Differential Diagnosis of ADHD

1. Differential Diagnosis of ADHD UPIQ Learning Collaborative November 13, 2015 Kristi Kleinschmit, MD Kristi.kleinschmit@hsc.utah.edu

2. Objectives • Case presentations • Discussion of differential diagnosis, reviewing diagnostic criteria and targeted psychiatric review of systems to help come to diagnosis. • Rule is comorbidity, not simplicity • Review of assessment tools that can aid in diagnosis. Screeners available at www.uacap.org

3. Differential Diagnosis • Anxiety spectrum • Depression/Mood Disorders • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • Trauma • Learning disabilities • Sleep issues • Substance Abuse • Medical issues

5. Differential Diagnosis • Anxiety spectrum • 6% to 20% of children (AACAP) • Depression • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • Trauma • Learning disabilities • Sleep issues • Substance Abuse • Medical Issues

6. GAD Criteria (DSM IV) • At least 6 months of "excessive anxiety and worry" about a variety of events and situations. • Difficulty controlling the anxiety and worry. • The presence for most days over the previous six months of 1 or moreof the following symptoms: 1. Feeling wound-up, tense, or restless2. Easily becoming fatigued or worn-out3. Concentration problems4. Irritability5. Significant tension in muscles6. Difficulty with sleep D. The symptoms are not part of another mental disorder, cause “clinically significant distress or problem functioning,” and are not due to substance or medical illness.

7. Social Phobia • Marked fear or anxiety of social situations involving possible scrutiny • In kids, anxiety must occur in peer setting, not just with adults. • Fear of acting in a humiliating/embarrassing way, leading to rejection • Social situations usually provoke fear/anxiety • Crying, tantrums, freezing, failing to speak D. Avoidance of endured with intense anxiety

8. Other Anxiety Disorders • Separation Anxiety • Obsessive Compulsive Disorder (ask for cleaning, organizing, counting, rituals/routines, checking behavior, evenness) • Panic Disorder (ask about panic attacks)

9. Targeted Review of Systems • Is he shy? (although not always the case) • Any history of separation anxiety? • Is he a worrier? Upset if anyone home late? Needs things just so? • Nightmares?? • Does he seem to get easily upset when things do not go the way he expects them to? Melt downs with disappointments? • Does he have frequent stomachaches or headaches or other somatic complaints? • Perfectionistic? Needs lots of reassurance? • Tense, avoidant, irritable?

10. Interviewing the Child Most kids don’t admit to “worrying.” Try asking if they feel nervous, chest tightness, sweaty palms, shaky, trouble sleeping, heart racing. Ask about panic attacks and what triggers. • “I can’t sleep because my brain won’t shut off. • “My thoughts race at bedtime.” • “My stomach always hurts before school” • “I’m afraid the kids won’t like me or will laugh at me.” • “I feel scared for no reason” Mental Status Exam: Activity may be fidgety. May have constricted affect, intermittent eye contact, overinclusive speech or minimal speech. Concentration may be impaired.

11. Anxiety versus Depression • Irritability prominent • Poor concentration • Sleep problems • Prominent need for reassurance • Lots of somatic complaints (aches) • Poor eating if nausea, but not consistent. • Anxious avoidance, due to worries of failure, perfection. Some things still fun. • Oppositional often. • Suicidality rarely • Irritability prominent • Poor concentration • Sleep problems • Prominent self-deprecation/worthless • Some somatic complaints, (poor energy) • Decrease appetite • Isolation, Anhedonia, nothing is fun anymore. • Oppositional sometimes. • Suicidality one of criteria

12. Anxiety versus ADHD • Fidgety • Poor concentration • Distractible • Doesn’t turn in assignments due to fear of failure • Lots of somatic complaints (aches) • Insomnia. • Perfectionistic, so paralyzed to begin things • Rarely impulsive or risk-taking. • Fidgety • Poor concentration • Distractible • Doesn’t turn in assignments due to forgetfulness • No real somatic complaints • Sleep is restless • Careless mistakes • Resistance to start HW • Impulsive

13. Anxiety Screeners • SCARED (Screen for Child Anxiety Related Disorders) • Validated for ages 8 and older • Self-report and parent/teacher forms • Free online at www.uacap.org • GAD-7 • Quicker to fill out, not as much differentiation between disorders • Free online at www.uacap.org • CY-BOCS for OCD

15. Differential Diagnosis • Anxiety spectrum • Depression • 10% of ages 12-17 (NIMH, 2013) • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • Trauma • Learning disabilities • Sleep issues • Substance Abuse • Medical Issues

16. DSM IV Criteria for Major Depression (unchanged in DSM 5) A) Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure1) depressed mood most of the day, nearly every day (subjective or objective). Note: In children and adolescents, can be irritable mood.2) markedly diminished interest or pleasure in all, or almost all, activities 3) significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.4) insomnia or hypersomnia nearly every day5) psychomotor agitation or retardation nearly every day 6) fatigue or loss of energy nearly every day7) feelings of worthlessness or excessive or inappropriate guilt 8) diminished ability to think or concentrate, or indecisiveness, nearly every day 9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide C) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

17. Targeted Review of Systems • Irritable or sad? • Decreased interest in friends, previously enjoyed activities? Isolative? • Poor sleep, poor energy? • Changes in appetite? • Talking of wishing to die, being worthless, hopeless? • Ruminations of wrong-doing? Easily down on self? • Seeming to move too fast or too slow.

18. Interviewing the Child • Most kids don’t admit to feeling sad either. Try asking about being hard on themselves when they make mistake. Being more snappy with family/friends. • Trouble sleeping, poor energy or concentration. • Body moving too fast or too slow • Guilty feelings • Hopeless, worthless, should have never been born? • “Everyone would be better off if I wasn’t here.” Mental Status Exam: Constricted/blunted affect, slow soft speech, thoughts of suicide or worthlessness. Concentration may be off.

19. Diagnostic Screener • PHQ 9-A

21. Differential Diagnosis • Anxiety spectrum • Depression • Asperger’s/Autism • 1 in 54 8 y/o’s in Utah (Utah ADDM 2010) • Oppositional Defiant Disorder/Conduct Disorder • Trauma • Learning disabilities • Sleep issues • Substance Abuse • Medical Issues

22. Autism • DSM diagnostic changes: • Used to be 3 domains (social, communication, and restrictive/repetitive interests). Now there are 2: Social communication/interaction and Restrictive/repetitive patterns • All is Autism, no more Aspergers, Rhett’s, PDD NOS • Often higher functioning is missed until older • Gold standard for diagnosis is clinical interview and Autism Diagnostic Observation Scale (ADOS) and/or Autism Diagnostic Interview (ADI). • Clinical interview can be used to diagnose • Utah Autism Info: • http://www.cdc.gov/ncbddd/autism/states/addm-utah-fact-sheet.pdf

23. Targeted Review of Systems • Does he struggle to make/keep friends? Friends too old or too young? • Can he hold a conversation, or does he monopolize? • History of imaginative play? • Restricted interests or inflexible routines? • Does he make eye contact? • Can he read the social tone of a room? • Does he share things about his day with you? • Think of autism as an anxiety disorder: • Melt downs with unexpected change or transitions

25. Differential Diagnosis • Anxiety spectrum • Depression • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • 6% prev/ 4% prev. (SAMHSA 2009) • Trauma • Learning disabilities • Sleep issues • Substance Abuse • Medical Issues

26. DSM 5 updates • ODD • Angry/irritable mood; Arugmentative Behavior; Vindictiveness • < 5 y/o, most days for 6 months; >5 y/o: once per week x 6 mos • Mild: Only 1 setting; Moderate: 2 settings; Severe: 3 or more • Conduct Disorder • Aggression to people and animals; Destruction of Property; Deceitfulness or Theft; Serious violations of rules • Childhood-onset (<10 y/o) vs Adolescent onset (no sx < 10 y/o) • wIth limited prosocial emotions • Mild, moderate, or severe

27. When you see ODD/CD, think “What else am I missing?” • Of those with lifetime ODD, 92.4% meet criteria for at least one other lifetime DSM-IV disorder. • Mood (45.8%), • Anxiety (62.3%) • Impulse-control (68.2%) • Substance use (47.2%) disorders. • Conduct Disorder: 39% girls, 46% boys met criteria for at least one other DSM diagnosis (Maughen 2004) • 1/3 to ½ of kids with ODD have ADHD • 25% of children and up to 50% of teens with CD have ADHD

28. Screeners • Vanderbilt has good screeners for ODD/CD • School or psychologist could do further testing • Think of disruptive behavior disorders when ADHD screeners are weakly positive, or different between settings

30. Differential Diagnosis • Anxiety spectrum • Depression • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • Trauma/psychosocial stressors • Learning disabilities • Sleep issues • Substance Abuse • Medical Issues

31. Wide range of traumatic experiencesand psychosocial stressors • Sexual/Physical abuse/Neglect • Domestic violence exposure • Animal attack • Loss of caregiver (death, deportation, incarceration) • Car accidents • Witnessing violence to others • Natural disasters • Chronic hospitalizations • Homelessness • Food insecurity • Parentified children • Many, many others…..

32. Screening tool • Trauma-informedclinical interview • Traumatic Experiences Questionnaire for Young Children (TEQ) 10-13 (www.uacap.org)

34. Differential Diagnosis • Anxiety spectrum • Depression • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • Trauma • Learning disabilities • Sleep issues • Substance Abuse • Medical Issues

35. Learning Disabilities • 5% of school-aged children have diagnosis and services for LD, thought to miss another 15% who struggle. • National Center for Learning Disabilities 2014 • Can be missed during elementary school, especially in disruptive kids or quiet kids • Parents to request testing through school, or outpatient psychological assessment (insurances vary on payment)

37. Differential Diagnosis • Anxiety spectrum • Depression • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • Trauma • Learning disabilities • Sleep issues • Substance Abuse • Medical Issues

38. Sleep Disorders Prevalence • Obstructive Sleep Apnea 1-3% • “Behavioral Insomnia” 5% of school-aged kids • Primary Insomnia 5-20% (greater in teens) • Parasomnia: 5-35% • PLMD and RLS 2-78% • Narcolepsy TBD, adults 1 per 2000 • ICD-9 PCP billing data reviewed: only 3.7% had sleep disorder diagnosis (Meltzer 2010)

40. Differential Diagnosis • Anxiety spectrum • Depression • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • Trauma • Learning disabilities • Sleep issues • Substance Abuse • 5% of teens past year (CDC 2011) • Often can co-occur with ADHD • Medical issues

43. Differential Diagnosis • Anxiety spectrum • Depression • Asperger’s/Autism • Oppositional Defiant Disorder/Conduct Disorder • Trauma • Learning disabilities • Sleep issues • Substance Abuse • Medical issues

44. Medical Issues to think about • Intra-uterine insult • Substance exposure, prenatal infection • Prematurity • Seizures • Hearing loss • Vision problems • Elevated Lead levels, anemia, hypo/hyper thyroidism • Head trauma

45. References: • American Academy of Child and Adolescent Psychiatry. Child and Adolescent Mental Illness and Drug Abuse Statistics. www.AACAP.org. Last reviewed March 18, 2009. • American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 1998; 37(10 suppl): 63S-83S. • American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders. J Am Acad Child Adoles Psychiatry. 2007; 46(2): 267-283. • American Academy of Pediatrics. Enhancing Pediatric Mental Health Care: Report from the American Academy of Pediatrics Task Force on Mental Health. Pediatrics. 2010; 125 (suppl 3): S69-S160. • American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Association. • Birmaher B et al. Psychometric properties of the screen for child anxiety related emotional disorders (SCARED): A replication study. J Am Acad Child Adolesc Psychiatry. 1999; 38:1230-1236. • Center for Disease Control. Mental Health Surveillance Among Children-United States, 2005-2011. Supplement 2013 May; 62 (02): 1-35. • Maughan B et al; Conduct Disorder and Oppositional Defiant Disorder in a national sample: developmental epidemiology; J Child Psychol Psychiatry 2004; 45:3:609-621. • Meltzer LJ et al; Prevalence of diagnosed sleep disorders in pediatric primary care practices. Pediatrics2010 June; 125 (6): e1410- e1418. • Nock MK, Kazdin AE, Hiripi E, Kessler RC. Lifetime prevalence, correlates, and persistence of oppositional defiant disorder: results from the National Comorbidity Survey Replication. J Child Psychol Psychiatry. 2007 Jul;48(7):703-13. • Utah Autism and Developmental Disabilities Monitoring Project. 2010. • Zuckerbrot RA, et al. Guidelines for Adolescent Depression in Primary Care: I. Identification, Assessment, and Initial Management. Pediatrics. 2007; 120:e1299-e1312 • Zuckerbrot RA, Jensen PS. Improving Recognition of Adolescent Depression in Primary Care. Arch Pediatr Adolesc Med. 2006; 160:694-704. J Child Psychol Psychiatry. 2007 Jul;48(7):703-13.