 8 or so but impulsive behaviors can get worse - in adolescents - substance use, risky sexual behavior, impaired driving
Inattention subtype - reduced ability to focus attention and reduced speed of cognitive processing and responding - sluggish tempo, daydreaming and off task; cognitive and academic problems; more common in kids born prematurely less than 32 weeks
Careless mistakes, difficulty maintaining attention in play, school or home; difficulty listening, fails to follow through, difficulty organizing, loses objects frequently, easily distracted, forgetfulness in routine activities
Usually not apparent until child is 8-9 years old
To meet criteria for ADHD - core symptoms MUST impair function in academic, social or occupational activities
Social skills often impaired - poor self esteem, increased risk for depression and anxiety
At least 4 years old - poor school performance, difficulty making and keeping friends, difficulty with team sports
Comprehensive medical, developmental, educational, psychosocial evaluation
Medical, social, family histories; clinical interviews with caregiver and patient; review of info about school and daycare; evaluation for emotional, neurodevelopmental, behavioral disorders
SAFETY important - injury prevention - increased risk of intentional or unintentional unintentional injury
VERY STRONG genetic component
Autism spectrum disorder - important differential diagnosis
Vanderbilt rating scale - 90% sensitive when used appropriately
Educational evaluation: completion of ADHD rating scale (Vanderbilt), narrative summary of classroom behavior, report cards and schoolwork, school-based multidisciplinary evaluations if possible
Teacher who has worked with students for 4-6 months – last year’s teacher
Public schools federally mandated to perform appropriate evaluations at no cost to family if suspected of disability (ADHD or learning disability)
Psychological testing is not necessary, nor is EEG
DSM-5-TR - American Psychiatric Association - > or equal to 6 symptoms of hyperacitvity and impulsivity OR 5 or greater symptoms of inattention
These must:
Occur often
In more than one setting
Persist for at least six months
Present before age 12 *controversial
Impair function in academic social or occupational activities
Be excessive for the development level of the child
Cannot be accounted for by other health conditions
Age 4 – can be applied only if there is SEVERE HYPERACTIVITY - that is shown to persist
Script and Notes based on UpToDate article on ADHD in children and adolescents, updated August 2025
