The answer may lie, at least in part, with the common procedures and clinical atmosphere in which ADHD is assessed. Conducting a sensitive and sophisticated review of a kid’s life situation can be time-consuming. Most parents consult with a pediatrician about their child’s problem behaviors, and yet the average length of a pediatric visit is quite short. 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 behavior. 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 kid’s problems and are often primed to cut to the chase, narrowly listing behaviors along the lines of the following:

Yes, Amanda is very distractible. To say that Billy is hyperactive is an understatement. Frank is impulsive beyond belief.

All too often, forces conspire in the doctor’s office to ensure that any discussion about a 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 kid’s behavior. It is easy to understand why parents may favor a sure and swift approach, with a discussion converging 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 as opposed to 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 the following 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.

It is normal for preschoolers to think big and engage in magical thinking about their abilities, relatively divorced from the nature of their actual abilities. Even first graders, according to research by psychologist Deborah Stipek of the University of California at Los Angeles, believe they are “one of the smartest in the class,” whether this self-assessment is valid or not. 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, kids need to get better at aligning their self-beliefs about personal accomplishments with their actual abilities. They also need to get better at realizing how a desired outcome is fundamentally connected to how much effort and commitment they put into a task. The ways in which caregivers deal with kids’ successful and not-so-successful demonstrations of supposed talents have a bearing on how well kids form accurate beliefs about their true abilities. This brings us to the next ingredient of normal childhood narcissism—recognition craving.