Counseling Points - Psychiatric Nurse 11/08 - (Page 8)

Table 3. Differential Diagnosis of ADHD • Organic disorder • Sensory integration disorders • Medication-induced effects (e.g., antihistamines, phenobarbital, beta-agonists) • Seizure disorder (e.g., absence seizures) • Learning disabilities • Thyroid abnormality (e.g., hyperthyroidism) • Mental retardation • Brain neoplasm or frontal lobe abscess • Lead intoxication (e.g., neurocognitive deficits) • Pervasive developmental disorder • Anxiety disorder (e.g., generalized anxiety disorder, obsessive-compulsive disorder) • Juvenile bipolar disorder—manic presentation • Post-traumatic stress disorder (e.g., from abuse or neglect) • Adjustment disorder • Tourette syndrome/multiple tic disorder • Age-appropriate hyperactivity • Multiple life stressors and transitions (e.g., divorce, move, chronic illness in family member) • Inappropriate school or work placement • Family conflict or psychopathology • Inconsistent limit-setting and disciplining by parents have symptoms that merely mimic ADHD. Patients with severe anxiety will often internalize their anxiety and appear distracted or disorganized. In addition, their anxiety may drive externalizing behaviors, such as tantrums, agitation, and sleep dysregulation. Findings from both clinical and epidemiologic studies have concluded that concomitant ADHD and anxiety disorders are present in approximately 25% of children.24 If the clinician does not detect the co-morbid anxiety and treat it first, stimulant therapy may worsen the person’s anxiety, panic (if present), and agitation. For example, in clinical practice it has sometimes been observed that people with obsessivecompulsive disorder (OCD) may experience increased obsessive thoughts and compulsive behaviors from stimulant therapy. Co-morbid Depression. ADHD and depression have common symptoms that include psychomotor agitation and distractability. The lifetime rate of major depressive disorder among children with ADHD is estimated to be about 26%.24,25 Co-morbid Tic Disorders. Recent research indicates that most children with co-morbid ADHD and tic disorders do not experience an exacerbation of tic symptoms with methylphenidate; others may find that the benefits COUNSELING POINTS™ 8 of treatment outweigh any minor increase in tics.8,26 It is important to evaluate the severity and functional impairment from the individual’s tics prior to treating ADHD symptoms. Stimulant therapy has been shown to improve ADHD behaviors, social skill deficits, and aggression in children with chronic tics or Tourette syndrome.23 Many children with ADHD and a co-morbid tic disorder do tolerate stimulant therapy, but it is important to use stimulants with caution and monitor the individual closely.23 Co-morbid Conduct Disorder and Oppositional Defiant Disorder. ADHD can be co-morbid with both CD and ODD.18 In children with severe oppositional behavior, it is important to determine if there is an underlying, untreated, mood disorder. In many children, once the mood is stabilized, oppositional behavior improves. Individuals with ADHD and co-morbid CD are at an increased risk to develop antisocial behavior as well as substance abuse disorders.18,23 Co-morbid Bipolar Disorder. It is often quite challenging to differentiate between symptoms of ADHD and a mood disorder such as bipolar disorder, because both disorders have overlapping symptoms of inattention, hyperactivity, and impulsivity (Table 4).27,28 Several studies in children and adolescents support the co-morbidity between ADHD and juvenile bipolar disorder. 29-31 Patients with co-morbid ADHD and bipolar disorder often have higher levels of impairment in functioning and are more treatment resistant to mood stabilizers.32 In fact, bipolar disorder with co-morbid ADHD may represent a subtype of either ADHD or bipolar disorder.23 Co-morbid Substance Abuse Disorders. In children and adolescents with ADHD and a co-morbid substance abuse disorder, difficulties in daily functioning may persist into adulthood resulting in poor academic and occupational achievement, social impairment, and an increased rate of separation and divorce.23 Health care professionals need to remember that ADHD symptoms may interfere with substance abuse interventions. Individuals with ADHD and a co-morbid substance abuse disorder should be referred to a mental health specialist in substance abuse disorders.They should be carefully and closely monitored and participate in a substance abuse cessation program in addition to receiving pharmacological treatment. Co-morbid Sleep Disorders. Recently, there has been an increased awareness of the co-morbidity of ADHD with sleep disorders. Sleep dysregulation may be related to the ADHD or to use of medications such as psychostimulants. From clinical experience, we have observed that changes in sleep patterns can cause cogni-

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Counseling Points - Psychiatric Nurse 11/08

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