In the recent past individuals might not have been diagnosed with ADHD until adulthood, but now it seems that many educators and parents are quick to attribute a student’s problem behavior to ADHD. While it is true that behavioral dysregulation is associated with ADHD, it is also important to keep in mind that there are other causes of problem behavior, and that behavioral issues are largely secondary to the neuro-developmental challenges faced by youngsters with ADHD.
ADHD and its Associated Problem Behavior
As reported by the CDC, an estimated 7 million (11.4%) children aged 3–17 have ever been diagnosed with ADHD in the United States. ADHD is a neurodevelopmental condition that is likely related to both brain structure and genetic factors, and while certain environmental factors can exacerbate the condition (e.g., distracting and chaotic settings, bombardment with input from devices, dietary factors, etc.), they do not cause ADHD per se.
As described in the DSM-5, ADHD can present as primarily inattention, as hyperactivity/impulsivity, or as a combination of both. Some signs of Inattention include:
- A lack of attention to details and a tendency to make careless mistakes
- Difficulty maintaining attention on tasks or play/work activities
- Not appearing to listen even when spoken to directly
- Difficulty following through on instructions, especially verbal instructions
- Frequently failing to finish schoolwork, chores, etc. because of losing focus, getting side-tracked
- Difficulty with organizing tasks and activities, often late and/or forgetful
- The tendency to dislike and avoid tasks that require sustained mental effort
- Frequently losing or misplacing items
- Distractibility and procrastination
Some signs of hyperactivity/impulsivity include:
- Frequent fidgeting, tapping of hands or feet, squirming in a chair, or being unable to sit when remaining seated is expected
- For children, running or climbing in situations where it is inappropriate or dangerous; for teens and adults, frequently feeling restless
- Inability to play or take part in leisure activities quietly
- Frequently appearing “on the go” or “driven by a motor”
- Talking excessively
- Blurting out answers before someone finishes the question or interrupting others while speaking or engaging in an activity
- Difficulty waiting to take a turn
According to the National Institute of Mental Health (NIMH), symptoms must have begun in childhood, before the age of 12, for an individual to be diagnosed with ADHD. To meet the diagnosis, a person’s symptoms must occur for at least 6 months, be present in two or more settings (e.g., at home and at school), and significantly interfere with social, school, or work functioning. Boys are diagnosed twice as often as girls and are more likely to be hyperactive while girls more often appear inattentive. ADHD can be missed in girls since their behavior is less disruptive and may be dismissed as daydreaming or “ditzy”.
ADHD symptoms can manifest differently depending on the age group. Children most commonly have symptoms of hyperactivity and impulsivity while adolescents often appear restless, engage in risky behaviors, and have significant academic and relationship challenges. Adults can also show symptoms of inattention, restlessness, and impulsivity, and may appear to have a low tolerance for frustration, a tendency toward disorganization, and frequent emotional dysregulation. People with ADHD do not outgrow the condition per se, but with brain and physical maturity, increased analytical skills and judgment, and the development of compensation techniques, they can improve tremendously and have little disruption in adult occupational, emotional, and social functioning.
ADHD is not a behavior or discipline issue although children and teens with ADHD often exhibit behavior problems that arise because of their neurologically based vulnerability to dysregulation. They are not deliberately willful, lazy, aggressive, argumentative, or demanding. Rather, as they begin to realize how hard they must work compared with other students and experience the difficulties associated with ADHD, their anger, resentment, frustration, and defiance can build, leading to tantrums, avoidance, refusal, and oppositional behaviors. They often feel that because of their behavior they are “bad kids” and not as intelligent as peers. They frequently experience the world as being overly critical and can respond to these stressors with anxiety, depression, and problematic substance use.
Problem Behavior that is Unrelated to ADHD
Behavioral issues can be caused by numerous other factors so parents and educators should pursue thorough medical and mental health assessments before drawing the conclusion that ADHD is the root cause. Other medical/neurological issues such as hearing loss, sleep disorders, dyslexia, learning disabilities, and autism spectrum disorder must be considered. Students struggling with anxiety or depression, with the effects of a substance use disorder, or with the aftermath of trauma frequently express their pain in behavioral ways. For some students, aggression and other forms of behavioral acting out are survival strategies learned in response to a one-time or chronic exposure to trauma.
Numerous factors contribute to problem behavior, but there are two major themes: biological vulnerability coupled with environmental responses that inadvertently reward undesirable behaviors. For example, there is no clear cause of ODD (Oppositional Defiant Disorder) although biological/genetic factors coupled with environmental factors are often cited (as with pretty much every other mental health disorder!). Each baby is born with its own temperament that manifests in various ways such as energy level, curiosity and engagement with the world, whether they are calm or easily dysregulated, how responsive they are to being held/soothed by adults, etc. Some babies are experienced as “easy” while others are “fussy” or “difficult” and temperament starts immediately to shape a child’s interactions with the world and other humans. That said, how adults respond to problem behaviors no matter what the origin is critically important. One study reported by NIMH, for example, showed that criticizing a child with ADHD is likely to make symptoms worse.
Differentiating ADHD Behaviors from Other Behavioral Problems
As mentioned above, a diagnosis of ADHD must be made by a health professional, but here are some things to consider when trying to tease out what might be going on with a specific youngster:
- Children mature at different rates – the youngest child in a class might be a year± less mature than the oldest child, and youngest students are more often labeled as having ADHD when compared with peers.
- ADHD is not the likely diagnosis if the behavior occurs in only one setting.
- A “Can’t vs. Won’t” perspective is essential: Talking with a student and his parents about what makes it difficult to stay in the seat, or not interrupt, or comply with a request, can help identify what aspects of behavior are out of the child’s immediate control. Children may not always be able to reply to “What can I/we do to help?” but it is a question worth asking.
- Schools can use standardized rating questionnaires such as the Connors Rating Scale that includes both teacher and parent components as a preliminary screening method.
- Educators should scour records and speak with caregivers about other possible explanations: other health conditions, family stressors, a trauma history, etc.
Some Tips for School Professionals and Parents
Students with ADHD:
- Might misbehave so often there is the potential for more frequent criticism and consequences. As with all efforts at behavior change, rewards and positive feedback are much more effective.
- Require a lot of structure and consistency and must be given clear messages about what is expected from them. Instructions must be repeated often, verbally and in writing.
- Can have a hard time tolerating tasks that are repetitive, boring, or require persistent effort, and might act out to avoid them. Break these tasks into smaller chunks and/or find ways to make them more novel or interesting.
- May avoid team sports or other social activities because of their difficulty following directions and reading social cues. Parents, teachers, and coaches can collaborate to create environments that are sensitive to their needs.
- Are hard-wired to take risks so help them learn to differentiate the types of risks. For example, sparring in a martial arts class is better than fighting on the playground.
Conclusion
Untreated ADHD can lead to a cascade of other problems including academic failure, low self-esteem, substance use, social difficulties, and oppositional behaviors fueled by anger, frustration, and feelings of helplessness. Treatment is readily available, and it is widely accepted that training parents in behavioral management techniques, school-based classroom management strategies, and coaching children in SEL and EF skills should precede the use of medications.
Resources:
Diagnosing ADHD | Attention-Deficit / Hyperactivity Disorder (ADHD) | CDC
Bad Behavior? No. Your Child’s ADHD Symptoms Are to Blame (additudemag.com)
ADHD Symptoms & Behavioral Problems in Children | Drake Institute
