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Background


Now that we understand the terminology of ADD and AD/HD (and hopefully not too confusingly so), the remainder of this article will utilize the DSM terminology of “AD/HD.” Keep in mind that the term encompasses a whole range of symptoms, and a wide variety of medical and educational problems can be mistaken for AD/HD.  Some even coexist with AD/HD.


It is always essential for a child to be carefully evaluated.  Specialists are working to develop a more precise idea of which children and adolescents really have AD/HD and which have “look-alike” problems that only resemble this disorder.  Some children may have similar symptoms but have a completely different underlying problem.  Therefore, an accurate diagnosis is essential, particularly because the long-term course in treatment may be quite different for children with classic AD/HD.  Some of the educational and medical disorders that can mimic AD/HD are listed here:


Depression


Depression is certainly common in adolescents and children, just as it is in adults.  While it may seem unlikely that a depressed person would be “hyper” (since many depressed people seem to talk and think slowly),  some inattentive children with impulsive and hyperactive behavior are actually depressed.  Often “agitated depression” is manifest as irritability and restlessness.  These children may just have passing symptoms of depressed mood (e.g., feeling blue or demoralized) or more persistent or even chronically bad moods (dysthymic disorder), or have the psychiatric diagnosis of depression with its accompanying physical changes (major depression).  


Anxiety


Anxiety states caused by environmental stress may present at AD/HD.  Certain children living in a stressful home situation or adolescents dealing with social or academic pressures may look like they have AD/HD.  Even mild stress can produce symptoms that mimic AD/HD.  Certain medical disorders such as separation anxiety disorder or Obsessive Compulsive Disorder (OCD) are treated quite differently from AD/HD – even though many of the symptoms of these disorders may look similar.  However, stimulants often worsen the symptoms of these anxiety disorders, which are better treated with different approaches and medications.


Processing Problems / Learning Disabilities


Many “symptoms” of processing problems overlap with behaviors seen with AD/HD.  For example, children with Auditory Processing problems tend to “mishear” oral information; this can be misinterpreted as not paying attention.  Children with weak Auditory Memory do not follow oral directions well; this can appear to be daydreaming.  Children with dysgraphia or a deficit in Processing Speed have problems with completing written assignments; this can look like off-task behavior.  Moreover, these disorders are not mutually exclusive.  That means, a youngster may actually have both disorders at the same time.  Indeed, the probability of having either a learning disability or AD/HD in the general population is about 5%.  However, when a child is diagnosed with one disorder, the probability of having the other disorder jumps to 50%.  


Giftedness


Behaviors associated with giftedness often parallel characteristics of AD/HD with subtle differences.  Inattention may be evident in both cases, but AD/HD children show poorly sustained attention in almost all situations; with giftedness, the boredom and daydreaming occur in specific situations.  AD/HD children tend to have diminished persistence on tasks unless they have immediate consequences; gifted children have low tolerance for tasks that seem irrelevant to them. AD/HD children often have difficulty adhering to rules and regulations and poor delay of gratification.  In contrast, gifted children understand rules and regulations, but they tend to question customs and traditions, and their intensity and strong intellect may lead them to power struggles with authority figures.  In the classroom, gifted children may respond to non-challenging or slow-moving classroom situations by off-task behavior, disruptions, or other attempts at self-amusement.


Sensory Integration Disorder (SID)


A child with SID is considered “out-of-sync,” as the various senses (touch, movement, body position, sight, sounds, etc.) are not working properly in balance together.  For example, an SID child with oversensitive touch may avoid being touched and have problems with textures of clothing and food, yet the same child may be under-sensitive to movement and crave swinging, rocking, twirling and generally fidgety and active. Consequently, many of the symptoms of SID overlap with AD/HD including distractibility, social and emotional problems, unusually high activity level, impulsivity and lack of self-control.


Intermittent Explosive Disorder


Another biomedical condition that may mimic AD/HD is Intermittent Explosive Disorder (IED), formerly referred to Childhood Bipolar Disorder, until the May 2013 e The most severe version of bipolar disorder in adults is manic-depressive illness, but most common bipolar disorders are more mild. Bipolar disorder in children and adolescents can present with impulsivity, inattention and hyperactivity, along with overly strong feelings or an overbearing manner, irritability or unprovoked hostility, and often difficulty in “getting going” in the morning. It is only the more severe forms of bipolar disorder in adolescents and children that show amazingly energized and lengthy temper tantrums with gross destructiveness during their brief or lengthy rages.


About half of boys (and perhaps a quarter of the girls) with bipolar disorder fulfill diagnostic criteria for AD/HD, but bipolar disorder tends to appear in families in which depression or bipolar disorder has emerged before.  Although stimulants can sometimes help these children with bipolar disorder, stimulants often make the symptoms worse and can be quite risky.  Other medications can be much more helpful.


Other Issues and Medical Disorders


Certain medical disorders of sleep, malfunctions of the thyroid gland and excessive lead ingestion may also present with symptoms that are typical for AD/HD.  In certain circumstances, victims of sexual abuse, physical abuse or neglect can present with symptoms of AD/HD. Even after a limited period of abuse or neglect, these children may continue to show symptoms that are difficult to distinguish from AD/HD.





AD/HD:  

Look-Alike Disorders

age

Summary: Cautions in Diagnosis and Treatment

“Look-alike children” may fulfill the diagnostic criteria for AD/HD but have a completely different problem and, therefore, should receive a different diagnosis.  All of the above conditions may cause a child to behave impulsively and show difficulties in attention and hyperactivity that are hard (and perhaps impossible in some instances) to distinguish from AD/HD.  Particularly if a child’s situation is worsening with age, consider the possibility that AD/HD may not be the sole or even primary problem.  Also, if the AD/HD is associated with bad dreams, bad moods or disturbing thoughts, or if there is a family medical history of psychiatric disorders, then it is important to be sure that mimicking disorders and additional problems are not present.

If a medical or other psychiatric disorder is presenting as AD/HD, a treatment that merely improves the AD/HD symptoms may leave a residue of untreated behavioral problems, mood abnormalities or disorders of physiology.  In these cases, even if stimulants are helpful or if environmental changes improve the child’s self-control, it is critical to make sure that the other (and perhaps more serious) problems are not left to smolder.

Given the variety of disorders that can be mistaken for AD/HD, or that may coexist with AD/HD, a comprehensive evaluation of the child is always important.  Numerous problems must be contemplated, assessed and “ruled out” before a diagnosis of AD/HD can be made.  It is no longer sufficient to start treatment for AD/HD based on observations of “tuning out” or misbehavior.  This disorder needs a comprehensive evaluation that matches our growing awareness of the complexity that goes by the simple name of AD/HD.


Copyright:  Charlene Messenger, Ph.D.  All Rights Reserved.

Notice:  Leave of Absence Closure

Dr. Messenger will be starting  A Leave of Absence as of Friday, Jan. 20, 2017 for an unspecified time.  Assessments and consultation can be scheduled until then.  The website will remain available for educational purposes, until the office is reopened.