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