Inattention: Is it ADHD or Something else?I

Problems with inattention in children is a common complaint that parents bring up to the doctor's attention. To make a good assessment and management of this problem, one has to have a good work-up to find the cause of inattention. 

ADHD - Attention deficit Hyperactivity disorder is usually noted in childhood characterized by their poor ability to sustain attention on tasks, impulsivity and hyperactivity, which could be manifested as restlessness, squirming in their seat, and disruptive behavior.

There are some medical conditions that can present as inattention:

• Hypothyroidism, which is seen in a person with hypoactive thyroid
• Episodes of low blood sugar levels
• Children with seizure disorder, petit mal, episodes of brief lapse of consciousness without the usual generalized tonic-clonic spasms
• Children with high levels of lead, usually seen in children exposed to lead in their environment (old houses with peeling old paint on the walls)
• Children with anemia - low iron in their red blood cells
• Children with vision and hearing problems can present as inattentive and academic performance is negatively impacted as well.

There are also other Psychiatric conditions that can look like inattention:

• A highly anxious child who is worried about everything - his/her performance in school, problems at home with family members, peer problems - can look inattentive because of all these other preoccupations that may interfere in concentration at school.
• A child who has been or is currently experiencing physical/emotional or sexual abuse may appear disinterested and unable to apply self in school or at home.
• A depressed child can also present with inability to carry on usual activities at school or home and can be labeled as an "inattentive child".
• A child struggling with learning problems, such as difficulties in one or more subjects - reading, math, spelling may appear restless, unable to finish schoolwork or takes a long time to finish homework- which may all be attributed to inattention. 
• A hyperactive, disruptive and aggressive child can also be labeled as ADHD. Reasons for the restlessness and impulsivity may also be caused by other psychiatric conditions, such as depression (some children and adolescents may present as such when depressed), and post-traumatic disorder (children exposed to/victims of domestic violence).
• A child who had history of head trauma/injury (example injury while playing basketball or football) may present with problems of inattention after the traumatic incident.

Making a diagnosis of ADHD:

Before one can say your child has ADHD - the medical conditions described above will need to be excluded as possible causes of Inattention. This means blood tests to evaluate thyroid function, blood sugar level, anemia.  Red blood cell counts with Hemoglobin levels and lead levels may need to be done first. Vision and hearing have to be checked as well. 

A good psychosocial history has to be done and focus on the following:

1. Developmental history of child to see if there were signs of other developmental delays and emotional problems during early childhood years
2. Family relationships, sources of stress or tension for the child and the family.

Exploring this historical background can give a better understanding of underlying issues or concerns. When there is evidence of other psycho-social factors, management and treatment of the child, it may include individual psychotherapy for the child, family therapy, and other therapies to address developmental issues such as occupational therapy and address sensory and motor problems, which can cause learning problems, speech and language therapy for those with language problems and reading remediation classes for those with reading difficulties

It is also important to be aware that ADHD can also coexist with psychiatric conditions like anxiety, depression, PTSD, learning disorders and other neurodevelopmental disorders like autism and mental deficiencies.

Why is it important to know all these other possible conditions that can mimic or coexist with ADHD?

The optimal treatment of ADHD includes medication to improve attention, as well as medications to treat possible underlying psychiatric conditions, and psychosocial interventions such as individual and family therapy, occupational therapy, speech and language therapy, and behavior therapy. Correction of visual and hearing problems is also an important intervention.