Many children and adolescents present to their primary care provider’s office with concerns about inattention, poor focus or poor concentration. Since the primary care provider’s office is typically the first stop, it is important to be comfortable further evaluating the presenting problem, identifying associated symptoms, determining the diagnosis and implementing the best treatment plan. Many times symptoms of inattention represent Attention Deficit Hyperactivity Disorder (ADHD), but in many cases ADHD is not the cause of the inattention and treatment with a stimulant is not the best course of action.
It is important to flesh out the presenting complaint of “inattention”. Symptoms of inattention include: failure to give close attention/makes careless mistakes, difficulty sustaining attention, difficulty listening, difficulty following through on instructions/ completing tasks, poor organization, avoidance of activities that require sustained mental effort, easily losing things, being easily distracted, and being forgetful. Inattention may or may not be accompanied by symptoms of hyperactivity and impulsivity, like being fidgety and squirmy, having difficulty staying in seat, running and climbing excessively (in older children, feeling of restlessness), being “on the go” or “driven by a motor”, talking excessively, blurting out answers, having difficulty waiting one’s turn, and interrupting others.
When assessing inattention, it is important to consider all possible causes, which can include: depression, anxiety, reaction to trauma, family or psychosocial stressor, a learning disability, a sensory processing issue, intellectual disability, poor educational fit, traumatic brain injury, substance abuse, normal developmental variant, and rarely, psychosis. If these other causes have been considered and ruled out, the inattention symptoms are impairing in both the home and school settings and the symptoms began before age 7, then a diagnosis of ADHD is likely and a treatment course involving a stimulant medication will likely be helpful. Likewise if a diagnosis of ADHD has been made but a child does not respond to multiple medication trials including stimulants and non-stimulants, then the treating clinician should reconsider the diagnosis.
Here are two case examples to illustrate the point:
- 14 yo female presents with a chief complaint of “trouble focusing”. She previously maintained good grades and did not have concerns of inattention, hyperactivity or impulsivity in early childhood. She now has failing grades. Associated symptoms include: irritability, poor sleep, isolation including from friends and non-suicidal self-injury for the last 2 months. She has a family history of depression in her mother and maternal GM and older sister.
– This presentation is more consistent with a diagnosis of Major Depression than ADHD. Patients with depression commonly report poor concentration and trouble with attention. A diagnosis of ADHD would not be consistent with this presentation because the patient did not have symptoms begin before age 7. A good treatment plan would be to consider an individual therapy and possibly an SSRI. While a stimulant may help with her inattention, it would not be helpful for her other depressive symptoms.
2. 6 yo boy presents with a chief complaint of “inattention and impulsivity” primarily in the school setting. This child is in protective custody after being removed from bio parents because of physical abuse and neglect. He was not in school prior to the removal and was mostly socially isolated at home. He also presents with delays in speech and cognitive development as well as anxiety and aggression.
– This case example is more complicated because there are factors related to trauma as well as developmental and educational delays. It would be important to fully evaluate those delays with a full developmental evaluation, including assessing for intellectual ability and speech and language abilities. It is also important to ensure that he is in an appropriate educational placement prior to considering a diagnosis of ADHD. Also, because of the co-morbid anxiety, a stimulant may not be the best medication choice as stimulants can make anxiety worse. Other options might be atomoxetine (Strattera) or guanfacine (Tenex). Until a more thorough assessment can be completed, a more appropriate diagnosis might be Adjustment Disorder with Disturbance of Conduct and Emotion.
Hopefully, this discussion and these case examples help illustrate the importance of a thorough assessment when a child presents with a chief complaint of “trouble focusing”, prior to beginning treatment. Since most patients will first present to their primary care provider with this concern, it is important for primary care providers to be comfortable beginning that assessment process.