Is There an ADHD Spectrum?

By Ellen Braaten, PhD
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Q

I’ve heard people talk about kids having mild ADHD or severe ADHD. Is there such a thing as an ADHD spectrum?

A

This is a great question, and the short answer is “yes.” ADHD symptoms are something that exist on a spectrum or a continuum. But the longer answer is a little bit more complicated. There are two important factors to consider—the type of symptoms a child has and how intense they are.

The main signs of ADHD are inattention, hyperactivity and impulsivity. Some kids have trouble in all three of those areas. Some primarily have problems with inattention. And others may primarily have problems with impulsivity/hyperactivity.

People often think of ADHD (also referred to as ADD) as being just one thing. To some it might mean the stereotype of the hyperactive boy who can’t sit still in school. To others, it might mean the child who never seems to pay attention.

But no two kids with ADHD are exactly alike. Their symptoms can vary in type and severity. For instance, one child with hyperactivity might squirm in his seat during a lesson. Another might get up and walk around the room, touching everything in sight. So, you might think of the first child as having “mild” ADHD and the other as having “severe” ADHD.

This is why diagnosing ADHD can be tricky. ADHD isn’t an all-or-nothing thing. And sometimes what looks like ADHD might not be the sign of an issue at all.

Most kids will sometimes get antsy and squirm. All have times when they’re forgetful, struggle to wait their turn, and are easily distracted. That doesn’t mean they have ADHD, though.

In fact, kids with ADHD don’t just sometimes have this behavior. They constantly have it. And for a diagnosis of ADHD, their behavior must be severe enough to interfere with their ability to function at home and in school. That’s why I say there’s an ADHD spectrum.

A good evaluator will be thinking about that spectrum of symptoms that define ADHD. The challenge is to separate typical behavior from problems that can have a mild impact or a major one.

That can also help determine what type of ADHD treatment a child might need. Kids whose symptoms fall on the more significant end of the spectrum might receive multiple treatments. These might include tutoring, ADHD medication and behavioral strategies. Kids with milder symptoms may receive only behavioral strategies.

Imagine a fifth grader with severe ADHD symptoms. He has serious difficulty paying attention in school. He’s frequently out of his seat in the classroom, blurts out answers to questions, and is so distracted by even the slightest noise that he has trouble doing almost anything in class.

For that reason, his doctor has prescribed medication for ADHD. The school has given him IEP services and supports. He gets classroom accommodations and works with a specialist to improve executive function skills.

Now imagine an eighth grader who has difficulty staying organized and getting work done on time. Her symptoms of inattention are significant enough to cause difficulty at school. But they’re so mild that she wasn’t diagnosed with ADHD until the seventh grade.

This child has a 504 plan at school with accommodations. She also works with a private organization coach to build skills. Her doctor and parents talked about medication. But they decided her symptoms were mild enough that behavioral strategies would be enough to help her cope.

Recent genetic studies have looked at attention skills in the general population. They found that there’s a natural spectrum of functioning, with ADHD at one extreme.

One day genetic analysis may help us predict kids who will be at high risk for ADHD. For now, a diagnosis still depends on how severe the symptoms are. Evaluators use their clinical judgment to make that determination. And professionals consider where symptoms fall on the continuum to determine how to best help a child with ADHD.

Read about nine things a proper ADHD evaluation should include. And find out what to do if your child was recently diagnosed with ADHD.

About the Author

About the Author

Ellen Braaten, PhD 

is the director of LEAP and codirector of the Clay Center for Young Healthy Minds, both at Massachusetts General Hospital.

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