adhd comorbidity and differential diagnosis...adhd vs depression adhd •inattentiveness,...

ADHDCOMORBIDITY AND

DIFFERENTIAL DIAGNOSIS

DR. MANOJ BHATAWDEKAR

INATTENTION (CALL FOR FrEd)• Careless mistakes

• Attention difficulty

• Listening problem

• Loses things

• Fails to finish what he/ she starts

• Organisational skills lacking

• Reluctance to do tasks that require a sustained mental effort

• Forgetful in routine activities

• Easily distracted

HYPERACTIVITY- IMPULSIVITY(RUNS FASTT)

• Runs or is restless

• Unable to wait for his or her turn

• Not able to play quietly

• Slow?- oh no! On the go!

• Fidgets with hands or feet

• Answers are blurted out

• Staying seated is difficult

• Talks excessively

• Tends to interrupt

"Diagnostic criteria" is not just a list of "symptoms" as narrated by the patient/ relatives.

It is the clinical impression formed after listening to the symptoms and observing signs.

Previously they were just called children!!

Stephen Hinshaw Ph.D.

Case 1

• A 10 year old boy is found to be restless in the class

• Not attentive

• Appears not to participate in any activities

• Seems to be lost in his own thoughts, daydreaming

• Answers in monosyllables

• Work incomplete

• When questioned or confronted breaks down into tears

• Not interested in play activities

• Not eating well

• Lost weight

• Disturbed sleep

• All these symptoms started at a point in time

ADHD vs DEPRESSION

ADHD

• Inattentiveness, distractibility, losing things

• Failure to finish tasks or activities, reluctance to start if needs sustained mental effort

• Difficulty organizing

DEPRESSION

• Impairment of concentration and memory, preoccupation with mood

• Fatigue, anergia, loss of interest

• Anergia, cognitive impairment

ADHD vs DEPRESSION

ADHD

• Hyperactivity , fidgeting, restlessness

• Excessive talking

• Impulsive blurting of answers

• Restless sleep

• Irritability

DEPRESSION

• Agitation

• Agitated, complaining

• Preoccupied with complaining

• Insomnia

• Irritability

DISTINGUISHING FEATURES OF DEPRESSION

Depressed mood, anorexia, weight loss, suicidal ideation, guilt feelings, psychomotor slowing, mutism, fatigue

Case 2

• A 14 year old girl seems to be very hyperactive in the class

• Not sitting at one place

• Very talkative

• Disturbs others

• Does not obey instructions

• Often leaves her classroom

• Laughs a lot

• Often irritable, especially if her activities are thwarted

• Wants to do too many things

• Fights a lot with her peers

• Started at a point in time

ADHD vs BIPOLAR (MANIA)

ADHD

• Inattentiveness, distractibility, forgetfulness, losing things

• Failure to finish tasks, reluctance to start if needs sustained mental effort

• Difficulty organizing

• Hyperactivity, fidgeting, restlessness

BIPOLAR (MANIA)

• Flight of ideas, thought racing, distraction by grandiosity

• Flight of ideas, grandiosely above common tasks

• Flightiness

• Psychomotor acceleration, driven quality

ADHD vs BIPOLAR (MANIA)

ADHD

• Excessive talking

• Impulsive blurting of answers, interrupting, intruding

• Impatience, easy frustration, difficulty waiting

• Irritability

• Restless sleep

BIPOLAR (MANIA)

• Pressured speech

• Pressured speech, flight of ideas, impulsive poor judgment

• Pressured hyperactivity and impulsiveness

• Irritability, labile affect

• Decreased need for sleep

DISTINGUISHING FEATURES OF BIPOLAR MANIA

Extreme driven quality, sometimes episodic, prominent mood, irritable, grandiose, possible appetite change and weight change, family history of mood disorder

Case 3

• An 8 year old boy is found to be restless in the classroom

• His work is incomplete

• He tries to answer every question that is asked by the teacher

• He does not want to take part in sports

• He is scared to go to the playground

• He tries to please his teachers by 'over obedient' behaviour

• He is scared of getting low grades in the exams

• He wants to visit the toilet very often

• He wants to cling to his classteacher

• He very often cries while coming to school

ADHD vs ANXIETY INCLUDING PTSD

ADHD

• Inattentiveness, distractibility, forgetfulness, losing things, careless mistakes

• Failure to finish tasks, reluctance to start if needs sustained mental effort

• Hyperactivity, fidgeting, restlessness, on the go

ANXIETY INCLUDING PTSD

• Preoccupation with worry, intrusive memories, flashbacks, psychic numbing, hypervigilance

• Fear- induced paralysis of function, afraid to try, expecting failure, avoiding reminders

• Panic, agitation, anxiety-driven restlessness, nervousness

ADHD vs ANXIETY INCLUDING PTSD

ADHD

• Excessive talking

• Impulsive blurting of answers, interrupting, intruding

• Impatience, easy frustration, difficulty waiting

• Restless sleep

• Emotional and physiological instability

ANXIETY INCLUDING PTSD

• Anxious verbosity, obsessions, verbal rituals

• Anxious eagerness, reenactments

• Intolerance of delay that builds suspense or reminds of trauma

• Insomnia, nightmares

• Nervousness, physiological instability

DISTINGUISHING FEATURES OF ANXIETY INCLUDING PTSD FROM

ADHD

Phobias, worries, stress- induced onset, obsessions and compulsions, perfectionism, tremor, physiological symptoms, posttraumatic play

Case 4

• A 15 year old boy is found to be daydreaming

• Not attentive in the class

• Does not participate in activities

• Grades have fallen remarkably

• Reluctant to write

• Refuses to answer when asked a question

• Often found to be muttering to self

• Withdrawn

• Has expressed suspiciousness about his friends

• Does not communicate properly

• Gets into fights when provoked

• All these symptoms started at a point in time

ADHD vs PSYCHOSIS

ADHD

• Inattentiveness, distractibility, losing things, careless mistakes, forgetfulness

• Failure to finish tasks, reluctance to start if needs sustained mental effort

• Difficulty organizing

• Hyperactivity, fidgeting, restlessness, on the go

PSYCHOSIS

• Withdrawal from reality, preoccupation, loose association, distraction by hallucinations

• As above, abrupt change of activity

• Psychotic fragmentation

• Psychotic agitation, response to hallucinations

ADHD vs PSYCHOSIS

ADHD

• Excessive talking

• Impulsive blurting of answers, interrupting, intruding

• Impatience, easy frustration, difficulty waiting

• Irritability

• Insomnia

• Lability, instability

PSYCHOSIS

• Talking to hallucinations

• Responding to hallucinations

• Lack of social orientation

• Paranoid irritability

• Insomnia

• Unpredictability, lability

DISTINGUISHING FEATURES OF PSYCHOSIS

Delusions, poverty of thought, inappropriate affect, command hallucinations

Case 5

• A 9 year old boy is found to be inattentive in the class

• He does not follow instructions

• Seems to be lost in himself

• Gets irritable at times

• Does not communicate much in the class

• Has stereotyped movements of hands

• Unable to relate with others in social situations

• Motor clumsiness

• Obsessive insistence on sameness

ADHD vs PDD

ADHD

• Inattentiveness, distractibility, losing things, careless mistakes, forgetfulness

• Failure to finish tasks, reluctance to start if needs sustained mental effort

• Hyperactivity, fidgeting, restlessness, on the go

PDD

• Disregard of people, decreased responsiveness to attempted communication

• Abrupt change of activity, resistance to instructed activity, adherence to preferred activity

• Hyperactivity, twirling, pacing, flapping

ADHD vs PDD

ADHD

• Excessive talking

• Impulsive blurting of answers, interrupting, intruding

• Impatience, easy frustration, difficulty waiting

• Irritability

• Insomnia

• Lability, instability

PDD

• Compulsive stereotyped repetitions

• Obliviousness of personal space of others

• Easy frustration

• Tantrum when routine is interrupted

• Insomnia

• Lability, unpredictbility

DISTINGUISHING FEATURES OF PDD FROM ADHD

Impaired nonverbal/ verbal communication, lack of social relatedness, fantasy or social or imaginative play

PSYCHOSOCIAL CONDITIONS

• Abuse or neglect

• Poor nutrition

• Neighbourhood violence

• Chaotic family situation

• Being bullied at school

MEDICAL DISORDERS

• Partial deafness or poor eyesight

• Seizure disorder

• Fetal alcohol syndrome

• Genetic abnormalities (e.g. Fragile X syndrome)

• Sedating or activating medications

• Thyroid abnormalities

• Heavy metal poisoning

ADHD plus OPPOSITIONAL DEFIANT DISORDER

• 3- 6 years of age - 52.3%

• 7- 10 years of age - 31%

ADHD plus LEARNING DISORDERS

between 25- 40 %

ADHD plus CONDUCT DISORDER

7- 10 years of age - 14%

ADHD plus TIC DISORDER

7- 10 years of age- 11%

ADHD plus COMMUNICATION DISORDERS

3- 6 years of age- 21.9%

KEY POINTS IN DIAGNOSIS

• Clinical diagnosis based on interviews and rating scales

• No specific laboratory test

• A full psychiatric evaluation

• No role for 'therapeutic trials' with stimulants

• Family history, medical problems, substance abuse

• Talking to school personnel

KEY POINTS IN DIAGNOSIS

• Observing the child in the clinical setting may not be conclusive

• Observations in school most useful

• Rating scales for parents and teachers

REFERENCES

• Child and Adolescent Psychiatry - Dorothy Stubbe

• Rutter's Textbook of Child and Adolescent Psychiatry

• Child Psychopathology- Eric Mash

• Taking Charge of ADHD- Russell Barkley

• Driven to Distraction- Edward Hallowell