ContinuingEdCourses.Net Courses for Mental Health Professionals
Courses Approvals Contact Us My Account

Is It Really Beyond Normal? Misdiagnosing ADHD and Autism Spectrum Disorder
by Enrico Gnaulati, Ph.D.

3 CE Hours - $74

Last revised: 03/01/2023

Course content © copyright 2023 by Enrico Gnaulati, Ph.D. All rights reserved.

ContinuingEdCourses.Net is approved by the American Psychological Association (APA) to sponsor continuing education for psychologists. ContinuingEdCourses.Net maintains responsibility for this program and its content.

ContinuingEdCourses.Net, provider #1107, is approved as an ACE provider to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Regulatory boards are the final authority on courses accepted for continuing education credit. ACE provider approval period: 3/9/2005-3/9/2027.

ContinuingEdCourses.Net has been approved by the National Board for Certified Counselors (NBCC) as an Approved Continuing Education Provider (ACEP), ACEP #6323. Programs that do not qualify for NBCC credit are clearly identified. ContinuingEdCourses.Net is solely responsible for all aspects of the programs.

ContinuingEdCourses.Net is recognized by the New York State Education Department's State Board for Psychology (NYSED-PSY) as an approved provider of continuing education for licensed psychologists #PSY-0048.

ContinuingEdCourses.Net is recognized by the New York State Education Department's State Board for Social Work (NYSED-SW) as an approved provider of continuing education for licensed social workers #SW-0561.

ContinuingEdCourses.Net is recognized by the New York State Education Department's State Board for Mental Health Practitioners (NYSED-MHC) as an approved provider of continuing education for licensed mental health counselors #MHC-0229.

No conflicts of interest have been reported by the authors.
Take the Course Take the Test Buy your Certificate

 

Learning Objectives

This is an intermediate-level course. Upon completion of the course, mental health professionals will be able to:

This course relies on data from evidence-based practice, descriptive material from practice-based evidence, and theoretical information to assist mental health professionals differentiate between actual cases of childhood disorders, such as ADHD and autism spectrum disorder, and behavioral reactions to the normal psychosocial and developmental challenges all children encounter. The positions taken in this course are in no way meant to minimize the validity of these disorders, nor to dissuade mental health professionals against early evaluation, detection, and intervention. Although robust empirical findings and theoretical justifications are provided to support the positions taken in this course, the topics discussed are under-researched and further studies are necessary to lend relevant empirical support.

The material in the course is based on two chapters from Dr. Gnaulati’s book, Back to Normal: Why Ordinary Childhood Behavior is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder (Beacon Press, 2013).

Outline

Introduction

The training of mental health clinicians can predispose them to assign diagnoses to children when the behavior in question falls instead within the broad scope of normalcy.[1-2] It can be exceedingly difficult to disentangle transitory disturbing reactions to stressful life events; lags in socio-emotional maturation; struggles related to mismatches in where a child is at developmentally and the cognitive and behavioral expectations placed on him or her at school; the outcome of patterns of emotional reactivity in the parent-child relationship; the manifestation of incipient difficult personality traits; a combination of all of these – and clear-cut evidence of a mental health diagnosis.

Remarkably high rates of ADHD might be due to how symptoms of this disorder mimic normal childhood narcissism.[3-5] When assessing ADHD, common-sense questions need to be asked: Hyperactivity, or overdramatic attention-seeking behavior? Failing to finish tasks, or trouble persisting in the face of overconfident expectations? Disorganization, or magical thinking? Forgetfulness, or habitual under-preparation? Disproportionate numbers of African American children and adolescents are diagnosed with ADHD – one study showing rates of 14.5%, compared with 10% percent in the general population[6]– raising concerns that a medicalized approach shunts the focus away from socio-economic and educational disparities that contribute to ADHD-like phenomena.

When assessing high-functioning autism spectrum disorder, certain rule outs need to be entertained in order for an accurate diagnosis to be confidently arrived at: Is this a child whose presentation is better explained by delayed, but not impaired, language development? Problematic, but not disordered tantrumming and picky eating? The combination of incipient mental giftedness, introversion, and autonomy-seeking in boys? Or, the interplay of several, or all of these?[7-10]

This course will address all of these issues, enabling mental health clinicians working with children/adolescents and their parents to use non-pathologizing, developmentally normative ways of understanding and altering the types of struggling behavior that all-too-often gets mistaken for evidence of ADHD and/or autism spectrum disorder.

ADHD, or Childhood Narcissism at the Outer Edges?

In a typical U.S. classroom, there are nearly as many diagnosable cases of ADHD as there are of the common cold. In 2008, researchers from the Slone Epidemiology Center at Boston University found that almost 10 percent of children use cold remedies at any given time.[1] The latest statistics out of the prestigious Centers for Disease Control estimate that nearly one in ten school-age children have ADHD.[2]

The rising number of ADHD cases over the past four decades is staggering. In the 1970s, a mere one percent of children were considered ADHD. By the 1980s, 3 to 5% was the presumed rate, with steady increases into the 1990s. One eye-opening study showed that ADHD medications were being administered to as many as 17 percent of males in two school districts in southeastern Virginia in 1995.[3]

With numbers like these, we have to wonder if aspects of the disorder parallel childhood itself? Most readers of this course will recognize the core symptoms of ADHD. After all, the disorder and its associated symptoms are practically legendary: problems listening; forgetfulness; distractibility; prematurely ending effortful tasks; excessive talking; fidgetiness; difficulties waiting one’s turn; and being action-oriented. Many readers also may note that these symptoms encapsulate behaviors and tendencies that all children seem to find challenging. So what leads parents to dismiss a hunch that perhaps their child struggles with acquiring effective social skills or may be slower to mature emotionally than most other children instead of having ADHD?

The answer may lie, at least in part, on the common procedures and clinical atmosphere in which ADHD is assessed. A sensitive and sophisticated discussion about a child’s life situation and a possible ADHD diagnosis is time-consuming. Most parents consult with a pediatrician to determine whether their child has ADHD. Time is a scarce commodity for most pediatricians. The average length of a pediatric visit is about 16 minutes.[4] With the clock ticking and a line of patients in the waiting room, most efficient pediatricians will be inclined to curtail and simplify the discussion about a child’s problem behaviors. That’s one piece of the puzzle. Additionally, today’s parents are well-versed in ADHD terminology. They can easily be pressured into bypassing richer descriptions of their child’s problems and are often primed to cut to the chase, narrowly listing behaviors along the lines of the following:

All too often, forces conspire in the doctor’s office to ensure that any discussion about the child’s predicament is brief, compact, and symptom-focused instead of long, explorative, and developmentally focused, as it should be. The compactness of the discussion in the doctor’s office may even be reassuring to parents who are baffled and exasperated by their child’s behavior. It is easy to understand why parents may favor a sure and swift approach when the discussion converges on checking off lists of symptoms, floating a diagnosis of ADHD, and reviewing options for medication.

Childhood Narcissism

In my experience, the lack of a clear understanding of normal childhood narcissism makes it difficult for parents and health care professionals to tease apart which behaviors point to maturational delays and not ADHD. What is normal childhood narcissism? It can be boiled down to four tendencies: overconfident self-appraisals; craving recognition from others; expressions of personal entitlement; and underdeveloped empathy.

Let’s start with overconfident self-appraisals. The veteran developmental psychologist David Bjorklund says of young children:

Basically, young children are the Pollyannas of the world when it comes to estimating their own abilities. As the parent of any preschool child can tell you, they have an overly optimistic perspective of their own physical and mental abilities and are only minimally influenced by experiences of “failure.” Preschoolers seem to truly believe that they are able to drive racing cars, use power tools, and find their way to Grandma’s house all by themselves; it is only their stubborn and restricting parents who prevent them from displaying these impressive skills. These children have not fully learned the distinction between knowing about something and actually being able to do it.[5]

In a nutshell, it is developmentally expectable that preschoolers think big and engage in magical thinking about their abilities, relatively divorced from the true nature of their actual abilities. Even first-graders, based on research by UCLA psychologist Deborah Stipek, believe they are “one of the smartest in the class,” valid or not.[6] The play of young children is full of references to them being all-powerful, unbeatable, and all-knowing. As most parents intuit, this overestimation of their abilities enables young children to take the necessary risks to explore and pursue activities without the shattering awareness of the feebleness of their actual abilities. For maturation to occur, children need to get better at aligning their self-beliefs about personal accomplishments with their actual abilities. They also need to link up any expected outcome with how much effort and commitment they have put into a task. The ways in which caregivers deal with children’s successful and not-so-successful demonstrations of supposed talents have a bearing on how well children form accurate beliefs about their true abilities. This brings us to the next ingredient of normal childhood narcissism – recognition craving.

The eminent psychoanalyst Dr. Heinz Kohut had much to say about children’s showiness and its role in the acquisition of self-esteem. He was the one who brought the concept of narcissism into the spotlight during the 1980s. He proposed that adequate handling of a child’s “grandiose-exhibitionistic needs” is one pathway toward establishing a child’s basic sense of self-worth. Consider, for example, a female toddler who discovers for the first time that she can run across the living room unassisted. She brims with pride and is caught up in her all-powerfulness. Her mood is expansive. She turns to caregivers for expressions and gestures that mirror back her brilliance. Appreciation and joy shown by caregivers during these moments of exhibitionistic pride are absorbed like a sponge and become part of her self-experience. Such praise becomes the emotional glue that she needs to fasten together a basic sense of aliveness and self-worth.

Disappointment, of course, always lurks around the corner. children cannot always flawlessly shimmy across the monkey bars or execute a perfect cartwheel. Parents are not always able to pay attention to their children with exquisite sensitivity. Parents simply need to be good enough in their efforts to be tuned in to their child’s prideful displays a sufficient amount of the time. It also is important that parents do not emotionally rescue their child when their pride gets injured. Gushy statements aimed at putting Humpty Dumpty back together again should be avoided. When a narcissistically needy seven-year-old loses in a footrace with Joey, a neighbor, it’s better to avoid saying, “You are a great runner. Your dad and I even think you’ll be a wide receiver one day. Come on now. Wipe off those tears.” What his emerging sense of self needs is something more like, “Honey, I’m so sorry you lost… I know how bad you must feel… It feels so great to win…But you know Joey is on the all-star soccer team and has been practicing his running for months. It’s gonna be tough to race against him anytime soon. You can always jog with your dad on Saturday mornings. That will surely make your legs stronger, and who knows what might happen.” This sort of measured response ensures that kids will develop realistic self-appraisals. It also aids with the sort of self-talk that children need to acquire to help them restore their self-esteem in the face of failures and setbacks, without crumbling in shame or lashing out at others because their pride has been injured.

Caregivers usually find children’s exaggerated claims of what they can perform and witness-my-brilliance moments tolerable, if not cute and amusing. However, when encountering children’s expressions of personal entitlement, most caregivers bristle. It is tempting for most caregivers to think that something is morally or medically wrong with their six-year-old when he or she stubbornly refuses to eat pasta for dinner as everyone around the table chows down with gusto, or when their five-year-old defiantly runs down the driveway rather than file into the minivan with the rest of the family to see a movie at the mall. What are we to make of such extreme attempts on the part of children to stubbornly insist upon things going their way, or to act like they are special to the point of deserving extraordinary attention?

One way of thinking about this involves children’s need for autonomy. They need to have a measure of control over what happens to them and around them, to have access to sources of pleasure that arouse and enliven them, and to have the means to avoid sources of pain. Throughout their childhood, children also need a measure of control over the pace of life to which they are required to adapt, without becoming excessively understimulated or overstimulated much of the time. The proverbial “morning rush to get out the door” often sets the stage for some of children’s most bothersome displays of personal control. A sudden “fashion crisis” necessitating a last-minute dash to the clothes hamper, or a refusal to turn off the television and leave for school, can signify how exasperated a child is over the mandate that he or she move at a pace which is convenient for grown-ups but immensely stressful for him or her. These types of defiant behaviors also can signify how effective a child has been at pressing their agenda in the past, knowing parents will ultimately surrender to their wishes.

The final dimension of normal childhood narcissism I will discuss is empathy underdevelopment. Empathy is fundamentally an emotional experience. It involves “feeling along with others.” It entails a capacity to join with others and be sensitized to their emotions. Young preschoolers often hover nearby and make awkward attempts at comforting a crying friend. This shows a rudimentary emotional connection that is the basis of empathy. By the time children reach age four or five, caring behaviors become much more refined. By this age, most children are well on their way to naming and verbally elaborating upon the feelings others are manifesting. Of course, the greater the spectrum of emotions a child is allowed to experience – and allows him or herself to experience – the more fully he or she is able to empathize with others across a range of feeling states in a variety of emotional situations.

Maintaining a healthy degree of empathy is a balancing act. The struggle for young children often is to be sensitized to another person’s distress, anger, or excitement without becoming oversensitized or desensitized by it. When a child becomes overly upset in the face of another child’s negative feelings, this is what Nancy Eisenberg, a developmental psychologist, calls a “personal distress reaction.” These types of reactions tend to make children more self-focused because, once distressed, a child is more concerned about their own self-comfort instead of how to be a friend to someone else in need.

Empathic concern for others and feeling connected to them makes a child “ruthful.” It dissuades a child from engaging in “ruthless” acts of aggression. Where there is empathy, there is the experience of other’s suffering being one’s own to some degree. In conflicts, the emotional pain caused by aggressive actions reverberates back to the child via empathic connection. It acts as a deterrent against wilder acts of aggression. It stirs the motivation to back off, make up, and make amends.

Empathy maturation, more often than not, is something that needs to be coaxed along by parents, caregivers, and educators. children need to be coaxed into elaborating on how they think a friend might be feeling, “Marissa has a frown on her face. How do you think calling her a witch made her feel?” They need to be reminded of the importance of sometimes putting their needs aside for the time being. At Bob’s birthday party, for example, it is Bob’s time to be the focus of everybody’s enjoyment.

Childhood Narcissism and ADHD-Like Behavior

When I listen carefully to how parents describe their child’s ADHD-like behavior, their descriptions often touch upon normal and not-so normal levels of childhood narcissism of the sort I have just discussed:

Evidence of narcissistic struggles are nestled in these snippets of information I have collected over the years in my work with children who have been brought to me because of suspected ADHD. In the pages that follow, I will go through most of the core symptoms of ADHD and show how closely they resemble aspects of childhood narcissism. For now, let me give you a flavor of this approach by picking apart some of the examples I have provided.

Take Jonah’s situation. He falls apart emotionally when unable to immediately master a task. One hypothesis is that this is a symptom of ADHD (not that a single indicator is positive proof of a disorder). Difficulties with retention of information needed to successfully execute a task – say the twelve-times table – may predispose Jonah to tear up his math sheet and storm out of the room. However, another hypothesis is that he demonstrates a good dose of magical thinking. He believes mastering tasks should somehow be automatic – not the outcome of commitment, perseverance, and effort. Jonah’s self-esteem also may be so brittle that it fluctuates greatly. For instance, when Jonah anticipates success, he productively cruises through work, eager to receive the recognition that he expects from parents and teachers. He is on a high. He definitely feels good about himself. Then in the face of challenging work, he completely shuts down, expects failure, outside criticism, and wants to just give up. He feels rotten about himself. His life sucks. Wild swings in productivity sometimes are evidence of nothing other than shaky self-esteem in kids. These are children whose overall feeling about themselves is too dependent on outside praise and criticism. When they experience success, they believe they are outstanding individuals, yet when they experience failure, they believe they are worthless individuals.

Does George’s incessant talking and invasive behavior suggest that he is neurologically compromised, or does his overriding need to be seen, heard, and recognized propel him to be annoyingly demonstrative?

Does Michael’s refusal to abandon an ineffective problem-solving approach reflect difficulties with cognitive processing, or is it that acknowledging his limitations and reaching out for help is experienced by him as intolerably weak?

Does Samantha exhibit the disorganization commonly seen in ADHD children, or a sense of entitlement whereby she resists accommodating to the needs of others, believing that others should accommodate to her by giving her special dispensations?

Caley’s dramatic downturn in classroom behavior may or may not be due to the reemergence of ADHD. Maybe the overarching issue is her struggle to be “one of the gang” in the classroom, whereby sacrificing her personal autonomy to fit in and comply with rules and routines seems psychologically out of reach?

Does Ernesto have impulse control problems or are his emotional boundaries underdeveloped? Does he absorb the feelings of those he comes into contact with in ways that disorganize and frazzle him?

For that matter, does Gary have impulse control problems, or does he have a proverbial chip on his shoulder, quick to retaliate against those who shame him?

When we truly listen to parents and refrain from shoehorning their descriptions into nifty behavioral phrases, overlaps begin to emerge between ADHD phenomena and childhood narcissism.

Turning to the Research

I don’t expect readers to be entirely satisfied with my informal proposals linking ADHD phenomena with childhood narcissism. These days, scientific findings take on more of a vaulted status than ever before – especially with ADHD. This disorder is widely considered to be neurological in nature, perhaps best left to the brain specialists to investigate with modern imaging technology. If I leave out scientific findings demonstrating linkages of the sort I am proposing, I run the risk of being perceived as just another naysayer who naively equates ADHD exclusively with childish behavior. As we shall see later in this section, I am not in the same camp as the pediatric neurologist Fred Baughman, who has gone on record with his rather brazen perspective: “ADHD is total, 100 percent fraud.”[7] Therefore, off we go.

Let’s return to Frank. He thinks that he’s a good planner. According to his mother, that’s plain hogwash. The same discrepancy applies to his organization and attitude around homework. Is he, as his mother irksomely declares, a pathological liar? Could he be suffering from amnesia? Dr. Betsy Hoza from Purdue University would say that Frank is neither a pathological liar nor amnesia prone, but given to engaging in “positive illusory bias.” For years, she and her colleagues have examined the peculiar habit ADHD children often have of trumping up their beliefs about themselves relative to their true abilities. Across a variety of research projects, she has discovered that ADHD children tend to believe that they are more socially and academically competent than they indeed are. They also believe their capacity for self-control is higher than what parents and teachers confirm. Dr. Hoza holds fast to the theory that ADHD children inflate their self-images for protective reasons, because their ADHD confronts them with daily experiences of failure.[8]

But what if in many cases a child’s inflated self-image keeps setting him or her up for failure, and it’s not ADHD per se? What if unrealistic performance expectations makes a child reluctant to persevere in the face of challenge, or abort a task at the first sign of failure, rather than having ADHD? What if the primary concern is helping the suspected ADHD child to examine their overconfidence? Curiously, Dr. Hoza hints at the need for “humility training” with ADHD children because of the strength of their positive self-images. This comes remarkably close to acknowledging that she and her colleagues are really studying the ADHD-like effects of problematic childhood narcissism.

In 2006, Dr. Mikaru Lasher and colleagues from Wayne State University in Michigan did what several ADHD investigators have done before, and others have done since. They demonstrated to the scientific community that ADHD children tend to score very poorly on measures of empathy (showing concern for others and being aware of how you might be making them feel).[9] They even took a page from the work of Dr. Hoza. It was substantiated that ADHD children’s self-perceptions of empathy were inflated compared with what their parents were seeing. As cognitive psychologists, they chalked this up to the lack of cognitive flexibility shown by ADHD children. No doubt, if pushed, they would wax eloquently on ADHD children’s inefficient brains. Nonetheless, it is tempting to wonder if what they were really measuring were subtle narcissistic tendencies in ADHD children. Lacking empathy and exaggerating one’s skill set happen to be quintessential narcissistic traits!

ADHD children are seldom equated with perfectionism. Don’t perfectionists persevere until they get it right? Don’t they relish looking for the devil in the details? Don’t they scan their work for errors, and revise, revise, revise? These things are hardly ADHD behavior. Therefore, I had to reflect thoughtfully when I uncovered a bit of scientific knowledge on ADHD children put out by University of New Orleans psychologist Michelle Martel and her team: “We also found evidence of an unexpected rare group of youngsters with ADHD and obsessive or perfectionistic traits.”[10] What are we to make of this? Actually, there is another way to think of perfectionistic traits. A child who refuses help and keeps using an ineffective method over and over to no avail, is a perfectionist. So too is a child who avoids or fails to finish tasks that he or she cannot master easily and impeccably. Then again, there is the child who is only motivated to perform in areas where he or she has a track record of excellence. It must be these forms of perfectionism that Dr. Martel and her colleagues found to be true of a subset of ADHD kids. But wouldn’t that suggest that these particular ADHD kids fall on the outer edges of the continuum of normal childhood narcissism?

Let’s return to our clinical snippets. Take Maria. She’s the drama queen. Parents who think their child has ADHD often describe scenarios at home where the child reacts to minor setbacks with blood curdling screams, or to modest successes with over-the-top exuberance. I can’t tell you the number of times I’ve had parents in my office describe to me a homework scenario where their otherwise bright, thought-to-be ADHD kid complains bitterly, writhes around on the floor, and tears up homework in a rage – all to make the homework torture stop. Of course, some of these kids truly have ADHD and homework truly can represent a form of mental torture. But for others, dramatic displays of emotion are attempts to get out of tasks that warrant commitment, application, and effort. If their caregivers repeatedly succumb to the pressure, these children often do not acquire the emotional self-control necessary to buckle down and do academic work independently. These emotionally dramatic children appear on the surface as if they had ADHD. Dr. Linda Thede from the University of Colorado at Colorado Springs would probably concur. At an annual American Psychological Convention, her presentation on the 30 ADHD children she had rigorously studied revealed that they were more likely to have histrionic and narcissistic personality traits than non-ADHD children.[11] Histrionic is a fancy clinical word meaning overly dramatic.

This brings us full circle. Is it possible that ADHD symptoms are really normal narcissistic personality traits that become problematic for children at high levels? I would say this is certainly true in many, but not all cases. Hard-to-manage narcissistic traits oftentimes overshadow and better explain what on the surface looks like ADHD. It is these traits with which educators and mental health professionals should concern themselves. As we shall see in the following pages, ADHD can mask the formidable social and emotional challenges a narcissistically stuck child faces.

Hyperactivity, or Recognition-Seeking Behavior?

Sam had a mop of curly hair and an adorable Cheshire cat smile when I met him for the first time. It was a hot June day and I remember being impressed by his little biceps bulging out from his tee-shirt. His frame was large for a five-year-old. He swung the waiting room door back and gleefully dashed down the hallway to my office. It was this impetuous behavior that had gotten him in hot water at preschool. In fact, his habit of wandering off without permission during circle time, blurting out answers before being called upon, and ignoring warnings and reprimands by the preschool director had caused concern at his school. By the time of my initial meeting with Sam, I had in my possession an Achenbach Behavior Checklist filled out by his teacher. I had computer-scored it. He placed in the clinically significant range for ADHD.

Within minutes, Sam insisted on having me witness karate moves that he had learned from his Sensei. He kicked, twirled around, and chopped at thin air. I watched admiringly, “Sam, you are so fit and you move your body around so well!” He gobbled up my attentiveness. Noticing the handle of a rubber sword poking out of my toy chest, he grabbed a hold of it. Rather than hand me a rubber sword, he literally threw one at my feet. He motioned to me to fetch it and mock fight him. Most of Sam’s verbalizations revolved around his skillfulness as a swordfighter. When I pretended to stab him, he was quick to assert that he had “infinity lives.” I thought to myself, “Where does a five-year-old get an expression like that?” True to form, Sam disallowed me this same dispensation and delightedly told me that within seconds I’d be dead.

Sam is, of course, impulsive. But it wouldn’t be entirely valid to conclude that Sam is merely emitting an overflow of unintentional behavioral output, as the word impulsive means. There is intentionality in his actions. He seems eager to display his physical prowess. He clearly needs an audience. He seems bent on eliciting recognition from me. Herein lies the dilemma with children like Sam. When we closely scrutinize the social contexts in which hyperactive/impulsive behavior occurs, as well as the underlying intentions of the child, we frequently find that the behaviors are benign attempts to show off how physically effective one’s body is, and have this sensitively witnessed. When impulsive acts are in reality exhibitionistic acts, they are intended to be witnessed in some public, emotionally rewarding way. Adults often forget how much of young children’s egos, especially boys’ egos, are wrapped up in what can be done with the body, no matter how goofy or obnoxious this might appear. For children to be anchored in their bodies and feel decisive in their movements, they need outside recognition during these showy demonstrations. It’s the prideful gleam in the eyes of those watching that solidifies a child’s sense of personal effectiveness and aliveness.

The supposedly hyperactive child who is caught goofing off, clowning around, acting silly and generally drawing attention to him or herself may be manifesting yearnings to be seen, heard, and noticed. It is probably this phenomenon that makes pundits remark how we should be talking about Deficit in Attention Disorder (DAD), rather than Attention Deficit Disorder (ADD)! It is ironic that the acronym for Deficit in Attention Disorder is DAD. For kids, especially boys, it is from dad that a measure of prideful recognition is really needed to fortify the body self.

The child who seems especially needful of attention may be the child whose enthusiastic displays of mastery have been regularly met with rejection, indifference, or overindulgence by caregivers. This leads to what Heinz Kohut, the originator of modern narcissism theory, called “narcissistic vulnerabilities.” The developmental conditions are ripe for the child to become more stubborn, cunning, demanding, and desperate in their attempts to elicit or extract prideful recognition from others. The child who has been deprived of needed recognition, or been ego-neglected, develops the habit of emotionally holding out. Last ditch efforts are frequently made believing that finally a parent, teacher, or big brother will pay attention. On the other hand, the child who is used to an overgenerous outpouring of praise by caregivers can resent it when others are less generous in seeing him or her as brilliant.

Either way, these narcissistically vulnerable children are the ones who can be misperceived as ADHD. These are the children who have considerable difficulty being “one of the gang” in the average classroom where rules and regulations are set up to maximize learning for groups of students. These are the children who get emotionally triggered when forced to share the teacher’s attention with others. At home, their ego needs might be front and center and they expect to be front and center in their teacher’s eyes, or, at home their ego needs might be far from front and center and they desperately need to be front and center in their teacher’s eyes.

ADHD-type behavior abounds in these kids. Blurting out answers before being called on can reflect prideful expressions of specialness. This unpopular-with-teachers-habit also can reflect a desperate need to be seen as knowledgeable.

Risk-taking behaviors are sometimes evidence that a child will always take the dare if it elevates their social cache. A sideways glance, or fleeting chuckle from any classmate, but especially a popular one, can be such an ego boost.

Back-talking, talking out of turn, talking over people, talking off topic, or simply talking too much, can indicate how much a child needs, or expects, to be heard. I once had a cocky child come to see me related to an off-handed comment he had made during a classroom discussion in the aftermath of the World Trade Center attack, “911 – isn’t that a Porsche?” His teacher had reached her breaking point. She told me over the phone, “This boy is impulsive beyond belief.” Strictly seeing this as evidence of hyperactivity or impulsivity misses the point entirely.

Expertly twirling a pencil instead of completing a math assignment, or suddenly aborting a Lego construction project to perform cartwheels, can be the emotionally vulnerable child’s way of grasping at a tried-and-true talent, no matter how inconsequential. Displaying the talent in such moments readily elevates their feeling of self-worth in the face of a task tinged with some potential for failure.

Problems with waiting one’s turn can be due largely to difficulties managing the potential euphoria and emotional deflation swirling around in situations where emotionally vulnerable children are called upon to show their stuff. A child who frequently skips in line to shoot hoops on the playground (and thereby slowly becomes socially exiled by peers) might be a child who, once again, either desperately needs the accolades, or arrogantly expects them. These children can get emotionally undone by the anticipatory elation or deflation around winning and losing. They can also get emotionally carried away by the intense pride they feel in outdoing rivals or the intense envy they feel in being outperformed by rivals.

Needless to say, as parents, educators, and mental health professionals, we have to get smarter at detecting when a child’s hyperactive behavior belies emotionally hyperreactive behavior. If we reduce the former to the latter, we completely miss the boat. These children are demanding not because they have ADHD. They are demanding because they demand extra sensitivity due to their needs or expectations around being seen as extra special.

Failing to Finish Tasks, or Trouble Persisting in the Face of Overconfident Expectations?

Malcolm Gladwell, the darling of hard workers everywhere, didn’t know he was an anti-narcissist when he coined the “10,000 Hour-Rule.” In his blockbuster book, Outliers: The Story of Success,[12] he dispelled the myth that success is due to pure genius. His alternative viewpoint was a humble one. Put in somewhere in the region of 10,000 hours of practice at what you want to excel at and you have a shot at success. It also helps to be in the right place at the right time around people who are well-positioned to make things go right: so much for simply willing success to happen, or feeling entitled to success without putting in the hours. Of course, there are always those people who will stop at nothing to achieve greatness. They zealously apply themselves year in and year out. It’s as if they will rapidly decompose into a nobody if they don’t keep putting in the hours to become a somebody. That too is a type of narcissism, but not the sort that I think gets wrongly labeled ADHD, as we shall see.

Let’s go with Gladwell’s logic. How many hours of concerted application would that be for the average child to rise to the top in any academic subject or athletic pursuit? Assuming he or she enters kindergarten at age five, and graduates high school at age 18, that would be 769 hours a year, 64 hours a month, or two hours a day, give or take. And that’s for just one subject or pursuit!

By happenstance, the child also would need to endear him or herself to mentors who fortuitously find the child endearing. Any such mentors would have had to have put in their 10,000 hours to be in a position of genuine mentorship. And so the wheel turns. Of course, to take these numbers and propositions too literally would be bogus science. I am mostly trying to make a point, albeit in a roundabout way. To be successful at anything requires some combination of grit, perseverance, hanging in during the boring spells, and endearing oneself to others who happen to have advanced themselves in your cherished pursuit. These are qualities with which ADHD children struggle. They also are qualities that don’t come easily for children with narcissistic traits.

In his official website, the ADHD guru Dr. Russell Barkley defines one of the hallmark symptoms of ADHD as follows:

Poor sustained attention or persistence of effort to tasks. This problem often arises when the individual is assigned boring, tedious, protracted, or repetitive activities that lack intrinsic appeal to the person. They often fail to show the same level of persistence, “stick-to-it-iveness,” motivation and will power of others heir age when uninteresting yet important tasks must be performed. They often report becoming easily bored with such tasks and consequently shift from one uncompleted activity to another without completing these activities. Loss of concentration during tedious, boring, or protracted tasks is commonplace, as is an ability to return to their task on which they were working should they be unexpectedly interrupted. They may also have problems with completing routine assignments without direct supervision, being unable to stay on task during independent work.[13]

Buried in his book, Taking Charge of ADHD: The Complete, Authoritative Guide for Parents, Dr. Barkley locates the cause of this symptom, and others making up ADHD, in the brain. In particular: “…the orbital-frontal region, and its many connections through a pathway of nerve fibers into a structure called the caudate nucleus (which is part of the striatum), which itself connects further back into an area at the back part of the brain known as the cerebellum.”[14] Who wouldn’t be impressed and defer to the expert?

Yet when we widen the lens and reread his definition of this core symptom of ADHD, other causal hypotheses pop out. Viewed through another lens, Dr. Barkley has provided us with a marvelous description of children whose sense of grandiosity and entitlement render them unproductive.

A susceptibility to suddenly end a difficult task simply reflects, at times, grandiosity on the part of a child. These are the children who abort and abstain from tasks that cannot be immediately mastered. These are the children whose emotional life stance reflects the anthem, “I will pull back from, or refuse to play, a game at which I cannot be an easy champion.” They may have narrow domains which they naturally excel at and rely on to derive a sense of self-importance. But they always top out and reach a plateau because they resist the extra practice and effort required to go from being good at something, to being great at it. Domains which fall outside of their natural abilities, or that are not loaded for pleasure and easy ego boosts, are avoided or approached in a way that is rushed.

Children with hard-edged grandiosity expect to know things without having to learn them. They also cannot fully accept deep down inside how in order to be considered knowledgeable, they have to show what they knows on tests, homework, classroom presentations, etc. Having to “show their work” on math problems is a bummer. Teachers should just plain accept that they’re knowledgeable. Also, a trial-and-error approach to learning is anathema because the whole idea of failures and errors may not square with such children’s larger-than-life self-image.

Children with soft-edged grandiosity may be overreliant upon great achievements to buttress their feeble sense of self. One minute, the children are whipping through math problems, swelling up with pride over how versed they are, motivationally feeding off praise supplied by a teacher. The next minute, such children’s productive output comes to a grinding halt because they are stumped by one math problem: heck, that could mean the difference between an A and a B on an upcoming quiz. The whole enterprise of making errors, and either shaking them off or learning from them, is just too emotionally painful. A failed math quiz means that they are failures as individuals. Zoning out, being mentally preoccupied, drumming one’s fingers on the desk, in short acting ADHD-like, becomes a desperate means to cope with a failure experience.

Disorganization, or Magical Thinking?

Right before mid-semester grades are released, my business booms. This is the time of reckoning for those children who are amazingly adept at magical thinking. In a quasi-delusional way, they wholeheartedly believe that they are keeping pace with the work. They usually have their parents convinced. The mid-semester report card becomes the ultimate reality check. When it is released, there’s no fanfare. The children are in shock. The parents believe the children should be more in shock. The parents feel lied to. The children resent being called liars. In a Twilight Zone type of way, they were not consciously lying each time they swore the homework was done. They were just oddly emotionally detached from it all with words coming out of their mouths. That’s when I get called.

Marco, a sixth grader, is one such child. Handsome and articulate, he has definite swag. When I met him for the first time, he addressed me with, “Whaaassupp dude?” I rebutted, “What’s up is you’re in deep doo-doo.” Piecing together what Marco and his parents told me, as well as the information his teachers emailed me, the story of what was up with Marco was an all-too-familiar one. He had started out the school year strong, acing some key assignments. For weeks thereafter, he had rested on his laurels, replaying these successes in his head anytime he had doubts about whether his grades might be slipping. Because he was a 6th grader, his teachers expected him to self-monitor his homework. Weeks would pass between Marco handing in incomplete or inadequate homework and him obtaining concrete feedback from teachers. With the long gaps between feedback, he simply detached more and more from any reality-based notions of how his grades were going. In class, he frequently appeared bored and distracted. At home, his parents were on him to read more.

On the surface, Marco looks like he has ADHD. But, the real issue is his magical thinking, his capacity to maintain a state of mind where he thinks very highly of his own abilities, despite bountiful evidence to the contrary – in short, his capacity for “positive illusory bias.”

Another intriguing pattern of Marco’s was his penchant for doing well on tests, yet leaving homework undone, or failing to hand it in – even when it was completed. The latter is often seen as a red flag for ADHD. And, sometimes it is. Nevertheless, I have learned over the years that the pattern of does-well-on-tests/does-poorly-on-homework often bears upon – surprise, surprise – narcissistic phenomena. There may be glory in studying hard for and acing a test, but there is no glory in the monotonous grind of churning out homework. It can be adventurous and quest-like to cram for a test and rush to class, heart thumping, ready to show what you know in such a public way. Whipping through a test or in-class assignment and being one of the first to finish – even though speed might have compromised quality – confidently strutting to the teacher’s desk to turn in finished work, can be such a high. But planning and tracking what homework is due when, and trundling forth in a daze each morning to slot it away on the teacher’s desk – where it will likely not be handed back for weeks – is ever so private and does not exactly inspire chest-pounding.

Deriving ego satisfaction from the small victories associated with doing well on menial homework assignments is not particularly attractive to children like Marco. They want the big pay off that comes with doing well on a mid-term or final. That’s something about which they can brag. That’s something that can be floating around in the forefront of your consciousness allowing you to get a good night’s sleep, when in the back of your mind you know the homework D’s are coming down the pike.

Forgetfulness, or What’s-the-Point-of-Practicing Syndrome?

ADHD terminology has crept into common parlance so much in recent decades that I fully expect baby-boomers, as they head into their twilight years, to talk about “ADD moments” rather than “senior moments” when they misplace their keys. But not all moments of forgetfulness are due to ADD, or age-related cognitive decline. Forgetfulness can be none other than the outcome of resisting immersion in and repetitive exposure to subject matter – particularly if that subject matter musters little personal interest. If a child spaces out all the time in history class and fails to remember facts like: during George Washington’s presidency five states were added to the union – North Carolina, Rhode Island, Vermont, Kentucky, and Tennessee, it doesn’t necessarily mean that he or she’s in the ADHD red zone. It could mean that the child is utterly academically disaffected.

Re-enter Marco. Remember, he is the 6th grade client of mine with good looks and swag. If only Marco’s litany of complaints about school was new to me:

“Why study all those dead guys? I’m not planning on going to Cal Tech, so why do I have to memorize the periodic tables?”

“Where is knowing algebra going to get me in life? I don’t see why I have to show my work in math. Isn’t it enough just to get the right answer? My English teacher is boring. She won’t let me read Calvin and Hobbes during sustained silent reading time.”

Curiously, Marco has an encyclopedic knowledge of the weaponry in his favorite X-Box 360 game, Call of Duty ModernWarfare2, affectionately known to pre-teens around the world as COD. He is eminently able to rattle off facts about M4 carbines, SCAR-H’s and TAR-21’s. Not surprisingly, this was a subject matter he immersed himself in and to which he had repetitive exposure – so much so that he had nicknamed himself, “The COD Father.”

Dr. Daniel Willingham, a leading cognitive scientist and psychology professor at the University of Virginia, boldly states: “It is virtually impossible to become proficient at a mental task without extended practice.”[15] In his thoroughly practical book, Why Don’t Students Like School, he persuasively argues that there is only so much room in children’s working memory, the brain area responsible for deep thinking. For space to open up in working memory allowing for more creative and deeper thinking, basic ideas and mental functions have to become automatic. For them to become automatic, they have to be practiced over and over. Take the example of a girl learning to play tennis. If she is to master a good serve, she cannot be constantly consciously reminding herself to hold her non-serving arm high while tossing the ball with her other arm, and remembering to bring the racket all the way behind her back. Practice makes these steps automatic and not part of her consciousness when she serves; that way she can run other thoughts through her mind that improve her game, such as serving away from where her opponent is standing, or imagining where she will best reposition herself once she has served.

It is often proposed that ADHD children have deficits in working memory due to brain abnormalities. But we cannot overlook how deficits in working memory also are due to overconfident children resisting the sort of practice that makes basic knowledge automatic, freeing up working memory to work more efficiently and complexly.

We often get romantic about education, saying children need to find themselves at school. But maybe children like Marco need to focus more on losing themselves in their education. What I mean here is overcoming their narcissism and connecting to people, places, and things outside of their own narrow comfort zones. They need to get used to the idea that speed reading is no substitute for actual studying. It hardly leads to consolidation of information. Information superficially grazed from a text will evaporate fast. Overconfidence leads to inadequate planning, studying, and preparing. It leaves your mind going blank on tests.

Are Rising Rates of ADHD and Narcissism Related?

The story of Steven Slater, the Jet-Blue flight attendant who was dubbed a working class hero back in August, 2010 because of the dramatic fashion in which he quit his job, is proof positive of how accepting of narcissistic behavior Americans have become. Disgruntled because of a run-in with a passenger, Slater got on the plane’s PA system upon landing at JFK airport and, according to the New York Daily News, yelled: “To the f*cking a**hole who told me to f*ck off, it’s been a good 28 years. I’ve had it. That’s it.” He then activated the emergency chute, helped himself to two beers from the beverage cart, and slid down the emergency chute to the tarmac.[16] Within weeks, he had a Facebook fan page with over 210,000 members. A Steven Slater Legal Defense Fund was founded by fans which raised thousands of dollars for his legal defense; after all, his gallant actions resulted in charges of criminal mischief, reckless endangerment, and trespassing.

The facts of the case did not dampen Mr. Slater’s popularity. At 38 years old, he could hardly have had a 28-year career run as a flight attendant. The New York Daily News reported that another passenger on the same flight had asked Mr. Slater for a towel to clean up some spilled coffee only to see him “roll his eyes in a rude manner,” then grunt, “No, maybe when we get in the air. I need to take care of myself first, honey.”[17]The danger to his fellow workers on the tarmac posed by activating the emergency chute may have been lost on Mr. Slater, but not JetBlue officials who reminded the public that, “Slides deploy extremely quickly, with enough force to kill a person” and “Slides can be as dangerous as a gun.”[18]

Setting aside my armchair presuppositions about the Stephen Slater incident, what do social scientists have to say about the rise in narcissism in America? It may go against the grain, but the current worry of parents, according to Drs. Jean Twenge and Keith Campell, authors of The Narcissism Epidemic: Living in the Age of Entitlement, should not center on children and teens having too little self-esteem, but too much of it. They cite numerous studies conducted by themselves and other experts uncovering the steady increase in narcissism in the U.S. over the past several decades.[19] One poll they mention involves ninety-three percent of middle-school students in 2000 scoring higher on measures of self-esteem than the average same-aged peers did in 1980. Another indicates that one-third of current high schoolers are “completely satisfied with who they are” compared to one-quarter endorsing this same statement back in 1975. Yet another shows that fifty-percent of recent high schoolers believe they are capable of attending medical, law, dental or graduate school, twice the number of students who believed similarly in the 1970s.

Many college students now believe that good grades are more of an entitlement than something for which to strive. In a 2008 study mentioned by Drs. Twenge and Campbell, two-thirds of college students polled claimed they were deserving of leniency in a professor’s grading policy just for trying hard. One-third thought that by simply attending class, they should procure a B grade. Remarkably, one-third were of the opinion that they should be able to reschedule a final exam if it conflicted with their vacation plans. Present-day teenagers apparently think very highly of themselves. 91% view themselves as “responsible,” 74% as “physically attractive,” and 79% as “very intelligent.”

This begs the question: Is too much self-esteem a bad thing? The straightforward answer is yes. The line between too much self-esteem and unhealthy narcissism is a thin one. This is when children and teens stubbornly retain beliefs about their own abilities that are not backed up with successful accomplishments achieved through commitment and effort; feel entitled to special consideration and react negatively when they are viewed like all the rest; feel entitled to easy successes and react negatively when held accountable to having to put in the work; are more intent on elevating their social status and reputations than building wholesome and loving relationships; fend off appropriate criticism as due to grown-ups being uptight rather than experience it as accurate information about their shortcomings, thereby acknowledging mistakes and learning from them.

Curiously, the rising rates of narcissism since the 1970s parallel the upsurge in diagnosable cases of ADHD. If you recall from earlier, only one percent of children in the 1970s warranted an ADHD diagnosis. Present-day numbers range from 5%-10%, and even higher. What are we to make of this increase? It is tempting to speculate that at an underlying level, in many cases, ADHD and narcissism are really the same phenomena. Perhaps children’s ADHD-like behavior, such as problems listening, forgetfulness, difficulties waiting one’s turn, excessive talking, and prematurely ending effortful tasks, really reflect narcissistic personality traits. It should come as no surprise to us that children who are overconfident and needful of special attention tune others out, forget because they have not practiced enough, butt in front of the line, blurt out answers, and shy away from tasks that cannot be easily mastered.

Be Straight With Us: Does ADHD Exist?

When my lithe, quick-acting 10-year-old client Paula rifles through my office cupboards without asking, I’m not terribly annoyed. She has ADHD. However, when my sparky, bumptious seven-year-old client Frank engages in the same behavior, I get somewhat irked. He has a narcissistic flavor to his budding personality. They both know my office rule: no going through my cupboards without asking. Yet they both perpetually violate it. Based on behavior checklists I had their parents and teachers complete, both fit the criteria for ADHD. Yet, in my eyes, Paula has it and Frank doesn’t.

So what is it about Paula that makes her a bona fide case of ADHD? Her actions feel undeniably impulsive to me. It often does not occur to me to reflect on her motives when she behaves impulsively. For instance, Paula has a problem with compulsive stealing. On many occasions, I have had to intervene with her because she has stolen something shiny or colorful at school, or at a friend’s house. Typically, it is an object that is out in the open and ready at hand, not something hidden away that requires sneakiness to procure. She seems to steal simply because an object has the potential to stimulate her senses and can be had with immediacy. When she steals, it is as if she is utterly oblivious to the expected consequences. A look of genuine confusion is written on her face when I confront her with her stealing behavior. It takes me framing her stealing as a misdeed for her to actually experience it in any palpable way as a misdeed. She usually does not make excuses for her behavior, show outward signs of guilt or shame, or appear manifestly upset. She mostly wants to change the subject and talk about something else, not really appreciating what all the fuss is about.

Compare this to Frank’s stealing behavior. At the end of our play therapy sessions, we have a fun routine where I promise to give him two candies if he helps with cleanup. Most of the time, he pleads with me to give him three or four. I usually hold my ground, and he usually complies, though displaying more than a measure of frustration. On several occasions, I caught him taking four candies while my back was turned, slipping two into his pocket while watching me turn away to close the cupboard door where I keep my candy jar. We have a rule that if he takes more than two candies without permission, he is prohibited from having any candies that day. When I enforce this rule, he tends to erupt in anger, accusing me of being mean and refusing to leave the office until I give him at least one candy.

The difference between Paula and Frank is that he steals with apparent knowledge of the expected consequences, believing that if he puts up enough of a fracas the consequences will somehow not be enforced. When confronted with his misdeed, he does not look confused but mobilizes to make excuses for his behavior, offers a quick apology, and hopes to have the whole matter overlooked, or anticipates how he might get around the consequences. In short, his actions feel to me to be motivated by a narcissistic agenda whereby I should surrender to his wishes because he desperately needs things to go his way.

Another example will help distinguish signs of true ADHD. Frank and Paula are both in the habit of ending the games we play in the office midstream and jumping around from activity to activity. However, what motivates their behavior feels qualitatively different to me. Frank hates to lose. If he is behind in goals at foosball, cannot knock down cardboard targets easily with the Nerf guns in my office, or win handily playing cards, he is prone to make sudden, unilateral decisions to end a game or activity and start up a new one. His behavior seems rich with motives to me. He is trying to keep alive the fantasy that he should be an automatic champion at whatever he pursues. Ending a game or activity suddenly because he is losing is his way of keeping himself from being flooded with feelings of shame and frustration. Switching over to a game or activity that elevates his self-esteem shows how radically his self-esteem can fluctuate based on winning and losing.

When Paula ends or flits between games and activities abruptly, the context is not one of her self-esteem being on the line. She may become restless because she is cognitively unable to follow the rules, or has trouble keeping them in her short-term memory. The attraction of a different game in these moments is often based on her having played it a bunch of times and therefore is proficient at following its rules. Another game may simply appear more stimulating to her, or have caught her eye from across the room. Neither pride nor shame is in the air in any obvious way.

Even Frank’s and Paula’s overactivity feels different to me. It seems important to Frank that I be an audience who witnesses his jumping skills, boxing abilities, or prowess at wielding a rubber sword. He seems to thrive on my emotional involvement during these behavioral demonstrations, wanting me to recognize his bodily adeptness. My caring gaze in these moments matters to him. When Paula is overactive, she is moderately unaware of my presence in the room. She does not keep eye contact, appears mentally busy and physically overstimulated, needing to stay active to achieve some greater body-comfort level.

So, in ending, yes, like Dr. Barkley, the leading ADHD expert, I do believe that, “ADHD is real, a real disorder, a real problem, often a real obstacle”[20] ADHD can have life-long, debilitating effects and it’s a diagnosis that should not be ascribed casually to children. Medications are often necessary to afford the ADHD child a more functional life. But, medications frequently have unpleasant side effects. An ADHD diagnosis should be accurate to warrant a child taking medication despite these unpleasant side effects.

That said, it is my contention that ADHD is definitely overdiagnosed. As parents, educators, and mental health professionals, we need to become far more psychological, and far less neurological in our thinking when we encounter ADHD-like behavior in children. As I have tried to show in this section, oftentimes ADHD symptoms stem from common narcissistic struggles all children to a greater or lesser degree face. If we wrongly confuse this with ADHD, legions of children will be deprived of the educational, therapeutic, and parenting interventions necessary to assist them with building more realistic self-images and greater empathy skills, and with forming academic expectations based on real effortful application. Only in this way will their schoolwork habits and close relationships truly thrive.

Autistic, or a Brainy, Willful, Introverted Boy?

I have followed William in my therapy practice for close to a decade. His story is a prime example of the type of brainy, mentally gifted, single-minded, willful boys who often are falsely diagnosed with autistic spectrum disorder when they are assessed as young children.

Jacqueline, William’s mother, realized that he was a quirky baby within weeks of his birth. When she held him in her arms, he seemed more fascinated by objects in his field of vision than by faces. The whir and motion of a fan, the tick-tock of a clock, or the drip-drip of a coffee maker grabbed William’s attention even more than smiling faces, melodic voices, or welcoming eyes. His odd body movements concerned Jacqueline. William often contorted his body and arched his back upwards. He appeared utterly beguiled by the sensory world around him. He labored to prop himself up, as if desperately needing to witness it first-hand.

Some normal developmental milestones did not apply to William. He bypassed a true crawling stage, and walked upright by 10 1/2 months. He babbled as an infant and spoke his first words at 12 months; however, by age two, he was routinely using full sentences and speaking like a little adult.

When William encountered an interesting object or event as a toddler, he became so captivated by it that he completely ignored the people around him. During a music class, he once stood off to the side staring up at a ceiling fan while all of the other children sat together singing. Then, suddenly, William ran toward the teacher. As he glanced back and forth between the movements of his teacher’s lips and the chords he was playing on the guitar, he came within inches of running into the teacher’s face. At his two-year-old birthday party, while the other children were playing in the backyard, William methodically took some folding chairs, lined them up, and pushed them over one at a time – intrigued by the noises the falling chairs made. He repeated this series of events over and over throughout the afternoon, as if conducting a series of well-crafted experiments.

By age three, William began developing a passionate interest in a range of adult-like topics. After being read a book on Pompeii, he talked endlessly for months afterward about what he had learned. He pressured Jacqueline to check books out of the library on Pompeii in order to satisfy his need for more detailed knowledge on what Roman life was like before Mount Vesuvius erupted and buried the ancient city in ashes. He strove to know more about aqueducts and amphitheaters. He insisted that Jacqueline design a toga for him, which she did. He strutted around the living room not just pretending to be, but believing that he was, a citizen of the Roman Empire, circa AD 79.

Steve, the lovable host of the children’s TV program Blue’s Clues, became an idol for William. He avidly watched reruns of the show and lobbied his parents hard for a green shirt, khaki pants, and brown shoes so that he could look just like Steve – no compromises.

His next fascination was with the Titanic. William acquired a detailed knowledge of the design of the ship. Facts such as the exact length of the Titanic (882 ft. 9 in.) mattered to him. He also knew that its top speed was 23 knots. William insisted on having a uniform just like Captain Smith’s, the officer who was in command of the Titanic. Getting the color and the arrangement of the stripes and buttons correct seemed essential to William when he and his mother designed it. Jacqueline also helped William amass an impressive collection of pictures of ships, ocean liners, and uniformed officers which he studied on his own for hours on end.

At pre-school, William was a veritable Pied Piper. During his “Titanic phase,” he arrived at school sporting his Captain Smith’s blazer and cap. He orchestrated Titanic reenactment scenes, assigning roles and telling his classmates where to stand and what to do and say. This would usually go well at first. William’s enthusiasm was intoxicating, and the play scenes he devised were too exciting for the other children to pass up. However, more often than not, the other children eventually lost interest and wandered off because of William’s need for them to follow his script.

At home, William’s tantrums were wild and uncontrollable even as he approached age five. When he was asked by his parents to turn the TV off and join the family for dinner, he might scream and yell in protest, writhe around on the floor, and even throw and break things. Invariably, the situation that caused William to fly into a rage involved setting aside what he was doing in the moment to comply with a routine request – such as to get ready for bed, or get dressed for pre-school. He simply hated transitions. Unless his parents regularly planned activities that were in line with his interests, William inevitably became agitated, overactive, and unmanageable.

Mealtime was another “powder-keg” situation. William was repulsed by vegetables. If carrots, broccoli, or any other vegetable was placed on his plate, he thought nothing of throwing the entire dish on the floor. All he could stomach was a short menu of items like pizza, hot dogs, or peanut-butter sandwiches.

William’s parents were sociable. They spent a great deal of time in the company of other parents and children. They knew William’s tantrums, fussy eating habits, and social difficulties were beyond the pale. Their friend’s children were maturing, while William seemed stuck. When William was five years old, they decided to have him evaluated. A highly respected doctor at a university-based institute was sought out to conduct the initial evaluation. During a twenty-minute observation, William mostly sat staring at the doctor’s bookshelves – either ignoring or providing one-word answers to the questions he was asked. At the end of this brief observation, the doctor concluded that William was “on the spectrum” and had Asperger’s Disorder. The doctor reassured Jacqueline that her son’s difficulties were due to him having a brain disorder, and that she should in no way hold herself responsible. He advised her to have further testing conducted through the Institute to confirm the diagnosis, and to approach her local Regional Center to obtain services for him – “mostly as a precaution in case he can’t take care of himself when he gets older.”

Years later, when recounting this experience for me, Jacqueline said this news was like a “blow to the solar plexus.” But she convinced herself that failing to trust the conclusions of a highly-respected doctor from a prestigious university hospital was nothing short of staying in denial about William. She followed through with a recommendation to have William more thoroughly assessed by autism experts at this same hospital. Their assessment revealed that William had an IQ of 144 – placing him squarely in the mentally gifted range. A formal speech and language assessment indicated that William was well over a year ahead in all areas. However, in the final report, it was noted that while William was alone with the examiner, he was unable to initiate or sustain conversations. He either stared off into the distance, or interrupted the examiner to talk about off-topic subjects that were of interest to him – such as tornadoes, hurricanes, and earthquakes. When asked about friends, William made vague references to two girls who had moved away and was unable to recall any recent activities he had engaged in with them. Due mostly to his behavior in the room, the examiner assigned him a diagnosis of Autistic Disorder because of his “communication and qualitative impairments in reciprocal social interaction.” Jacqueline was confused by the report. She wondered if the examiner had taken any time to actively engage William? She knew that William could be quite animated and talkative when adults took a liking to him.

Nevertheless, William’s parents went along with the diagnosis and so began their bewildering odyssey into the mental health field. At the behest of the specialist who assessed William, they secured a lawyer to sue Regional Center to obtain autism services. Regional Center had unilaterally denied such services, claiming William needed to have been formally diagnosed as autistic prior to age three. It took $22,000 in legal fees to bring their case before a judge, who ordered William to be formally assessed by a medical doctor at Regional Center. That doctor determined that William had full-blown autism and did indeed qualify for services. However, as the years unfolded, William’s parents had lingering doubts. They approached me when he was age eight.

I agreed to meet with William and to offer my clinical judgment. Within minutes of playing with William, I knew, unequivocally, that he was not “on the spectrum.” He was enthralled by the range of dart guns I had in my office and asked if we could play a World War II game. I heartily complied. William took turns being Hitler, then Stalin, mentioning how he was in command of millions of troops who followed his orders. When I playfully acted as one of his minions awaiting orders to shoot the enemy, William became delighted. He threw himself into the role of dictatorial commander and ordered me to shoot an imaginary enemy soldier. I did so, making loud machine-gun noises. William was emotionally beside himself. He quickly asked if he could be Stalin and I could be Hitler, and if I would shoot him. We reenacted this Hitler-shooting-Stalin scene over and over, with William pretending to be in the throes of death, each time using louder gurgling sounds and ever-so-dramatic, jerky body movements.

For me, William’s imaginativeness, as well as the emotional give-and-take in our pretend play interactions, was proof positive that it was folly to consider him autistic in any way.

Fast forward to the present. William is now a high school student who is very active in student government. He is quite at ease with other teenagers who share his level of intellect. He continues to demonstrate the same thirst for knowledge that he had as a toddler. When classroom subjects interest him, his academic performance is stellar. When they don’t, William’s grades suffer. His report cards often contain peaks and valleys of A’s and F’s, which is immensely frustrating for his parents. His interests are not highly obscure, detail-oriented, and autistic-like, such as memorizing the names of dinosaurs, or the serial numbers on Ford trucks. He is an abstract thinker who labors to understand issues more deeply. For instance, he has a complex understanding of different forms of government, and he is able to articulate the arguments for and against democratic, fascist, and oligarchical arrangements. This conceptual, philosophical way of acquiring knowledge tends not to be autistic-friendly.

Granted, William is far more comfortable isolating himself and studying political geography and rock-and-roll memorabilia than he is hanging out at the mall. In addition, he can still explode emotionally when he is forced to switch activities, such as applying himself to his homework rather than researching Fender guitars or the geography of Iceland on the Internet. Moreover, he’ll only incorporate new food items into his diet when he has tried them at a fancy restaurant that didn’t have children-oriented foods such as pizza, hot dogs, or peanut-butter sandwiches on the menu. However, these traits and behaviors don’t mean that he’s autistic spectrum-disordered. They reveal William to be a brainy, somewhat introverted, individualistically minded boy whose overexcitement for ideas and need for control cause problems with parents and peers.

As we shall see, boys with these traits and behaviors are often falsely diagnosed with autistic spectrum disorder, especially when they are assessed at younger ages.

The Early Diagnosis Trap

True autism is a potentially very disabling neurological condition. Roy Richard Grinker, in his acclaimed book, Unstrange Minds,[1] masterfully documents the challenges he faced raising Isabel, his autistic daughter. At age two, she only made passing eye contact, rarely initiated interactions, and had trouble responding to her name in a consistent fashion. Her play often took the form of rote activities such as drawing the same picture repeatedly, or rewinding a DVD to watch the same film clip over and over. Unless awakened each morning with the same utterance, “Get up! Get up!,” Isabel became quite agitated. She tended to be very literal and concrete in her language comprehension. Expressions such as, “I’m so tired I could die,” left her apprehensive about actual death. By age five, Isabel remained almost completely nonverbal.

When the signs of autistic spectrum disorder are clear, as in Isabel’s case, early detection and intervention are essential to bolster verbal communication and social skills. The brain is simply more malleable when children are young. Isabel’s story in Unstrange Minds is a heroic testament to the strides a child can make when afforded the right interventions at the right time.

However, the earlier an evaluation is conducted, the greater the risk of a false diagnosis. Many toddlers can be autistic-like in their behavior when they are stressed. Sometimes the procedures used by experts to evaluate toddlers generate the sort of stress that leads a struggling, but otherwise normally developing toddler, to behavior that is autistic-like.

Nobody has made this point more clearly than the late Dr. Stanley Greenspan, the internationally recognized child psychiatrist who developed the popular Floortime approach to treating autistic spectrum disordered children. In his web-based radio show several years before his death in April, 2010, he cited an alarming statistic. Of the 200 autism assessment programs his team surveyed across the country, many of which were located in prestigious medical centers, only 10% emphasized the need to observe a child along with a parent or guardian for more than 10 minutes as they spontaneously interacted together.[2] He tended to observe children playing with a parent for 45 minutes or more, waiting for choice points to engage a child to determine if he or she was capable of more sustained eye contact, elaborate verbalizations, or shared emotional reactions. Dr. Greenspan believed that these conditions of safety and sensitive interaction were essential in order to obtain an accurate reading of a child’s true verbal and social skills.

For a sizable percentage of toddlers who don’t transition well to new surroundings, freeze up with strangers, or temporarily dread being apart from a parent, the formal nature of a structured autism assessment can lead to their becoming mute, hiding under a table, avoiding eye contact, hand-flapping, or exhibiting any number of other self-soothing behaviors that get misinterpreted as autistic-like. Trained professionals are supposed to conduct autism assessments in a standardized way. This is clinical jargon for being fairly neutral in one’s approach to the child. This might involve an examiner assuming a seating position that requires a child to turn their head 90 degrees to directly look at the examiner when their name is called. If the child fails to look up and make direct eye contact with the examiner after their name is called aloud several times, this is autism red-zone behavior. Yet many distressed or slow-to-warm toddlers will only respond to their name if an unfamiliar adult strives to be warm, engaging, and nonthreatening – not just neutral.

It is these autistic-like situational reactions of struggling toddlers during formal testing conditions that make a false diagnosis a real possibility. A 2007 University of North Carolina at Chapel Hill study found that more than 30% of children diagnosed as autistic at age two no longer fit the diagnosis at age four.[3] Several years ago, data supplied by parents of over 78,000 3 to 17-year-olds as part of a National Survey of Children’s Health revealed that nearly 40% had a previous, but not a current diagnosis of autistic spectrum disorder.[4]

There are other reasons why a sizable percentage of toddlers get erroneously diagnosed with autistic spectrum disorder. Up to one in five two-year-olds are late talkers.[5]They fall below the 50-word expressive vocabulary threshold and appear incapable of stringing together two and three word phrases. This sort of irregular language development is one of the hallmarks of early autism. Yet it is notoriously difficult to distinguish between toddlers with autistic spectrum disorder and those who are afflicted with delayed language development. The situation is further complicated by the fact that toddlers with delayed language development tend to share other features in common with autistic spectrum children. Scientific findings at the famed Yale Child Study Center have shown that toddlers with delayed language development are almost identical to their autistic spectrum disordered counterparts in their use of eye contact to gauge social interactions, the range of sounds and words they produce, and the emotional give-and-take they are capable of.[6] Consequently, many toddlers are placed in an autism red-zone who simply don’t meet standard benchmarks for how quickly language should be acquired and social interactions mastered.

Expanding autistic phenomena to include picky eating and tantrumming only amounts to more confusion when applied to toddlers. The percentage of young children in the U.S. with poor appetites and picky eating habits is so high that experts writing in the journal Pediatrics in 2007 commented: “it could reasonably be said that eating-behavior problems are a normal feature of toddler life.”[7] Tantrums also are surprisingly frequent and intense during the toddler years. Dr. Gina Mireault, a behavioral sciences professor at Johnson State College in Vermont studied children from three separate local pre-schools. She discerned that toddlers tantrummed, on average, once every few days. Almost a third of the parents surveyed considered their child’s tantrums to be distressing or disturbing.[8]

With the push to screen for and detect autistic spectrum disorder at progressively younger ages, the risk is greater that late-talking, picky-eating, tantruming, or transition-resistant toddlers will be misperceived as potentially autistic – especially if an evaluation is conducted in which the child is not sensitively engaged and put at ease. The risk is more acute, as I will soon illustrate, if this toddler is likely to develop into an introverted, cognitively-gifted boy who tends to be single-minded and willful in his approach to life learning. Even more basic than that, if we don’t have a firm grasp of gender differences in how young children communicate and socialize, we can mistake traditional masculine behavior for high-functioning autism.

How Boys Communicate and Socialize

A book I return to every so often is Eleanor Maccoby’s Two Sexes.[9] Her descriptions of boys’ and girls’ different speech styles jive with what I see daily in my office. She maintains, and I agree, that boys’ speech, on average, tends to be more egoistic than girls’. Boys are more apt to brag, interrupt, and talk over others, and ignore commands or suggestions. They are more inclined to grandstand, and “hold court,” trying to impress listeners with all that they know. They seem to be less socially attuned than girls. They are less likely to scan the faces and body language of others for cues on whether they should stop talking and start listening for basic social-sensitivity reasons.

Simon Baron-Cohen, the Cambridge University professor who popularized the extreme male brain theory of autism, would say that boys’ speech is more egoistic because, overall, boys tend to be less empathic than girls.[10] He backs this up with abundant scientific evidence. Putting yourself in someone else’s shoes to figure out what they might be feeling comes more naturally to girls. Girls are simply more inclined to read a person’s facial expressions in order to make sure that they are coming across sensitively. Faces tend to be sources of social feedback for girls in ways that they are not for boys. Dr. Baron-Cohen’s research team has discovered that even at birth, female infants will look longer at faces than male infants, and prolong mutual eye-gazing.[11]

Many boys just get perplexed when you try to empathize with them. As an example, I recently had the following interaction with Alan, an eight-year-old:

Alan: In my soccer game over the weekend, the other forwards on my team never passed to me. I was so mad.

Dr. Gnaulati: You were mad because your teammates didn’t pass to you, eh.

Alan: Why are you repeating what I just said? Didn’t you hear me?

This interaction with Alan captures how for many boys, grasping the literal content of their verbalizations matters more than “feeling understood.” Appearing attentive, asking probing questions, and reflecting back what someone is saying may be the empathic glue that cements a friendship for the average female. However, for the average male, following along with and responding to the literal content of what they are saying is what’s deemed valuable. A friend is someone who shares your interests and with whom you can have detailed discussions about these interests.

Watch boys at a sleepover and you’ll quickly realize that they need a joint activity to buttress social interaction and verbal dialogue. If that joint activity is a videogame such as Red Dead Redemption, the discussion will be peppered with pragmatic exchanges of information about how best to tame horses, free someone who has been kidnapped, or locate animal pelts. Without a joint activity that taps into their pre-existing knowledge about that activity, boys are often at a loss for discussion. There are long silences. Eye contact is avoided. Bodies become more wiggly.

Watch girls at a sleepover and any shared activity they engage in is often secondary to the pleasure they seem to derive from just hanging out and talking.

The stereotype of boys as logical, inflexible, and business-like in their communication habits is more than just a stereotype. A recent massive study out of the University of Florida involving 5,400 children in the U.S. ages 8-16 indicates that twice as many boys as girls fit this Thinking-Type temperament. Conversely, twice as many girls as boys fit the Feeling-Type temperament – tactful, friendly, compassionate, and preferring emotion over logic.[12]

Many boys feel compelled to be logical and exact in their use of language. They withdraw and shut down around people who use language more loosely. A glaring example of this was shown to me recently by a 14-year-old client named Jordan. His parents brought him in for therapy because he was racking up school detentions due to his being rude to teachers. Jordan secretly confessed to me that his English teacher must be dumb because she referred to certain assignments as “homework,” when she allowed them to be completed in class. She should have renamed them “schoolwork,” because they were being completed at school. In twenty-five years of therapy practice, I’ve never encountered a girl who has made such a comment.

As educated people, we don’t want to believe in overarching differences in communication styles between the sexes. When I was in college in the ‘80s and ‘90s, “essentialism” was a dirty word. To believe that males and females might be different in essential ways was akin to admitting that you were unenlightened. There’s still a pervasive sense in our culture that to be educated is to be gender-blind. Curiously, there’s a noticeable taboo against voicing aloud explanations for a child’s behavior in terms of their gender. If you don’t believe me, try saying some of the following things at your child’s next parent-teacher conference:

It’s this public discomfort with discussing children’s gendered behavior that gets many traditionally masculine boys inappropriately labeled as high-functioning autistic. Poor eye contact, long-winded monologues about one’s new favorite topic, being overly serious and business-like, appearing disinterested in other’s facial expressions, and restricting friendships to those who share one’s interests, may all be signs of Asperger’s Disorder or high-functioning autism. However, these same traits typify boys who are traditionally masculine in their behavior. Parents somehow have to ask the uncomfortable question in the doctor’s office: Is he high-functioning autistic or really a more masculine-identified boy? If it’s the latter, what a boy may need is some combination of acceptance and personal and professional help to finesse his social skills over time – not an incorrect diagnosis and unnecessary medical treatment.

Brainy, Introverted Boys Beware

Let’s return to William. With all respect to the good doctors at the university-based institute who evaluated him, they were not up on the literature on mental giftedness. We know this because William manifested certain brainy, mentally-gifted traits that can look autistic-like to the untrained eye, but aren’t. Take his tendency to burrow deep into a topic and crave more and more information on it. There was his Pompeii phase, then his Titanic phase. He just had to learn all that he possibly could about these topics. He talked the ear off of anybody who would listen to him about them. On the face of it, William’s obsessions appeared autistic-like. However, it is the enthusiasm with which he shared his interests with others that distinguishes William as brainy and mentally gifted, rather than autistic in any way. Remember, at preschool, he could amass a following. He experienced times where he was the Pied Piper. Other children were initially drawn to him when he held court or orchestrated his Titanic play. William lit up emotionally when he commanded the attention of the pre-schoolers who gathered around him.

When highly restricted interests are shared with relatively little spontaneity and enthusiasm, in ways that fail to entice children to come hither to listen and play – this is when we should suspect autistic spectrum disorder. The same is true when a child talks without interruption about a very technical topic, such as dinosaur names or bus schedules, seemingly indifferent to whether the listener congratulates him for his encyclopedic knowledge, or is peeved by the lecture.

Another characteristic of William’s that is evidence of mental giftedness and not autistic spectrum disorder is how fluid and changeable his areas of interest could be. As he got older, William became fascinated by subjects as diverse as world geography, ancient history, the lives of rock stars (especially the Beatles), and vintage guitars. He approached his new areas of interest with the same degree of mental engrossment that he had approached his old ones, regardless of how unrelated the new ones were to the old ones. Autistic spectrum disordered children tend to hold steadfast to their odd topics of interest over time and not substitute one for another too readily.

One of the drawbacks to early screening and detection of high-functioning autism is that small children’s cognitive development isn’t sufficiently mature enough to judge what their sense of humor is like. Often it is a sense of humor that separates true cases of mild autism from mental giftedness. Mildly autistic children often don’t really comprehend irony, sarcasm, or absurdity. Mentally gifted children, on the other hand, often thrive on irony, sarcasm and absurdity. This distinction was brought home to me recently in an interaction with an intellectual 11-year-old boy named Michael. His lengthy, detailed discourses on planets and the solar system made his parents wonder whether he might have Asperger’s disorder. One day, after meeting with his mother briefly for a check-in, I went out to the waiting room and warmly greeted Michael, “Speak of the devil, we were just talking about you.” Michael came back to the office and, as he picked up a rubber sword to engage me, jokingly warned, “I am the devil, and you will get burned.” I knew right then and there that Asperger’s disorder was completely out of the question.

Highly intelligent boys who happen to be introverted by temperament are probably the sub-population of children who are most likely to be erroneously labeled autistic. In her provocatively titled Psychology Today article, Revenge of the Introvert, Laurie Helgoe, a self-described card-carrying introvert, captures a key personality characteristic of introverts: “(They) like to think before responding – many prefer to think out what they want to say in advance – and seek facts before expressing opinions.”[13] Introverted, highly intelligent boys may appear vacant and non-responsive when asked a question like “What is your favorite animal?” Yet, in their mind, they may be deeply and actively processing copious amounts of information on types and defining features of animals, and zeroing in on precise words to use to articulate their complex thoughts. Thirty seconds, a minute, or even more time may pass before an answer is supplied. In the meantime, the listener might wonder if the boy is deaf or completely self-absorbed.

According to Laurie Helgoe: “Introverts seek time alone because they want time alone.”[14] Brainy, introverted boys may cherish and look forward to alone time, which allows them the opportunity to indulge their intellectual appetites full throttle, amassing knowledge through reading or Internet searches. Solitude creates the time and space they need to totally immerse themselves in their preferred interests. They may get more turned on by studying ideas, pursuing science projects, or by solving math problems than by conversing with people.

In our extroverted culture, where being a “team player” and a “people person” are seen as linchpins of normalcy, the notion that a brainy, introverted boy might legitimately prefer the world of ideas over the world of people is hard for most people to accept. Parents of such boys may feel terribly uneasy about their tendency to want to be alone and may try to push their sons to be sociable and to make more friends. But if you get to know such boys, they would much rather be alone reading, writing, or pursuing projects that stimulate their intellect than be socializing with peers who are not their intellectual equals. However, once they come into contact with a kindred spirit, someone who is a true intellectual equal with whom they can share the fullness of their ideas, that person just might become a lifelong friend. Around such kindred spirits, brainy, introverted boys can perk up and appear more extroverted and outgoing, wanting to talk as well as to listen. With people who share their interests, especially people who possess equal or greater knowledge in these areas, the social skills of brainy, introverted boys can be quite normal.

My Way or No Way: Autonomy-Seeking, Not Autism

I’d like to engage the reader in a thought provoking exercise. I’m going to list a collection of behaviors. As you peruse them, ask yourself if these behaviors are indicative of typical willful male toddlers, or possible autism at this age? Remember, the toddler years are from approximately age one to age three.

It may surprise the reader to learn that I obtained this list of behaviors from a Consumer Reports health-related article titled, What are the symptoms of autism?[15] If this exercise left you thinking that these behaviors might be characteristic of both willful male toddlers and autistic children, that’s commendable. This means that you have more than a passing familiarity with early childhood development. It also means that you are keenly aware of how toddler issues can get misconstrued as autistic tendencies.

The glee on the faces of toddlers upon discovering that they can propel themselves away from caregivers and into the world beyond – with the power of their own limbs – says it all. During the first year of life, they were relatively helpless. They were at the complete mercy of caregivers to gauge what they needed. Now their fast-evolving fine and gross motor abilities are being put to full use in exploring their surroundings. There is fire in their bellies. They insist on having personal control over what they get to see, hear, touch, smell, and taste, and for how long. This is what developmental psychologists call the “need for autonomy” that kicks in during toddlerhood. The word parents tend to use is “willfulness.” There is a world of sensory delight out there for toddlers to discover and sample, and they want nothing to get in their way.

Male toddlers advance at a faster rate than the opposite sex in their gross motor development and visual-spatial skills. The science is there. Generally speaking, boys are more physically capable of exploring their environments than girls. When they do, objects are likely to be the object of their exploration. Little boys, especially those with strong visual-spatial intelligence, can appear like they’ve entered a trance when they stare at, squeeze, lick, toss and fetch, arrange, stack, and knock down blocks – only to do it all over again. We forget how immersion in an activity, and repetition of it, can lead to an experience of mastery. Lining up trains, in identical order, making the same sounds, and pulling them with the same force, can rekindle the same feeling of mastery that was felt the first time this activity went well. Not all repetitiveness and needs for sameness speak to autistic tendencies. When a toddler appears driven to use his body effectively in the accomplishment of a task and to further an experience of mastery, it’s unlikely that he’s on the spectrum no matter how repetitive the task becomes – particularly if that toddler shows self-pride and wants others to share in the excitement of it all, even in quiet and subdued ways.

Boys’ level of engrossment in discovering and manipulating objects can lead them to be oblivious to their surroundings. They may not look up when their name is called. They may appear unconcerned whether you’re in the room or not. Self-absorption while studying objects is expectable behavior for male toddlers, especially for those on the upper end of the bell curve on visual-spatial intelligence.

Parents and educators shouldn’t assume the worst when male toddlers play alone. Research shows that boys are far more likely to engage in solitary play than girls at this age. Many little boys are satisfied playing alone, or quietly alongside someone else, lining up toy trains, stacking blocks, or engaging in a range of sensorimotor play activities. It is not until about age four or five that boys are involved in associative play to the same extent as girls.[16] That’s the kind of play where there’s verbal interaction, and give-and-take exchanges of toys and ideas.

The difference between a relatively typical male toddler immersed in solitary object play, and one who shows early signs of autistic behavior can be subtle. Typically developing male toddlers are more apt to experience periodic separation anxiety. They suddenly wonder where mommy is. Needing mommy in these moments takes precedence over the activity in which they were absorbed. Sometimes visually checking in and receiving a reassuring glance back from mommy is enough. Sometimes more is needed, like approaching her for a hug or a pat on the back. This inspires confidence that mommy will be available if and when needed. The toddler can then shimmy across the room and pick up where he left off playing. This “emotional pit stop” behavior is less apparent with toddlers on the spectrum.

Mentally gifted boys are often perfectionists. Projects need to be done just right, and they will continue to work on a project until it is exactly what they want. During toddlerhood, when early signs of perfectionism are mixed with regular needs for autonomy, the combination can make a child look very controlling. A cognitively advanced three-year-old boy who also is a perfectionist might spend hours arranging and rearranging, stacking and restacking blocks to construct a castle that he feels needs to be flawless if he’s to be satisfied. Attempts to get his attention, have him come to the kitchen for a snack, or put the blocks aside to get ready for bed are ignored or resisted. When such demands are issued suddenly, without forewarning, and instant compliance is expected, this is the emotional equivalent, for the toddler, of someone purposely tripping and badly injuring a front-place marathon runner right at the finish line. A tantrum is a distinct possibility. The child is in emotional pain due to being unable to prolong and achieve an experience of mastery.

Tantrums during the toddler years are, of course, commonplace. Under normal family circumstances, when a toddler’s maturation is right on schedule, parents can expect a tantrum from their three-to-five-year-old once every few days. That was the conclusion of Dr. Gina Mireault’s study cited earlier. Her research also revealed that according to parents, the top-ranked event that triggered a toddler’s tantrum was: “Denial of a request/not getting their way.”[17] Most tantrums are triggered by parents directly confronting children’s assertions of autonomy, or their need to have personal control over what they get to see, hear, touch, smell, and taste, and for how long. Tantrums can be exacerbated by fatigue and hunger. Toddlers have different temperaments, and this influences the frequency, intensity, and duration of tantrums.

But, in general, tantrums occur because a toddler is denied ice-cream before dinner, is prevented from grabbing grandma’s expensive Moorcroft pottery dish, insists on watching one more show when it’s bedtime – or any such expectable parental challenge to their need to prolong a pleasurable activity, or independently exercise sensorimotor mastery.

The tantrums of autistic spectrum children are less likely to be of the autonomy-assertion or mastery-seeking variety. Their tantrums more often than not reflect sensory overload. They may scream and writhe around on the floor because they are in physical pain due to their nervous system being bombarded by an intolerable level of stimulation. The sights and sounds at the mall when their family is shopping for holiday gifts may put them over the top. The buzz from and brightness of overhead lights might be a trigger. Rituals and routines are relied on to keep sensory stimulation at manageable levels. Tantrums may signal a need to keep a ritual or routine exactly the way it was to protect the child from sensory overload.

Sometimes what appears to be an autistic-like tantrum is really what Dr. Stanley Greenspan, the world-renowned child psychiatrist, calls, “sensory craving.” This applies to toddlers whose ability to self-regulate their feelings while they’re in the act of exploring their environments is underdeveloped:

Many children show a pattern we call “sensory craving,” where they’re running around the house trying to get more sensation into their system, whether it’s staring at fans, or bumping into things or touching everything or just shifting from one toy to another in a seemingly aimless way, or just spinning around and jumping around or shaking their arms and legs in seemingly disjointed ways. These all look like terrible symptoms and they scare parents and they scare some professionals as well, understandably so. But they’re often signs of sensory craving – a child wants more sensory input, but doesn’t know how to do it in an organized social way.[18]

These are toddlers that Dr. Greenspan thinks need abundant “sensory meaningful” interactions with parents and care providers to help them become more self-composed over time. This could amount to matching the child’s energy and activity level in a fun airplane ride game. Scooping him up, asking him to point his fist in the direction in which he wants to be flown, with a thumbs up for faster, and a thumbs down for slower – would be sequences of sensory meaningful interactions that still honor his need for autonomy.

Temper outbursts and quirky behavior around food preferences are widespread among autistic spectrum children. But the same can be said of toddlers. It’s important to have a sense of perspective regarding the pervasiveness of toddlers’ habit of latching onto preferred foods and rejecting new offerings. A survey of over 3,000 households with infants and toddlers conducted by nutrition experts at the University of Tennessee, Knoxville, indicates that a whopping 50% of two-year-olds are considered picky eaters by their caregivers. These nutritionists believe the numbers are so high because mothers are not persistent enough in introducing new foods in ways that ensure they’ll eventually be eaten: “When offering a new food, mothers need to provide many more repeated exposures (e.g., eight to 15 times) to enhance acceptance of that food than they currently do.”[19]

Let’s call this the “8-to-15 times rule.” If a toddler reacts with revulsion, aggressively throwing dishes on the floor, or refusing to eat each time a new food item is introduced after 8-to-15 separate attempts, chances are that he or she’s a picky eater. This is particularly true if in the process, the parent stayed calm and conveyed confidence that the new food item was good to eat – not being too insistent on the one hand, or tentative on the other.

But certainly not all picky eaters are that way because they are on the spectrum. Autistic spectrum children who are picky eaters often have odd food preferences, such as only eating foods which are yellow-colored. Their reactions after repeated exposure to new foods frequently remain acute, or become even more blustery. It’s not about power struggles and control. A new food item may literally assault their senses. The smell, look, and texture of that food may induce a type of sensory revulsion and disgust. They can’t be around it. Either it has to go, and the food item gets thrown or mashed up, or the child has to go – perhaps agitatedly running off.

Off the Spectrum

The younger in age a child is when professionals screen for milder forms of autism, the greater the risk that a struggling child will be misperceived as a disordered one. A vast number of toddlers present in the doctor’s office with a hodge-podge of social and emotional difficulties, such as poor eye contact, overactivity and underactivity, tantrumming, picky eating, quirky interests, or social awkwardness. These phenomena need not be seen as tell-tale signs of autistic spectrum disorder. Sometimes they merely are evidence of a perfect storm of off-beat events in social and emotional development, mixed with difficult personality traits – with the upshot that the child, for the time being, is very out of sorts.

When we mistake a brainy, introverted boy for an autistic spectrum disordered one, we devalue his mental gifts. We view his ability to become wholeheartedly engrossed in a topic as a symptom that needs to be stamped out, rather than a form of intellectualism that needs to be cultivated. Boys like William don’t need to be channeled into unwanted and unnecessary social skills classes to obtain formal instruction on how to start and sustain normal conversations. They don’t need to be prodded to be more sociable with the neighborhood child whose mind works completely differently than theirs. They need unique school programs that cater to the mentally gifted in which others will not be chagrined by their intense love for ideas, and where they have a shot at making true friends and therefore have the opportunity to feel truly sociable.

Conclusion

The education and training of mental health professionals tends to prime them to think in terms of disease and disorder, shunting them away from first considering common-sense psychosocial and developmental explanations for children’s troubling and troublesome behavior. In this course we have learned that ADHD symptoms often mimic normal childhood narcissism. ADHD tendencies sometimes can be more comprehensively explained and accurately treated insofar as they reflect struggles children manifest with overconfident self-appraisals, desperate needs for recognition from caregivers and peers, personal entitlement, and underdeveloped empathy. Viewing all ADHD tendencies as forms of neurological dysfunction meriting behavioral and pharmacological treatment can obscure the narcissistic functions and intentions ADHD-like behavior sometimes serves, leaving truly afflicted children void of the right kind of psychotherapeutic treatment – inroads to acquire more measured self-appraisals, obtain corrective emotional experiences replete with affirmation of their displayed mastery, lessen their susceptibility to feel entitled, and develop their empathy skills.

Sophisticated clinical terminology characterizing autism spectrum disorder, such as “deficits in socio-emotional reciprocity, nonverbal communication, and developing and maintaining age-appropriate relationships,”[20] really boils down to run-of-the-mill behaviors such as manifesting sufficient happiness when someone else is happy, keeping good eye contact, responding to your name, and finding other children your age interesting enough to want to engage them socially – social and emotional skills that during toddlerhood (the most common age for children to be evaluated for autism spectrum disorder) are mastered at uneven paces across children, and genders. We always have to ponder and rule out developmental and social-contextual factors when evaluating children of tender years. When a toddler repeats words and phrases, is entranced by stimulating objects, lines up and stacks toys, runs away when overstimulated, or displays rigid food preferences, is he or she working through something developmentally, exhibiting a situational negative reaction, or showing evidence of autism?

A developmentally informed perspective of this sort minimizes the potential for a false autism diagnosis to be assigned a child and the attendant distress parents encounter from such an avoidable event.

For additional reading on the topics covered in this course and more, you may be interested in Dr. Gnaulati’s book, Back to Normal: Why Ordinary Childhood Behavior is Mistaken for ADHD, Bipolar Disorder, and Autism Spectrum Disorder (Beacon Press, 2013). The book documents the myriad reasons why common childhood disorders are on the rise and the overlooked normal childhood reactions to stressful life situations, lags in socio-emotional growth, emergent difficult personality traits, patterns of reactivity in the parent-child relationship, academic learning style mismatches – or a perfect storm of all of these – get confused for evidence of a psychiatric disorder.

References

(Note: To return to the course after having clicked a footnote, click the Back button in your browser.)

Introduction

1. Defresne P, Mottron L. (2022). Clinical situations in which the diagnosis of autism is debatable: An analysis and recommendations. Canadian Journal of Psychiatry. 67(5), 331-335. doi:10.1177/07067437211041469

2. Merten, E. C., Cwik, J. C., Margraf, J., & Schneider, S. (2017). Overdiagnosis of mental disorders in children and adolescents (in developed countries). Child and Adolescent Psychiatry and Mental Health, 11, Article 5. https://doi.org/10.1186/s13034-016-0140-5

3. Weissenberger, S., Ptacek, R., Klicperova-Baker, M., Erman, A., Schonova, K., Raboch, J., & Goetz, M. (2017). ADHD, lifestyles and comorbidities: A call for an holistic perspective – From medical to societal intervening factors. Frontiers in Psychology, 8, Article 454.

4. Emeh, C. C., Mikami, A. Y., & Teachman, B. A. (2018). Explicit and implicit positive illusory bias in children with ADHD. Journal of Attention Disorders, 22(10), 994–1001. https://doi.org/10.1177/1087054715612261

5. Silverman, M. R., Bennett, R., Feuerstahler, L., Stadterman, J., Dick, A. S., Graziano, P., & Roy, A. K. (2022). Measuring emotion dysregulation in children with attention-deficit/hyperactivity disorder: Revisiting the factor structure of the Emotion Regulation Checklist. Behavior Therapy, 53(2), 196–207. https://doi.org/10.1016/j.beth.2021.07.004

6. Cenat JM, Blais-Rochette C, Morse C, et al. (2020). Prevalence and risk factors associated with attention-deficit/hyperactivity disorder among US black individuals: A systematic review and meta-analysis. JAMA Psychiatry. Published online September 09, 2020. doi:10.1001/jamapsychiatry.2020.2788

7. Bishop, J. C., & Rinn, A. N. (2020). The potential of misdiagnosis of high IQ youth by practicing mental health professionals: A mixed methods study. High Ability Studies, 31(2), 213–243. https://doi.org/10.1080/13598139.2019.1661223

8. Kubicek, L. F., & Emde, R. N. (2012). Emotional expression and language: A longitudinal study of typically developing earlier and later talkers from 15 to 30 months. Infant Mental Health Journal, 33(6), 553–584. https://doi.org/10.1002/imhj.21364

9. Machado, B. C., Dias, P., Lima, V. S., Carneiro, A., & Goncalves, S. (2021). Frequency and correlates of picky eating and overeating in school-aged children: A Portuguese population-based study. Journal of Child and Family Studies. Advance online publication. https://doi.org/10.1007/s10826-021-01936-0

10. Silver, J., Bufferd, S. J., Dougherty, L. R., Goldstein, B. L., Carlson, G. A., & Klein, D. N. (2022). Is the distinction between tonic and phasic irritability meaningful in 3-year-old children? European Child & Adolescent Psychiatry. Advance online publication. https://doi.org/10.1007/s00787-022-01995-8

ADHD, or Childhood Narcissism at the Outer Edges

1. “One in Ten Children Using Cough Syrup,” Science Daily, August 4, 2008; see http://www.sciencedaily.com/releases/2008/08/080804111648.htm

2. http://www.cdc.gov/Features/dsADHD/

3. Gretchen B. Le Fever, Ardythe Leslie Dawson, and Keila V. Dawson, “The Extent of Drug Therapy for Attention-Deficit Hyperactivity Disorder among Children in Public Schools,” American Journal of Public Health 89 (1999):1359-64.

4. Alicia Merline, Lynn Olsen, and William Cull, “Length of Pediatric Visits Actually Increasing,” Pediatric Academic Societies Annual Meeting, May 2009; see http:// www.aap.org/research/abstracts/2009/8abstract09.pdf

5. David F. Bjorklund, Why Youth is not Wasted on the Young (Malden, MA: Blackwell Publishing, 2007), 115.

6. Deborah Stipek, “Children’s Perceptions of their own and their Classmates’ Ability,” Journal of Experimental Child Psychology 73 (1981): 404-10.

7. Fred A. Baughman, Jnr., The ADHD Fraud: How Psychiatry Makes ‘Patients’ of Normal Children (Bloomington, IN: Trafford Publishing, 2006).

8. Betsy Hoza, William E. Pelham, Jennifer Dobbs, et al., “Do Boys with Attention-Deficit/Hyperactivity Disorder have Positive Illusory Self-Concepts?” Journal of Abnormal Psychology 111 (2002): 268-278.

9. Mikaru S. Lasher, Barry S. Markman, Robert D. Rothermel and John W. Deluca, “Cognitive Flexibility and Empathy in Children with ADHD,” American Psychological Association Convention Presentation, August 12, 2006.

10. Michelle M. Martel, Timothy Goth-Owens, Cecilia Martinez-Torteya, and Joel T. Nigg, “A Person-Centered Personality Approach to Heterogeneity in Attention-Deficit/Hyperactivity Disorder,” Journal of Abnormal Psychology 119 (2010): 186-196.

11. Linda L. Thede, “Personality and Mood Differences in ADHD, Asperger’s Disorder, and Autism,” American Psychological Association Convention Presentation, August 7, 2003.

12. Malcolm Gladwell, Outliers: The Story of Success (New York: Little, Brown and Company, 2008).

13. See http://www.russellbarkley.org/content/adhd-facts.pdf

14. Russell A. Barkley, Taking Charge of ADHD (New York: Guilford Press, 2005) 71.

15. Daniel T. Willingham, Why Students Don’t Like School (San Francisco: Jossey-Bass, 2009) 107.

16. Alison Gendar, Oren Yaniv, and Dave Goldiner, “JetBlue Flight Attendant who Went Nuts was in Bed with Boyfriend When Found by Cops,” New York Daily News, September 3, 2010.

17. “JetBlue Flight Attendant: Hero or Heel?” CBSNews, August 12, 2010; see http://www.cbsnews.com/stories/2010/08/12/earlyshow/main6766242.shtml.

18. Courtney Comstock, “JetBlue Doesn’t Want Steven Slater to be a Hero Anymore Because ‘He Could Have Killed Someone, ’” BusinessInsider Web site, August 13, 2010; see http://artciles.businessinsider.com/2010-08-13/wall_street/30044633_1_slides-memo-steven-slater

19. Jean M. Twenge and W. Keith Campbell, The Narcissism Epidemic (New York: Free Press, 2009).

20. Quoted in Elizabeth Carpenter-Song, “Caught in the Psychiatric Net: Meanings and Experiences of ADHD, Pediatric Bi-Polar Disorder and Mental Health Treatment Among a Diverse Group of Families in the United States,” Culture, Medicine and Psychiatry 33 (2009), 69.

Autistic? Or a Brainy, Willful, Introverted Boy?

1. Roy Richard Grinker, Unstrange Minds (New York: Basic Books, 2007).

2. Stanley I. Greenspan, “The Misdiagnosis of Autistic Spectrum Disorders: The Most Important Signs of Progress;” http://www.icdl.com/distance/webRadio/documents/2-26-2004.pdf.

3. Lauren M. Turner and Wendy L. Stone, “Variability in Outcome for Children with an ASD Diagnosis at age 2,” Journal of Child Psychology and Psychiatry 48 (2007): 793-802.

4. Michael D. Kogan et. at., “Prevalence of Parent-Reported Diagnosis of Autistic Spectrum Disorder Among Children in the US, 2007,” Pediatrics 124 (2009): 1395-1403.

5. Linda Carroll, “Toddler of Few Words? Late-talkers Can Catch Up;” http://today.msnbc.com/id/43610567/ns/today-parenting/t/toddler-few-words-late-talkers-can-catch/

6. Rhea Paul, Katyrzyna Chawarska and Fred Volkmar, “Differentiating ASD from DLD in Toddlers,” Perspectives on Language Learning and Education 15 (2008): 101-111.

7. Charlotte M. Wright, Kathryn N. Parkinson, Deborah Shipton, and Robert F. Drewett, “How Do Toddler Eating Problems Relate to Their Eating Behavior, Food Preferences, and Growth,” Pediatrics 120 (2007): 1069-1075.

8. Gina Mireault and Jessica Trahan, “Tantrums and Anxiety in Early Childhood: A Pilot Study,” Early Childhood Research and Practice 9 (2007): 10-19.

9. Eleanor E. Maccoby, The Two Sexes (Boston: Harvard University Press, 1998).

10. Simon Baron-Cohen, The Essential Difference (New York: Basic Books, 2003).

11. Baron-Cohen, The Essential Difference, 5.

12. Thomas Oakland and Chryse Hatzichristou, “Temperament Styles of Greek and US Children,” School Psychology International 31 (2010): 422-437.

13. Laurie Helgoe, “Revenge of the Introvert,” http://www.psychologytoday.com/print/46944.

14. Helgoe, “Revenge of the Introvert,” 3.

15. See http://www.consumerreports.org/health/conditions-and-treatments/autism/what-are-the-symptoms.htm.

16. Stephanie Barbu, Guenael Cabanes and Gaid Le Maner-Idrissi, “Boys and Girls on the Playground: Sex Differences are not Stable Across Early Childhood,” PlosONE 6 (2011): 16407.

17. Gina Mireault and Jessica Trahan, “Tantrums and Anxiety in Early Childhood: A Pilot Study,” Early Childhood Research and Practice 9 (2007): 10-19.

18. Stanley I. Greenspan, “The Do’s and Don’ts of Early Identification and Early Intervention;” http://www.icdl.com/distance/webRadio/documents/12-16-2004.pdf.

19. Betty R. Carruth, Paula J. Ziegler, Anne Gordon, and Susan I. Barr, “Prevalence of Picky Eaters Among Infants and Toddlers and Their Caregivers’ Decisions about Offering a New Food,” Journal of the American Dietetic Association 104 (2004): 57-64.

20. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author, p. 60.

 

Take the test

 

© Copyright 2004-2024 by ContinuingEdCourses.Net, Inc. All rights reserved.