One important factor in determining impairment is the basis for comparison. To whom should an individual be compared in order to make a diagnosis of ADHD? The DSM-IV (2001) states that the ADHD symptoms must be "maladaptive and inconsistent with developmental level" (p. 92). For children, "developmental level" might be taken as referring simply to age groups. One could argue that a five-year-old is not impaired in her ability to pay attention if she can pay attention as well as most other five-year-olds. The DSM-IV does not, however, spell out the full range of meanings for "developmental level," which could also be taken to refer to level of intelligence. At the lower boundary, this reinterpretation would mean that one would not make the diagnosis of ADHD for an eight-year-old developmentally disabled child with an IQ of 60 by comparing his ability to sustain attention with that of other eight-year-olds with normal IQ. This is generally accepted.
What is more controversial is the assessment of impairment at the upper boundary of ability—that is, for the very bright individual whose overall cognitive competence as measured by standardized tests of intelligence is in, say, the top 5 to 10 percent of the age group. Should this individual be considered impaired if he is chronically unable to organize and sustain effort for his work, to remember what he has just read, or to perform other cognitive tasks as compared to a same-age student with cognitive abilities scored in a similar range?
If the superior-range student can perform most other cognitive tasks as well as other students in the top 5 to 10 percent of his age group, it would seem that symptoms of ADD syndrome that chronically and significantly depress his capacity to use his abilities should be counted as clinically significant impairment. Assessment of impairment ought to take into account the overall level of cognitive abilities in the individual being as-sessed—otherwise, only those whose impairments are most global and most severe will likely be eligible for treatment. A high school student who demonstrates superior ability on a standardized IQ test but consistently gets very low grades is certainly working below his ability. This failure might be due to depression, to substance abuse, to deliberate defiance of parental expectations, or to many other factors; one possible cause could be ADD syndrome.
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