Diagnostic Challenge 3: ADHD Symptoms

Diagnostic Challenge #3: ADHD symptoms: What's normal, what's not?

Certainly, we've all had at least an occasional problem with distraction, concentration, daydreaming, fidgeting, and not paying attention when we should. Likewise, who among us hasn't had that socially awkward moment we later regret? So, what makes these ordinary problems of everyday life, different from ADHD? The previous section discussed how the symptoms of ADHD can appear similar to other disorders. However, these symptoms can also be confused with ordinary, normal behaviors as well. In this section, we'll look at the similarities and differences between ADHD symptoms and ordinary differences among normal, healthy people.

One way to conceptualize, "What is normal and what is not?" is to understand the concept of a continuum. Nearly all behaviors and personality characteristics fall along a continuum. A person can have all a particular characteristic in its most extreme form. Or, at the other extreme end, a person could have none of that characteristic. I think we easily understand that part. The tricky part is, where do we draw the line in the sand and say, now THIS is where normal ends and abnormal begins? In the past, this lack of clarity regarding ADHD symptoms may have contributed to missed diagnoses or inaccurate ADHD assessments. Fortunately, this has begun to change.

The method that psychologists use to decide what is normal is this: To what degree does the symptom, behavior, or characteristic interfere with the person's functioning and the responsible fulfillment of important life roles? For example, I have a friend who is terrified of the dentist. She has even experienced a full-blown panic attack, while driving to the dentist. She would meet all the criteria for Dental Phobia except for one thing. She still manages to go to the dentist, gets her teeth cleaned twice a year, etc. In other words, her symptoms would not meet the diagnostic criteria for a phobia, because the symptoms do not interfere with her ability to function well. Her ability to function well is demonstrated by the fact she continues to take good care of her dental health. The ability to take care of one's health demonstrates the fulfillment of important life roles.

Normal aging & memory loss

Some memory loss is considered normal for people as they age. However, there are significant variations among people. Some people's memory skills remain highly functional well into their 90's. Others experience impairment earlier in life. Research is focused on determining what causes these differences. One area of study is investigating why certain brain functions are more vulnerable to decline than others. For example, long-term memory and working memory, tend to decline with age. Meanwhile, vocabulary remains mostly intact.

Although it is typical for individuals to have some memory loss as they get older, this limitation can also become confused with ADHD symptoms. Normal memory decline affects executive functioning skills such as concentration and decision-making. As you will recall, these same executive functioning skills are impaired in ADHD. So, when evaluating an adult, these normal changes in memory can potentially look like ADHD symptoms of executive function impairment, along with difficulty learning new material. However, further analysis reveals that the executive function impairment is relatively recent and cannot be traced back to childhood. This fact clearly rules out ADHD, since symptoms must be present before age 12.

However, one might question why the same symptoms are "normal" in aging adults, but considered an impairment in those with ADHD. As mentioned above, normal can be defined in various ways, including the extent of interference with daily functioning or even the percentage of people in the population who experience such problems. In individuals with ADHD, these types of problems are present since childhood and most children do not experience similar problems. In addition, it interferes in several aspects of daily functioning. So, by either definition, memory impairment is a problem for those with ADHD. One could argue that memory impairment is also a problem for older adults since not all adults experience the loss and it does interfere with various aspects of functioning. However, for now, it is considered a normal aspect of aging.