Attention Problems Don’t Always Mean ADHD
What neuropsychological testing can—and can't—tell you about your kid
You come to my office for your kid’s neuropsych feedback session, and I walk you through the results of the evaluation. I tell you that your daughter struggled on some of our tests of attention and executive functioning. Not all of them. She held her own on tasks that required simple attention and working memory. But when we looked at sustained attention, inhibitory control, and cognitive flexibility, she fell apart. Her performance was pretty consistent with what you told me at the intake: She ignores instructions, homework is a nightly battle, and she constantly loses track of time. But her teacher says none of this is happening at school. Her homework is handed in correctly. She follows directions. She pays attention in class. She has an active, healthy social life. So no, I tell you, she doesn’t meet criteria for ADHD.
You’re confused, understandably. The tests confirmed attention and executive functioning problems, so doesn’t that mean she has ADHD?
I explain that’s not how the diagnosis works.
Our paper-and-pencil tests of attention and executive functioning aren’t diagnostic; they are descriptive. They attempt–albeit imperfectly–to isolate a single cognitive skill, and then they tell us how well a kid demonstrated that skill compared to others their age on one particular day in a quiet room with an adult giving them their full attention. It’s useful. Since executive functioning is multifactorial, it helps to pinpoint which specific aspect is giving a kid trouble, and we can tell if what we’re seeing is a real deficit or just normal kid challenges.
But as a predictor of diagnosis, our tests are weak. Attention and executive functioning problems aren’t specific to ADHD. Not even close! They show up in nearly every diagnosis we test for–anxiety, depression, learning disorders, autism, you name it. Trouble focusing and regulating are among the most common symptoms in all of psychology since so many different things can cause them.
That’s why ADHD gets diagnosed off a checklist instead. (I realize it seems unscientific and arbitrary, but I don’t make the rules!) To meet criteria for a diagnosis, you need six or more symptoms of inattention, six or more of hyperactivity, or both, showing up before age 12 and causing impairment in more than one setting. That impairment doesn’t have to show up in grades, though it often does: the classic image is one of a disorganized backpack, misplaced homework, misread directions, and ‘careless’ errors. But a kid can be getting straight A’s and still be impaired in school if the impairment is social, emotional, or behavioral in nature. Picture the kid who drives everyone crazy by blurting out answers. Or the kid who can’t lose a game without flipping over the entire board. Or the kid who can’t sit still at circle time.
But when we see nothing like that, which is what’s going on with your daughter, the ADHD label seems like a real stretch.
So you ask: Maybe she’s just good at masking? Or maybe the ADHD is just really mild? Both fair questions. As I’ve said before, kids with real ADHD generally can’t hide it so well that it’s completely imperceptible at school. And mild isn’t a vibe, it’s an actual clinical term–it means that the kid has few, if any, symptoms beyond the minimum required. Your daughter doesn’t have even the minimum required, so it’s not mild ADHD. It’s not ADHD.
But I want to be really clear: I believe you. Your daughter has genuine attention and executive functioning vulnerabilities, and what you’re seeing at home and what we’re detecting on testing is real. It’s just not ADHD. The good news, though, is that a full neuropsych doesn’t stop at attention and executive functioning. We look at those results alongside everything else–mood, learning, language, academics, and more–and, in that context, we can usually find our answers.