Attention-Deficit/Hyperactivity Disorder: The Diagnostic Process From Different Perspectives*

CASE By the time she was 9 years old and in the middle of her third-grade year, Julie’s parents realized that she had a problem with learning compared to other children. Her mother said that she was “always flighty”—daydreaming and not consistently connected when talking to her friends or family members. At open house, her second-grade teacher commented that “Julie is a good kid, a smart kid, but she is often not attentive during class discussions.” Reading skills were described as “somewhat slower” than with other children her age. Because she was making progress and did not exhibit any disruptive behaviors, Julie’s second-grade teacher and parents decided to observe her over the next year. In the third grade, Julie was not able to keep up with the class in reading. She read slowly and often had difficulty when asked questions about a story she had read in class. Her math skills were above average and her spelling was at the class level. Julie’s parents described social interactions as “bubbly— sometimes too quick to talk when in a group of other girls.” She had several friends, but friendships were rarely sustained. Julie’s father noted that she “seemed to worry a lot” about her appearance and how other kids felt about her. She was especially fearful of shots in the pediatrician’s office and barking dogs. She enjoyed going to her ballet class but “often cried and seemed worried about her performance” prior to recitals. Julie was an only child. Her parents had a solid marriage and often engaged Julie in weekend activities. They both worked full-time; her mother taught English as a second language, and her father worked in construction. Her mother completed college, although she recalled struggling with math. She described herself as a “worrier” and endorsed fears about flying, meeting new people and taking vacations. She stated that she experienced anxiety when there were changes in her adult life (eg, a new school assignment or planning a meeting with her principal). Julie’s father completed high school but had a history of reading problems. He took special reading classes beginning in elementary school, but as an adult, he rarely read a newspaper or a novel. He recalled that teachers told his parents that he was “hyperactive” and that his overactivity in class and poor attention impaired his learning. In the pediatrician’s office, Julie was observed to be initially shy but could be engaged in conversation. Her speech was clear and intelligible, although she answered questions with short phrases. She was not hyperactive, but her attention to directions and questions was limited. Growth parameters, a screening audiogram and visual acuity and a complete physical examination were normal.