In other situations, there may be little question about the presence of the symptoms, but considerable uncertainty about their causes. The parents, child, and the child's teachers may all agree that the child has some symptoms of ADHD, yet factors other than ADHD are likely to blame. For example, the family may be suffering from severe financial hardship with both parents unemployed. One parent may be seriously addicted to alcohol, causing disruption or abuse at home. An older sibling may be severely defiant toward the parents and intimidating to the patient. A beloved grandparent may be dying of cancer. Or a child's favorite teacher may have left on maternity leave for several months, replaced by a series of ineffective substitutes.
Such stressors, especially when more than one is present, may be the primary cause of the child's apparent ADHD impairments, or they may simply be exacerbating ADHD impairments that have been present since birth. The incidence of unemployment, marital conflict, substance abuse, and frequent changes of residence is elevated among individuals with ADHD. The presence of environmental stressors, even if they are many and severe, does not rule out a diagnosis of ADHD any more than such stressors would rule out a diagnosis of asthma.
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