What Are the Symptoms of ADHD in Children?

I was that child. Not the one who wrecked the classroom, but the one who looked out of the window. My grades were not bad, I always did my homework; I just did it on the last night. Because I did not disturb anyone, no one asked anything, and I got my diagnosis at twenty-three.

So while writing this article there is a child on my mind, and that child is not loud.

Let me say right away: there is no diagnostic tool here, and there cannot be. My aim is to show when consulting a specialist becomes meaningful. Every child is active, every child sometimes does not listen, every child forgets things. Where the line falls is less unclear than people think.

The three areas where symptoms cluster

The diagnostic criteria group the symptoms under three headings (American Psychiatric Association, 2013).

Inattention

• Overlooking details, making careless mistakes
• Being unable to sustain attention during play or homework
• Seeming not to listen when spoken to directly
• Being unable to follow instructions through to the end, leaving tasks unfinished
• Having difficulty organizing
• Avoiding work that requires sustained mental effort
• Often losing belongings
• Being easily distracted by outside stimuli
• Forgetting daily tasks

Hyperactivity

• Being unable to stay still, hands and feet constantly fidgeting
• Getting up where sitting is expected
• Running or climbing in inappropriate situations
• Having difficulty playing quietly
• Being constantly on the go
• Talking excessively

Impulsivity

• Answering before the question is finished
• Having difficulty waiting for their turn
• Interrupting others, butting into their games

What is actually decisive

Every child has some amount of every item above. What is sought in an assessment is not ticking off a list but seeing the pattern.

Being above what is expected for the age. A five-year-old being unable to sit for ten minutes is expected. For a twelve-year-old the same behavior means something different. The measure is not an absolute threshold; it is comparison with peers.

Being seen in at least two settings. A picture seen only at home or only at school calls for another explanation; it may be pointing to something about the setting. In the glossary it appears as the two-setting rule.

Genuinely affecting functioning. It needs to be creating visible difficulty in academic, social or family life. A child who is active but happy, has friends and keeps up with their lessons is not looked at for a diagnosis.

Having started early. It is required that the symptoms appeared in childhood; not a picture that began one morning.

Persistence. A period of a few weeks is not enough; a pattern spread over months is sought.

A child may also be going through a hard period. A move, a loss, a separation, a change of school or tension at home can produce similar symptoms. Telling these apart is the specialist's job, and this is the part that should not be rushed.

The three presentation types

The criteria define three presentations. In the criteria these are called presentation types.

Predominantly inattentive. The quiet, dreamy child who falls behind. The one who does their homework and forgets it at home, whose bag is missing something every morning. They do not disturb anyone, and for exactly this reason they are not seen. I described this picture in detail in the article on inattentive type ADHD.

Predominantly hyperactive-impulsive. The active, talkative child who stands out in the classroom. The picture that is noticed earliest and referred earliest.

Combined. Both together. This is the picture most often seen in clinic referrals.

The presentation is not thought of as a fixed category; it can shift over the years. Someone who looks combined in childhood can look predominantly inattentive in adolescence, because outward activity tends to decrease with age.

Why it is missed in girls

The review by Quinn and Madhoo (2014) shows that the predominantly inattentive picture is more common in girls and that this delays diagnosis.

The mechanism, I think, is very simple and very painful: a child looking out of the window does not disturb the order of the class. When the teacher is not bothered, no referral comes. On top of that comes the compliance expected of girls, and the child learns to hide it as early as primary school. What they have learned has a name: masking.

The result is a crowded group that I am part of: women diagnosed in adulthood. The same sentences are on the report cards. "Dreamy." "Not using her potential." "She could do it if she worked harder."

Reading those sentences years later is a strange feeling. No one acted in bad faith; no one asked the right question.

Prevalence and the "is it exaggerated" question

A meta-analysis pooling studies from around the world reports the prevalence of ADHD in children and adolescents at about 5 percent and shows that the differences between countries stem largely from differences in method (Polanczyk et al., 2007).

Knowing this number is useful: in a class of thirty it means one or two children on average. So it is neither "every child has it" nor "very rare."

Where to apply in Turkey

Assessment is the job of a child and adolescent mental health specialist. The route usually goes like this:

• Child and adolescent psychiatry outpatient clinic. The diagnosis and treatment decision is made here. Whether it is a state hospital, a university hospital or a private practice makes no difference; what is decisive is the doctor's specialty.
• School counseling service. It can be the first point of contact for observation and referral. The school counselor's in-class observation is one of the most valuable pieces of information you have when you go to the doctor.
• Guidance and Research Center (RAM). For educational assessment and referral to support education. The glossary has an entry for the guidance and research center.

The NICE guideline (2018) emphasizes that assessment requires gathering information from more than one source: the family, the school and, if possible, the child themselves. A diagnosis made in a single meeting on the basis of a single account is an incomplete diagnosis.

What to prepare when going for an assessment

Things that will be useful to take with you to the specialist:

• Teacher observations, report card comments, and old years' report cards if you have them
• A short note over a few weeks on which behavior happens how often; "three times this week" instead of "often"
• Information on whether there is a similar picture in the family
• Observations about sleep pattern, eating and screen habits
• The areas where the child is doing well. Most people forget to write this down, yet the picture is not described by deficits alone.

This preparation directly raises the quality of the assessment. The weakest data a doctor has is what is remembered at the moment of the meeting.

Tests on the internet do not diagnose. Online scales are only screening tools; they carry no meaning on their own and can give completely different results depending on the child's mood at that moment. The glossary entry on false positives explains why these tools can mislead.

Two common mistakes

The first is waiting. The sentence "they'll grow out of it" is very common and sometimes turns out to be right; but when it turns out wrong, what is lost is not only time. In those years the child builds a story about themselves, and that story becomes "I can't do it."

The second is rushing. Looking for a diagnosis on the basis of a week of observation, or loading a whole picture onto a single behavior, does not work either.

I wrote about how the same picture looks in adulthood in the article on ADHD symptoms in adults; the appearance differs markedly from childhood.

A note

When I think about myself as a child, what I want most is actually not a diagnosis. It is for someone to stop and say "you are not lazy, something is hard for you, let's see what it is."

If you have doubts, consulting rather than waiting means saying that sentence to a child earlier. If you have ADHD yourself and are going through this process as a parent, the article on being a parent with ADHD may also help you.