Differential Diagnoses
Proper differential diagnosis of ADHD, CD and ODD
requires not only discrimination among the three disorders, but also from a
wide range of other psychiatric, developmental and medical conditions. ADHD can
be conceptualized as a cognitive/devel-opmental disorder, with an earlier age
of onset than CD. ADHD children more frequently show deficits on measures of
attentional and cognitive function, have increased motor activity and greater
neurodevelopmental abnormalities. In contrast, CD children tend to be
characterized by higher levels of aggression and greater familial dysfunction.
A significant proportion of children present with
symp-toms of both ADHD and CD, and both conditions should be diag-nosed when
this occurs. Comorbid ADHD and CD is consistently reported to be more disabling
with poorer long-term outcome than either disorder alone. These children show
persistantly in-creased levels of aggressive behaviors at an early age. This is
in contrast to the more typical episodic course seen in children who have CD
alone.
It appears that among children with ADHD, those who
are most hyperactive/impulsive are at greatest risk for developing ODD. ODD
symptoms, such as “loses temper”, “actively defies”, and “swears”, are less
characteristic of children with ADHD. In general, the onset of ODD symptoms
peaks by age 8 years and shows a declining course thereafter, while
hyperactivity and at-tentional problems appear at a much earlier age and often
persist, although the levels of inattentiveness and/or hyperactivity often
decrease with age.
A diagnosis of CD supersedes ODD since
approximately 90% of children with CD would also meet criteria for ODD, and
some question whether they represent a spectrum of severity or distinct
diagnoses. Although the majority of ODD children will not develop CD, in some
cases ODD appears to represent a developmental precursor of CD. In cases where
ODD precedes CD, the onset of CD is typically before age 10 years (childhood
onset CD). In children who have the onset of CD after age 10 years, symptoms of
ODD and ADHD are usually not present dur-ing early childhood. It has been shown
that children with ODD demonstrate lower degrees of impairment and are more
socially competent as compared with children with CD. Furthermore, children
with CD come from less advantaged families, and have greater conflict with
school and judicial systems as compared with children with ODD.
Mood and anxiety disorders, learning disorders,
mental retardation, pervasive developmental disorders, organic mental disorders
and psychotic disorders may all present with impair-ment of attention, as well
as hyperactive/impulsive behaviors. The diagnosis of ADHD in DSM-IV requires
that the symptoms of inattention/cognitive disorganization and impulsivity/hyper-activity
are not better accounted for by one of the above condi-tions. Differentiating
ADHD from bipolar disorder in childhood is complicated by the low base rate of
bipolar disorder and the variability in clinical presentation. A positive
family history of bipolar disorder is especially helpful in diagnosing bipolar
disor-der in children. In addition, a variety of medical conditions such as
epilepsy, Tourette’s disorder, thyroid disease, postinfectious and/or post
traumatic encephalopathy and sensory impairments can present with symptoms
similar to ADHD and must also be considered. Finally, many medications which
are prescribed to children can mimic ADHD symptomatology. Examples include
anticonvulsants (e.g., phenobarbital), antihistamines, deconges-tants, bronchodilators
(e.g., theophylline) and systemic steroids.
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