During the assessment process it is of great importance for the physician or clinician to consider other possible causes of inattention, impulsivity, or hyperactivity in your child (or teen, or yourself). In fact, this is probably the most important element of a good assessment. There are several possible causes of these behaviors, especially in children, and the clinician must have great certainty that these other possible causes have been ruled out before giving the label of "Attention Deficit Hyperactivity Disorder" to your child.

One of the first things to have ruled out is a thyroid problem. Only MD's can do this, so off they go for a physical. This is not a common problem, but it does happen, even in children. Thyroid problems can cause inattention, learning problems, even hyperactivity and impulsivity in some. Once that has been ruled out by the doctor, then other environmental or emotional causes of inattention, impulsivity, or hyperactivity need to be ruled out.

Depression in children often causes inattention, as in adults, and also often causes impulsivity and irritability and excessive restlessness or agitation. Anxiety disorders in children can result in agitation, impulsivity, hyper- vigilance, motor restlessness, and excessive startle responses, as well as inattention to task. Significant emotional traumas can also result in these behaviors. Physical or sexual abuse, divorce or other significant loss, or the death of a loved one.

Physical traumas can also cause the same behaviors as ADHD, such as a minor head injury from an auto accident, sports injury, falling as a child, and so on. For example, one of my "ADHD" kids, who was extremely hyperactive and also very oppositional and at times violent toward others, took part in one of our research projects. As part of the study we "brain mapped" him (QEEG) at the onset of the study. We saw two small head injuries in the back of the head and one big injury in the front of the head.

The frontal problem was expected, but the problems in the back of the head were not. I simply asked the parents, "When did he bash the back of his head?" They thought for a minute and remembered that when he was about six weeks old he had fallen out of his crib onto a hard flood so hard that they had to call an ambulance to take him to the hospital. They had forgotten about the incident during the clinical interview, but the mapping showed a clear problem. He fell on the back of the head, causing those injuries, and the brain "sloshed" forward causing the frontal injuries. These injuries have resulted in a lack of inhibition and cortical control, temper outbursts, and learning problems. The diagnosis here would not be ADHD, but rather a head injury.

Mark my words, in the next five years you will see lots of research showing that playing soccer causes minor head injuries from "heading" the ball. A brain researcher friend of mine has seen this several times now in treating soccer players (professional and collegiate) for memory problems and other cognitive problems.

Every once in a while we see someone who has been exposed to toxins come down with cognitive problems. We live one of the biggest agricultural areas in the world, and sometimes people get sprayed by chemicals, or get exposed to pesticides other ways. This can result in all kinds of neurological problems.

Tourette's Syndrome is also commonly misdiagnosed as ADHD. Think of it as basically ADHD with tics, and it is a close genetic cousin to ADHD. But it is important to know the difference, as the treatment for ADHD is often stimulants, and sometimes stimulant medications can make Tourette's worse. You can learn a great deal about Tourette's Syndrome in a great book by David Comings, MD, titled, "Tourette Syndrome and Human Behavior." It should be available through your library.

What are the major things to look for then? The big clue is in knowing whether the target behaviors (inattention, or impulsivity, or hyperactivity) have always been apparent to some degree or other, or if they just started one day. And if they just "started one day," then did they start as the result of some event (traumatic or environmental) ?

ADHD is usually "always there" while the other things tend to have a starting date. Tourette's is the exception, as sometimes it has "always been there," and sometimes it has a starting date. Realistically, if it looks like ADHD, then it probably is, but as a clinician the other possibilities must always be ruled out before making a diagnosis and developing a treatment plan. Information on the different types of ADHD and specific treatment recommendations is available at the ADHD Information Library.

Douglas Cowan, Psy.D., is a family therapist who has been working with ADHD children and their families since 1986. He is the clinical director of the ADHD Information Library's family of seven web sites, including http://www.newideas.net, helping over 350,000 parents and teachers learn more about ADHD each year. Dr. Cowan also serves on the Medical Advisory Board of VAXA International of Tampa, FL., is President of the Board of Directors for KAXL 88.3 FM in central California, and is President of NewIdeas.net Incorporated.