Monday, February 12, 2007

My Child is Inattentive and Hyperactive

My child is inattentive and hyperactive!” I hear this as a presenting complaint about two hundred times each year (from among our clinic’s 400 referrals each year). My first response (after my unspoken… “And?!?!… you had to have been told something about children and this behavior before becoming pregnant?”) is to tell parents that all children (and adults) are inattentive and hyperactive. The question is, “How much does the inattention (or hyperactivity) differ from the norm?”. Einstein aptly informed us that “all is relative” and that a behavior cannot be understood independent of the observer. A parent who exhibits significant symptoms of inattention and hyperactivity may perceive similar child symptoms as the norm. A parent who resides within a chaotic, unpredictable and inconsistent home environment may not recognize features of inattention as a problem. The symptoms defined as the “norm” in one home or “not a problem” in another home may be perceived as disruptive, disabling or catastrophic to the parent whose world corresponds to a Franklin Covey Day Planner. The central role played by the parent (observer) in the diagnostic process is obviously problematic since the presence of a diagnosis is potentially more dependent upon the parent than the child.

The solution to the dilemma introduced by observer bias is the use of standardized tests to assess processing capacities/abilities and deficits/impairments. Standardized tests are measures (or tests) that are presented to children (or adults) using a standardized (consistent, predictable, etc.) method with specific (standardized) instructions to maximize consistency among observers (testers). The diagnostic task is to identify whether the presenting symptoms/complaints (ie., inattention, hyperactivity, etc.) are part of the normal bell curve (within the norm for children the same age) or are outside of the normal bell curve relative to the child’s peers.

All human behavior or performances tend to be normally distributed such a low number of people exhibit a high level of performance, a low number of people exhibit a low level of performance and most people fall in the middle. As an example, a few people are very fast, a few people are very slow, but most people fall in the middle. A few people are very strong, a few people are very weak, but most people fall in the middle. Standardized tests are simply measures of behavior or performance and, as a result, performance on tests is normally distributed with a few children scoring high and low, and a large number of children scoring in the middle. Within the standardized testing method, observations obtained on a single child are compared to this normal bell curve. The task is to identify the extent to which the child’s behavior deviates from the norm. Definitions (often referred to as “cutoff scores”) regarding what constitutes abnormal behavior or the presence of a disorder differ. However, most clinicians tend to classify scores that deviate from the norm by over two standard deviations (ie., observed among less than five percent of children) as abnormal or of sufficient severity to warrant a “disorder” diagnosis.

So… is “my child is inattentive and hyperactive?” The answer is “yes”… and so are you. “Does my child’s inattention and hyperactivity deviate from the norm sufficiently to be an impairment relative to the demands of the normal environment (home or school)?” The answer is “I don’t know” and it is very unlikely that any other single observer will have the answer to that question (including physicians, psychologists, etc. are also biased observers). The solution… complete an evaluation that utilizes standardized measures.

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