Health and Psychology

In the past week a colleague of mine and I have seen about 6 children that appear to have been misdiagnosed with attention deficit disorder or attention deficit hyperactivity disorder.  The children had a few things in common.  They were all reportedly diagnosed by their elementary or preschool teachers and referred to their primary care physicians for medication.  They all live in an underserved community and were all boys.

The hallmark of Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder (also known as ADD or ADHD) is difficulty with sustained attention and concentration.  It may include impulsivity or hyperactivity.  It isd a diagnosis of exclusion of other conditions.  The gold standard for diagnosis is a continuous performance test.  This is a computer based test that measures response time in miliseconds.  The test is either auditory or visual or both and is long and boring making it easy to lose focus.  The test is administered by a psychologist or neuropsychologist that has training in diagnosis and testing.  Cognitive testing can show difficulties in working memory and will allow for some other difficulties to be ruled out like depression, anxity and learning disorders.  Teacher and parent questionnaires can also assist in the diagnosis but only after a careful history to exclude other conditions is done.

So let me talk about the children that were misdiagnosed.  The first was a young boy that was hit by a car a couple of years ago.  He had blank staring episodes, bed wetting and repetitive movements in addition to inattention.  It's likely he's having absence seizures.  He was given a referral to neurology.

The second is a child with a chronic medical condition.  The medication causes difficulty paying attention, and unusual changes in mood and behavior.  He was referred back to his physician for a medication reevaluation.

The third child had a relative die recently.  He is clinically depressed.  The whole family is having difficulty coping.  He isn't sleeping and has lost weight and has crying spells.  Yes he can't pay attention, but his problem is due to grief and depression.

The fourth child is highly anxious.  Hyperactivity and inattention help to manage the constant worries and nerousness the child has about catastrophic thoughts.  Therapy to lessen anxiety is likely to help.

The fifth child has been removed from his family home due to child abuse.  He is in foster care.  He has nightmares and flashbacks of very violent events to himself and others in his family.  He is threatening to hurt other children periodiclly.  His inattention is due to physical and psychological trauma.

The sixth child is hyperactive and inattentive when he's at school doing reading out loud.  He has a significant learning disability that hasn't been assessed.  When he gets out of his seat he gets sent to a different classroom and doesn't have to read out loud.  Once he gets into a specialized educational program and his reading disorder is addressed, he will likely improve.

Psychologists and neuropsychologists can perform specific tests that allow for other conditions to be ruled out and can assess the impact of medication on symptoms and test performance.  Elementary and preschool teachers are not able to provide a definitive diagnosis of an attentional problem, nor are primary care physicians.  A diagnosis by medication trial can incorrectly classify a child and fail to deal with an underlying condition that may need treatment.