ADHD Differential Diagnosis Treatment Algorithms Part 1€¦ · ADHD Differential Diagnosis &...

December 19, 2016 Keith Cheng, MD

ADHD Differential Diagnosis &

Treatment AlgorithmsPart 1

The ADHD Brain

Learning Objectives

• Know which history items that will help distinguish ADHD from Anxiety Disorders

• Know which history items that will help distinguish ADHD from Depression

• Know which history items that will help distinguish ADHD from Trauma

• Be able to use Texas Algorithm for treating ADHD• Know when to use combination therapy for

ADHD

Differential Diagnosis

Things that can look like ADHD

• No breakfast before school• Poor sleep hygiene• Up all night playing video games or watching

TV, or surfing the internet, facebooking, etc…• Being bullied at school• Domestic Violence• Drug and/or alcohol use

ADHD Differential Diagnosis

• Disruptive Mood Dysregulation Disorder (DMDD)• Anxiety Disorders• Trauma Disorders• Mood Disorders• Substance Use Disorders• Learning Disorders• Mental Retardation• Developmental Disorders• Psychotic Disorders

DSM-5 ADHD CriteriaOften does not give close attention to details, makes careless mistakes

Often has difficulty sustaining attention in tasks or play activities

Often does not seem to listen when spoken to directly

Often does not follow through on instructions and fails to finish tasks

Often has difficulty organizing tasks and activities

Often avoids, dislikes tasks that require sustained mental effort

Often loses things needed for tasks and activities

Is often easily distracted by extraneous stimuli

Is often forgetful in daily activities

Often fidgets with hands or feet or squirms in seat.

Often leaves seat in situations when remaining seated is expected

Often runs about or climbs in situations where it is inappropriate.

Often unable to play or engage in leisure activities quietly.

Is often "on the go" or often acts as if "driven by a motor”

Often talks excessively. Blurts out answers before question completed

Often has trouble waiting his or her turn (e.g., while waiting in line).

Case Vignette #1

• Adriana is a 6 year girl seen for not sleeping. Sleeps on 4-6 hours a night. She is also extremely bossy and buts into everyone’s business. She is almost always very irritable and does not follow directions. She constantly interrupts conversations and then refuses to let others speak. Insists on sleeping with parents. She can play for hours sorting beads by herself, but has little patience with playing “Candyland.” She has been treated with Adderall with only modest benefit. School refusal major concern.

Differential Dx Anxiety DisordersSelected DSM-5 criteria ADHD Anxiety

Problems Concentrating XXX XXX

Avoidant Behaviors XX XXX

Hard to remember things XXX XXX

Doesn’t follow directions XXX XXX

Fidgety, Squirmy, Restless, motor restlessness XXX XXX

Talks Excessively XXX X

Extreme Distractibility XXX XX

Irritability XX XXX

Muscle Tension XX

Sleep Dysregulation X XXX

Case Vignette #2• Joe is a 19 y/o college student. He is coming to the

student health center with a complaint about not being able to concentrate. He has no energy to study. He states he is recently failing class quizzes and wants some stimulants from you so he can pass his classes. He denies any drug use and says he only occasionally uses alcohol. He is desperate to pass his classes or he will lose his student loans. No history of ADHD in elementary school. Insomnia is now a big problem. “I’m under so much stress I’m not eating.” Lost weight. Nothing is fun anymore. Medical history & drug screen negative.

Differential Dx Mood DisordersSelected DSM-5 criteria ADHD MDD


Avoidant Behavior XX XX


Doesn’t follow directions XXX XX

Fidgety, Squirmy, Restless, motor restlessness XXX

Talks Excessively XXX

Extreme Distractibility XXX

Mood dysregulation, irritability XX XXX

Anhedonia, diminished interests XXX

Weight Loss, XX

Sleep Dysregulation X XXX

Fatigue, Loss of Energy XX

Recurrent thoughts of death XX

Feelings of worthlessness XX XXX

Case Vignette #3• Bennie is a 9 y/o boy who has always had

problems with school. He is always avoiding doing in school work. He has very poor self-esteem. He says is the stupidest kid in his class. His school work is known for being illegible. His teacher also notes that he is constantly inattentive and doesn’t focus on his assignments. He tends to stay inside during recess, but his classmates like him because he is always nice to others.

Differential Dx Learning DisordersSelected DSM-5 criteria ADHD LD

Problems Concentrating XXX XX

Avoidant Behavior XX XXX

Hard to remember things XXX XX


Fidgety, Squirmy, Restless, motor restlessness XXX


Extreme Distractibility XXX

Poor academic skills and performance below age peers XXX

Learning difficulties begin in school age years XXX XXX

Academic learning issues not due to physical issues XXX XXX

Poor reading, writing, math skills XX XXX

Case Vignette #4

• 11 year old boy who doesn’t follow directions, always ‘lost in space’ according to his teacher.

• Parents note he is always last to engage in family activities

• His younger siblings have more friends, he trouble keeping friends

• Can’t concentrate on homework• Frequently confused in noisy social situations

Autism Spectrum Disorders vs ADHD

Selected DSM-5 criteria ADHD Autism



Hard to remember things XXX X




Extreme Distractibility XXX XX

Difficulty Sleeping, decreased need for sleep X XX

Reduction in awareness in environment X XXX

Self-destructive behavior X XX

Case vignette #5• Eric is a 13 y/o who is becoming increasing difficult

to manage at school. He has always had problems with focus, but able to get by. His attention span is now shorter than ever. Sitting next to the teacher is no longer helpful. He is restless all the time and needs to get up and walk around after sitting in one place for longer than 10 minutes. He is now cranky and no one can stand being around him. He used to sleep okay, but not has problems falling asleep. Recently he has been starting lots of new projects but never finishing him. His grades are worse than ever although he states he’s never felt better about himself.

ADHD vs Bipolar ManiaSelect DSM-5 diagnostic criteria ADHD Bipolar


Avoidant Behavior XX

Hard to remember things XXX XX



Talks Excessively XX XXX

Intrusive, buts into others activities XXX XXX

Inflated Self Esteem or grandiosity XXX

Decreased need for sleep X XXX

Flight of Ideas, racing thoughts XXX

Distractibility easily drawn into irrelevant stimulant XX XX

Increased goal or non directed activities XX XXX

High Risk Activities with painful consequences XX XXX

Case Vignette #6• Lydia is a 17 y/o nursing student. She has

always had problems with keeping up in school. She has now flunked two classes. Recently can’t concentrate in class. Wonders if she needs Ritalin so she can keep up with her classwork. Says she has difficult sleeping at school because of nightmares. On MSE she appears distracted. Frequently forgets what she wants to say. Reticent to talk about her family history.

PTSD vs ADHDSelect DSM-5 diagnostic criteria ADHD PTSDProblems Concentrating XXX XXX






Blurts Out XXX

Difficulty Sleeping X XXX

Reduction in awareness in environment XXX XXX

Reckless and self-destructive behavior XXX XXX

Absence of emotional responsiveness XXX

Marked diminished interest in activities XXX

Detachment or estrangement from others X XXX

Flashbacks and intrusive distressing memories XXX

Case Vignette #6

• 9 year old boy is impulsive always getting into fights

• Can’t pay attention in class; always having “meltdowns”

• Easily distracted by classmates and siblings; always has to have “just as much”

• Cranky, cranky, cranky• Teacher wants child on ritalin

Disruptive Mood Dysregulation Disorder (DSM-

5)

A. Severe recurrent disproportionate temper outbursts manifested verbally or physically

B. The temper outbursts are inconsistent with developmental level

C. The Temper outbursts occur, on average, three or more times per week

D. The mood between outbursts is persistently irritable or angry nearly every day

E. Symptoms present 12 months without 3 consecutive month absence of symptoms

F. Symptoms happen have to be present in two or more settings

G. Diagnosis should not be made before age 6 years or after 18 years

H. By history or observation the age of onset is before 10 years

I. There has never been a distinct period more than day consistent with mania/hypomania

J. Not be explained by autism, PTSD, anxiety, dysthymia, MDD

K. Symptoms not attributable to a medical or neurological condition

Cannot be comorbid with: ODD, IED, Bipolar. Can be comorbid with MDD, ADHD, CD, SUD. No bipolar diagnosis are ever present. If ODD and DMDD symptoms are both present, then DMDD should be diagnosed.

ADHD Co-morbidity

ODD/CD (50%)

Learning Disorder (33%)

Anxiety (25%)

SUD(25%)

Depression(25%)

Bipolar (15%)

Medical Masqueraders• Seizures• Sleep Apnea• Anemia (Low Ferritin)• Traumatic Brain Injury• Thyroid Abnormality• Vitamin D Deficiency• Fetal Alcohol• Heavy Metal poisoning• Genetic Syndrome• Medication Side-effects• Visual or Hearing

Impairment

TREATMENT

Optimizing Environmental Factors

• Eating/nutritional/diet Habits• Sleeping Habits• Video Game: use late at night/hours per

day/other addictions• Substance Abuse, caffeine use• Trauma/being bullied at school or in the

community• Family Stresses/Dynamics

Optimizing Nutritional Status

• Balanced Nutritious Diet

• Raw foods vs processed foods

• High Omega 3 fatty acids

• Iron rich foods• Minimize/Eliminate

Junk Food

Treat Co-occurring Disorders

• CBT for Anxiety Disorders, PTSD, Depression

• Parent management training for ODD/CD

• Substance Abuse interventions

• Academic Supports for youth with LD

• ABA for Autism

The Problem with Medications

• Money, insurance issues

• Parental Abdication

• School Abdication• Child Abdication• What about

learning ADHD coping skills

• Medication side-effects

Complications of Stimulant Treatment

• Is Addiction a complication?

• Growth Retardation• Tics• Cardiac Issues

Med Treatment Algorithm Youth

Stimulants

Nonstimulants

Combo Treatments

Make your own Algorithm

• Safety• Effectiveness• FDA Approved• Side-effect profile• Cost• Regimen Adherence

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Texas Algorithm 2005

StimulantAnother

StimulantAtomoxetine

TCA or Bupropion

Bupropionor TCA

Alpha 2a Agonist

Cheng Algorithm 2013

StimulantAnother

StimulantAtomoxetineor Alpha 2a

Alpha 2a or Atomoxetine

Bupropionor TCA

Combo Therapy

ADHD Differential Diagnosis Treatment Algorithms Part 1€¦ · ADHD Differential Diagnosis &...

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