Sometimes you can't see the forest for the trees.
When I was a school social worker, I was asked to work with "Joey", a fourth grade boy who was always hitting others on the playground. He didn't listen in class or finish his work and was oppositional with teacher.
So I met with his mother. Attractive, sweet, quiet person. Didn't know what to do with him. New stepfather was "harsh" with him, according to Mom. I gave her info on Time Out and a possible behavior contract.
When I called her to see how things were going, I often woke her up in the afternoon although she wasn't working. She always sounded sad, exhausted, and overwhelmed, though "Joey" was her only child. She hadn't tried Time Out or anything else to improve his behavior.
"Joey's" teacher, experienced and well-organized, was tired of his disruptive behavior, but agreed to a behavior contract and kept a record of his response to it. He had good days and bad days. Generally, his behavior improved a little; his work and homework improved quite a bit.
I interviewed "Joey" before adding him to a group. He was cute, confident, cautious. His mother was "good". His stepfather, "mean." Wouldn't elaborate on these descriptions.
In group, he was unfailingly quiet, focused, and well-behaved. He got along fine with the other kids and rarely got a "check" that might cost him group play time if he ended up with three of them.
This was fairly typical for a child I suspected of having ADHD. They always do better in a small, structured group than the normal (overstimulating for them) classroom or playground.
What bothered me was Mom's seeming depression and lack of ability to change "Joey's" behavior in any way. She did, at my urging, talk to her doctor and begin to take an anti-depressant. This helped with her depression, but not with "Joey's" outbursts and aggression at home.
Finally, after getting suspended for punching a boy, "Joey" blurted out to me that his stepfather hit his mother--a lot.
Ouch. I hadn't even thought about that. Joey might have ADHD, but he also had a bad male model, anger at his stepfather and at himself for not being able to protect his mother. Add anxiety about her safety which would cause or contribute to his inability to concentrate.
Many of the kids at the shelter show symptoms of ADHD, especially after they feel safe there and less depressed. When you hear about the aggression and "fits" of temper in their father figures, you wonder what these men were like as kids.
Did they, too live in a violent home or were others violent toward them because of their problems?
ADHD combined with aggression has the worst prognosis. I don't believe in throwing medication at every child who appears to have ADHD, but are we missing something here?