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Is it Still ADHD When Symptoms Emerge After Age 7?
One of the current diagnostic criteria for ADHD is that impairment from symptoms must be evident prior to age 7. This means children whose symptoms emerge at a later age can not be diagnosed with ADHD, and it is assumed that their symptoms are reflective of some other condition or are secondary to school failure. (For a complete discussion of diagnostic criteria click here.
This age of onset criteria was included in DSM-IV because ADHD has always been considered a disorder that arose during early childhood. When symptoms emerged beyond the early childhood years, it was believed that this could not be ADHD, but instead reflected behavior arising in response to failure at school and/or the development of another psychiatric condition (e.g. depression).
A study recently appearing in the Journal of the American Academy of Child and Adolescent Psychiatry casts doubt on the validity of this belief. In this study, 380 children between the ages of 4 and 17 who met symptomatic criteria for ADHD were compared according to whether the initial impairment from their ADHD symptoms was evident prior to age 7.
Results indicate that the validity of the age of onset criteria depends on what type of ADHD the child was diagnosed with. Recall that the core symptoms groups for ADHD are problems with attention and problems with hyperactivity/impulsivity. According to current diagnostic guidelines, children who show attention problems but not hyperactive/impulsive problems are diagnosed with ADHD, Predominantly Inattentive Type. (This is what used to be called ADD, a term which is no longer technically correct). Children with hyperactive/impulsive symptoms but not attention symptoms are diagnosed ADHD, Predominantly Hyperactive/Impulsive Type. Children who display symptoms of each type are diagnosed with ADHD, Combined Type.
Results indicated that nearly all subjects diagnosed with the hyperactive/impulsive subtype of ADHD first showed impairment from their symptoms prior to age 7. Nearly 20% of the combined group and 43% of the inattentive group, however, did not show impairment by this age. These were all children that trained clinicians agreed had "true" cases of ADHD, and imposing the age of onset criteria would thus have reduced the accurate identification of these cases.
These results question the usefulness of requiring an early age of onset for diagnosing ADHD, especially for the combined and predominantly inattentive subtype. My own experience is that for children who display only the attention problems, difficulties often do not emerge until late elementary school or even middle school.
This is probably because children with attention symptoms only are generally not behavior problems, and are often able to get by in the early grades when the academic demands are not that great. This is especially true for a child who is above average inability because they can often do okay in their school work even if they have trouble attending.
As children move in to the later grades, however, academic demands and the need to sustain attention increase considerably. Children also begin to get more homework. At some point, it doesn't matter how smart you are - you simply need to be able to sustain attention and concentration in order to do well academically. In middle school, children also change from having a single teacher to having multiple teachers. When this occurs, it becomes increasingly difficult to stay organized and keep track of assignments from multiple classes. As a result, a child who did okay in prior grades can suddenly start to struggle in a major way.
Many times, because a child has done well in earlier grades, the assumption is made that he or she must now be unmotivated or lazy. As a child starts to struggle and do poorly, they often can lose their motivation as a result. Parents and children can start butting heads and get locked into an escalating power struggle and conflict as a result.
It is important for parents to be aware that ADHD symptoms, and the difficulty these symptoms cause, will vary tremendously depending on the context. In some situations, a child with ADHD will appear indistinguishable from his or her peers. In other situations, the symptoms will be quite apparent and create significant difficulties. Unfortunately, the classroom environment is often one of these latter situations, and this is especially true of how most middle schools are structured. Trying to alter these environments in ways that make it more likely for a child with ADHD to be successful can thus become a critically important aspect of a child's treatment.
It should also be stressed that although requiring a strict cut off like age 7 apparently reduces diagnostic accuracy, it is important to be very careful when diagnosing ADHD in a child whose symptoms do not create significant impairment until a later age. When this occurs, it is usually the case that there would have been some clear indication of symptoms at an earlier age, even if the difficulties they created were not especially severe. Thus, teachers may have noted that the child had trouble completing assignments, or seemed to daydream and be off task more than peers.
When ADHD symptoms first emerge in an older child without their being ANY prior evidence that they were present, however, it is likely that these symptoms do reflect a different type of problems. For example, a 12 year old who had NEVER displayed any prior attention problems is suddenly observed to have real problems with sustained attention and stops completing assigned work. This situation would be more likely to reflect some type of emotional disorder rather than ADHD and would warrant a careful evaluation in which all alternative possibilities were carefully considered.
Note: This article originally appeared in Attention Research Update, an online newsletter written by Dr. David Rabiner, a Duke University psychologist and former member of CHADD's Professional Advisory Board. You can learn more about Attention Research Update and sign up for a free subscription at www.helpforadd.com.