Children and Behavioural Problems by: Martine, F, Delfos (2004). Pg. 186 – 190.
ADHD, Attention Deficit-Hyperactivity Disorder, versus
hyperactivity
When we look at the five problem areas (externalising conduct disorder and problem, internalising
conduct disorder and problem and ADHD), we can say that the diagnostics for ADHD have been
developed the most. At the same time the usual diagnostics are rather limited. Many diagnosticians
restrict themselves more or less to the criteria stated in the DSM-IV (American Psychiatric Association
1994). On the basis of the characteristics of ADHD, also compared to other conduct difficulties, it is
possible to refine the diagnostics and to obtain more certainty about the image.
Below I list questions to use in order to diagnoseADHD.
Questions in order to diagnose ADHD
1. Do the criteria of the DSM-IV apply?
2. Are there neurological indications for immaturity or hyperkinesis?
3. Are there other maturation disorders?
4. Are there learning disorders?
5. Did the problems start in early childhood: as a baby, as a pre-schooler
or in the first year of primary school?
6. Are there family members who have ADHD?
7. Does the child adjust easily?
8. Does the child have a good me–other differentiation?
9. Is the child able to self-reflect?
10. Does the child have a need to play with other children?
11. Does the child remain active during a conversation? (This question is
useful if the element of hyperactivity applies.)
12. Are there circumstances that explain the child’s behaviour?
The DSM-IV has a symptom list for the three aspects that play a part with ADHD:
hyperactivity, impulsivity and attention deficit (Question 1). On the basis of this list of symptoms we can
formulate a diagnosis, although it would be wiser to speak of a hypothesis which can be researched
further. Because it concerns strongly subjective criteria here and experience with the problems plays a
part, the following questions are intended to test the diagnosis more sharply and to support it.
Neurological examination is also possible in order to underpin the diagnosis (Question
2). The most appropriate people to do this are the psychiatrist, paediatrician and neurologist. The degree
of maturation of the motor apparatus can be measured neurologically and signs of hypokinesis, too little
movement, or hyperkinesis, overactivity, can be diagnosed. Although it appears that the corpus callosum
of children with ADHD is smaller than average and the prefrontal brain is underdeveloped,we
do not yet have standardisation at our disposal, enabling us to find individual abnormalities, as is possible
with, for example, IQ.
The diagnosis of ADHDwithout hyperactivity and impulsivity is often hard to make. We tend to imagine
a chaotic child when we think of ADHD; this is, however, not the case with the form AD(H)D-attention
deficit. A second difficulty is that the child with ADHD without inadequate attention function seems to
functionwell in structured situations like a school. In that case the behaviour of the child is not recognised
at school and people are quick to point, unjustly, at the childrearing by the parents as the cause of the
behaviour.
Children and Behavioural Problems by: Martine, F, Delfos (2004). Pg. 186 – 190.
To support the diagnosis of ADHD we can check whether there are other symptoms of a delayed
maturation (Question 3). These symptoms do not necessarily have to be present but are an extra indication
when they do occur. A number of areas that we can pay attention to can be distinguished. The first is the
child’s temperament as a baby.When the child cried a lot as a baby, this is possibly an indication for
problems with the maturation of the brain. The second question is whether the child showed any sleeping
disorders, because many maturation disorders occur during the night and maturation takes place for an
important part during the night. The third area is the development of toilet-training. Late toilet-training
can be a sign of late maturation. When the child is toilet-trained at night and not in the daytime, then it is
not a maturation problem but more a behaviour problem. If it is a case of delayed maturation of the
bladder muscles then this plays a role at least at night. Finally, there is the area of the learning disorders
where indications for delayed maturation can be found: dyslexia, mathematics disorder and writing
disorder or dysgraphia (Question 4).
The diagnostics of dyslexia has been well mapped, for example thanks to the work of people like Dumont
(1990, 1994), and is still being researched. As far as the writing disorder is concerned, Hamstra-Bletz and
de Bie (1985) mapped the specific way of writing of children with a writing disorder. Table 2.1 showing
maturation disorders can be found in Chapter 2. Because children with ADHD are expected to be
normally intelligent, an intelligence test will in principle not offer anything to hold on to for the diagnosis
of ADHD.
ADHD, as a disorder of the maturation of the central nervous system, is already present from earliest
childhood, but is not always clearly noticeable. I have already stated that there are three phases when the
disorder becomes apparent, depending on the requirements set by the development tasks to the child: as a
baby, as a pre-schooler and in the first year of primary school (Question 5). When it is not possible to
point at one of these moments based on the anamnesis, case history, then the diagnosis ADHD is not
plausible. The behaviour of the child with ADHD is structural, systematic. If the child is hyperactive, then
this will show in all ‘free’ situations. If the child has attention deficit this will become noticeable in all
tasks that require concentration. If the child is impulsive, then it will always want to give into its wishes
and new stimuli that occur. When the child only shows certain behaviours in specific situations,
then it might be a conduct problem instead of ADHD. A child with ADHD-hyperactivity-impulsivity,
without attention deficit, will generally function well at school. The structured situation ensures that the
child does not attract attention by chaotic and active behaviour, except in free situations like the
schoolyard and at home. Because there are strong indications thatADHDis hereditary (Question 6) and
seems to be easy to inherit, it is probable that there are family members who also have or had ADHD. It
mainly occurs with boys. It is therefore useful when diagnosing to find out whether it occurs within the
family. When it occurs with a family member, for example the father, the extent that he has controlled it
is a possible indication for the pace of maturation of the son. The chances are that the child will show the
same pace of maturation. This is an indication for the prognosis. Because of their disturbing behaviour
children with ADHD are easily confused with children with externalising conduct problems.When
describing the various problems I stated similarities and differences (see Table 6.1 in Chapter 6).
With the diagnostic outline, however, we start from a child who only has the disorder ADHD, although in
many cases it goes together with one of the forms of conduct difficulties. Although he keeps on starting a
new activity because of his impulsivity-hyperactivity, the child with ADHD has difficulty in adjusting to
situations (Question 7) and is more likely to make his own plan than do what someone else asks.
The child with ADHD does not, in principle, have a strongly underdeveloped me–other differentiation
(Question 8), unless there is co-morbidity with a disorder where that is the case. They will also not come
across as unscrupulous. As a result of a reasonably developed me–other differentiation, the child will be
able to self-reflect (Question 9) and he will understand his part in an event pretty well. This also means
that he suffers because of the fact that his insights and possibilities to direct his behaviour are not
synchronised. Children with ADHD do generally show anxiety and are weighed down with
Children and Behavioural Problems by: Martine, F, Delfos (2004). Pg. 186 – 190.
conflicts with the environment. Despite the many conflicts that the child experiences and the rejection by
peers, the child withADHDwill need to play with others (Question 10). Not thinking egocentrically and
having a reasonable empathic capacity ensures that the child needs to be with other people. Other
children, however, often see the impulsive, hyperactive peer as someone who disturbs their play.When the
child is hyperactive, it will be even more troubled by it when a situation is exciting or when he is required
to sit still for a long period of time, for example during a conversation (Question 11). Finally, when the
diagnosis ADHD does not apply, there must be factors in the child’s environment that lead to the problem
behaviour (Question 12). When the questions stated above do not lead to ADHD, but there is
hyperactivity, then this is an indication for hyperactivity as a way of expressing underlying problems.
Co-morbidity
Although the various conduct problems and ADHD are described separately, there is the possibility of comorbidity,
the occurrence at the same time of various disorders or problems. When discussing ADHD I
stated that, as a result of the frustrationswhich the child meets with his environment, conduct problems
can arise. This co-morbidity often occurs in the group of children with ADHD, and applies both
to internalising and to externalising problems. Because the child with ADHD shows difficult behaviour
for the environment, he will often get into conflict with the environment and on those grounds develop
behaviour problems. This means that children who have ADHD almost always exhibit problematic
behaviour that is not directly caused by their predisposition in addition to the behaviour that is.
Moreover, ADHD and the externalising conduct disorder do not exclude each other. With these two
disorders some areas of the central nervous system are involved which are partly different and partly the
same, but are not working in opposite directions. This means that co-morbidity of ADHD and the
externalizing conduct disorder is possible. This will, however, occur less frequently. The same
goes for ADHD and the internalising conduct disorder. The latter will seldom occur and if it does then it
will do so more with girls than with boys. The characteristics of conduct disorders in internalising and
externalising forms exclude each other. They cannot therefore occur at the same time. If there is a
combination of externalising and internalising characteristics in the behavior then we are dealing with
conduct problems.
In order to make the right diagnosis it is important to diagnose all problems separately. In this way
everything can be mapped correctly. When a child with ADHD has indications for an inadequate me–
other differentiation, then it is necessary to examine the diagnostic criteria of the externalising conduct
disorder alongside the finding of ADHD. Because the child with ADHD has, in principle, a normal me–
other differentiation, an inadequate me–other differentiation is an indication of different
problems or co-morbidity with a different disorder. These could be the conduct disorder or a contact
disorder like PDD-NOS (Pervasive Developmental Disorder – Not Otherwise Specified).