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Same Story, Different Day
As luck would have it, ( bad luck anyway) I lost my hard drive again and had to reformat. While I was able to replace most of the programs, I am unable to replace the email I lost. Some of you had written with address changes, file requests etc and I have been unable to comply with your requests. Please forgive the inconvenience and please write again with your requests and I will get right on it.
In addition, I lost my copy of the February 2000 edition of Added Attractions. If anyone has a copy, would you please forward it me. I would greatly appreciate it! My email address is Contact Us.
DIFFERENTIATING BETWEEN ADHD AND PERVASIVE DEVELOPMENTAL DISORDER (PDD)
One factor that often complicates the accurate diagnosis of ADHD is the need to rule out other conditions as a better explanation for the child's symptoms. For example, children with mood disorders, anxiety disorders, or learning disabilities can sometimes display a pattern of symptoms that resemble ADHD. Diagnostic errors can occur unless a careful evaluation to rule out these alternative explanations for a child's symptoms has been made.
In young children especially, pervasive developmental disorders can sometimes be confused with ADHD. The category of pervasive developmental disorders includes several different diagnoses including autism, Asberger's Syndrome, and a residual category labeled Pervasive Developmental Disorder - NOS (i.e. not otherwise specified). The latter is reserved for children whose symptoms do not fully match the more specific diagnoses in this category and is generally associated with less severe impairment than the other diagnoses in this group.
Distinguishing children with ADHD from high-functioning children with PDD-NOS is probably one of the most difficult differential diagnoses to make. As a result, a number of children with PDD-NOS may be misdiagnosed with ADHD and treated inappropriately as a result.
The authors of a study appearing in a recent issue of the Journal of Learning Disabilities attempt to provide a set of research based guidelines to help with this difficult and important distinction (Roeyers, H., Keymeulen, H., & Buysee, A. (1998). Differentiating ADHD from Pervasive Developmental Disorder Not Otherwise Specified. Journal of Learning Disabilities, 31, 565-571.) In this study, 27 children with ADHD were matched with 27 children diagnosed with PDD-NOS on both chronological age and IQ. These children had been diagnosed with PDD-NOS or ADHD based on an extensive and rigorous diagnostic evaluation.
The parents of these children were then interviewed to learn about any pregnancy and/or birth complications, and were also asked to provide detailed information about their child's development between birth and age 4. The goal was to identify factors that reliably distinguished between children in the two groups in the hope that this would aid clinicians involved in making this differential diagnosis. The results can also be helpful to parents who may have concerns about whether the diagnosis of PDD-NOS may apply to their child.
An extensive questionnaire was developed by the authors for parents to complete. The first part of the questionnaire included items asking about pregnancy and birth cmplications. The second portion included over 100 items that asked about a child's functioning in 12 broad areas including feeding, sleeping, toilet training, activity level, communication, motor development, social development, social behavior, information processing, behavior problems, play, stereotypic (i.e. unusually repetitive) behaviors, and anxiety. Parents were asked to rate whether or not a specific problem applied to their child in 6 different age periods: 0-3 months, 4-6 months, 7-12 months, 13-24 months, 25-36 months, and 37-48 months.
They were also asked when they first suspected that something was wrong with their child, and at what age their child received his or her final diagnosis. The main results of this interesting and important study are summarized below.
PREGNANCY AND BIRTH COMPLICATIONS
There were no significant differences in pregnancy complications between the two groups. Overall, about 25% of mothers reported problems during pregnancy. A significantly larger percentage of cildren with ADHD were reported to have exhibited "extremely loud" crying immediately after birth (32% vs. 9%).
0-3 MONTHS Virtually no differences between children in the 2 groups were reported by parents for the first 3 months of life.
4-6 MONTHS During this period, parents of children with PDD-NOS reported that their child had shown significantly more behavior problems than were reported by parents of children with ADHD. The single item responsible for this difference was that children with PDD-NOS were more likely to be described as having been unresponsive to social stimulation (63% vs. 20%). In other words, these children were recalled by their parents as having been more difficult to engage and interact with, and to be more in their "own world".
7-12 MONTHS Children with ADHD were reported to show more hyperactive behavior during this period than children later diagnosed with PDD-NOS. Children with PDD-NOS continued to be seen as less responsive to social stimulation.
13-24 MONTHS Children with ADHD were recalled as displaying more "reckless" behavior during this period. Children with PDD-NOS continued to be seen as less responsive to social stimulation. In addition, their parents were more likely to report that their child had displayed motor tics and indications of excessive anxiety. The parents of children with PDD-NOS also recalled that their child experienced difficulty understanding gestures and emotions, and did not show any symbolic play (i.e. pretend or make-believe play). It should be noted that although children with ADHD were described as more "reckless", differences in overall activity level between the 2 groups was no longer significant. Thus, differences in "hyperactivity" between the groups seemed to disappear after the first year as children with PDD-NOS became increasingly active. This is important because it implies that in older children, one can not rely on hyperactivity alone - one of the core symptoms of ADHD - to differentiate between children with ADHD and children with PDD-NOS.
25-36 MONTHS Children with ADHD continue to be recalled as having been more reckless. Children with PDD-NOS continue to be recalled as less responsive, less able to understand emotions and symbolic gestures (e.g. facial expressions), more likely to show motor tics, and more anxious. In addition, parents of children with PDD were more likely to report that their child was experiencing difficulty with peer relations during this period (89% vs. 42%).
37-48 MONTHS The two groups continued to differ on the factors described for the 25-36 month period.
OTHER DIFFERENCES In addition to the differences noted above, parents of children with PDD-NOS reported being aware earlier on that something was wrong with their child. Among the parents in this study, the mean age at which they first became concerned about their child's development was 13 months. For parents of children with ADHD, in contrast, the average age was 38 months - more than 2 full years later.
Parents of children with PDD-NOS also experienced more difficulty in the evaluation and diagnostic process. On average, children with PDD-NOS were not diagnosed until an average of 48 months from when they first reported concerns to a health care professional. For children with ADHD, an average of 20 months elapsed between parents' initial report of concerns and the final diagnosis.
CONCLUSIONS AND IMPLICATIONS This interesting and important exploratory study suggests that among very young children and older preschoolers, the most consistent factors to differentiate children with ADHD from children with PDD-NOS is that children with ADHD engage in more reckless behavior. Children with PDD-NOS, in contrast, are more likely to appear socially unresponsive, to experience difficulty in understanding emotions and symbolic gestures, and to display motor tics and high levels of anxiety. After the first year of life, differences in activity level may not be found.
Misdiagnosing a child with ADHD when he or she really has PDD-NOS can have important negative clinical implications. Stimulant medication is more likely to be effective in children with ADHD, and it may even exacerbate symptoms in children with PDD.
Non-medical approaches will also often be different for children with these diagnoses. For a child with PDD, it is generally believed that effective treatment requires high parental involvement, a structured approach characterized by high predictability in the environment for the child, and a focus on the development of basic socialization skills (e.g. getting and staying engaged with others, being able to take part in reciprocal interactions), communication training, and the generalization of these skills so that the child can apply them with different people. Note that the primary focus is on helping the child to develop the basic building blocks for effective interpersonal relating - i.e., being able to tune in to others in a more sustained and consistent way.
For preschool children with ADHD, there is typically a greater focus on helping parents learn child management techniques, providing a structured preschool environment where there are clearly established rules and consequences, helping children develop self-control, and, medication if the child's symptoms are too difficult to manage after behavioral measures have been implemented. The focus on basic engagement and reciprocal interaction skills would generally not be needed. Thus, a child who really has PDD-NOS rather than ADHD would not be likely to get the help he or she needs in this crucial area. Also, because PDD-NOS is likely to be associated with more significant and ongoing impairment in social relations, parents of a child who is misdiagnosed may have unrealistic expectations for how their child will respond to treatment.
I think this is an important study in that it provides a timely reminder about early aspects of a child's social development that need to be considered in a thorough evaluation for ADHD.
If you are a parent of a child who has been diagnosed with ADHD, and have concerns/questions about whether PDD-NOS may be a more accurate diagnosis for your child's problems, than it would REALLY be important to consult with an experienced child mental health professional or a developmental pediatrician. I would suggest consulting with a professional who has extensive experience in children's early social and emotional development, and who has worked with children who have pervasive developmental disorders.
Such a professional is most likely to be able to provide you with the information and answers you need to know about how to best help your child.
David Rabiner, Ph.D. Licensed Psychologist Duke University http://www.helpforadd.com
Dr. Steven Richfield March, 2000 www.parentcoachcards.com
Do you have any suggestions for children (and fathers) who don't "bounce back" well? My husband and our kids, ages 8 and 15, respond to disappointments with extreme reactions. Not only do they remain angry and sullen for long periods, but they also need to blame someone, and usually it's a family member. This strains relationships and makes those around them wary about making plans with them.
Emotional resilience provides for the ability to quickly recover from disappointments. For some children and adults, the unexpected nature of disappointments is experienced as an assault on their perception of control. Those of us with higher needs for control over the people and surrounding circumstances in our lives may have greater difficulty taking setbacks in stride. This is partly due to the premium that is placed on "scripting" the way things are done so much that outside forces may not have as much opportunity to change the course of events. It's an attempt to shield ourselves from outside control, and the possibility of disappointment.
Children with a high need for control are especially prone to getting trapped by their disappointment feelings because so much of life is actually not under control. In my therapeutic work with them I use the metaphor of being sideswiped by something unexpected and finding oneself in the "disappointment ditch." The more they complain and blame their aches on others, the harder it is to break free. Blaming may also temporarily relieve their feelings of powerlessness. And if a parent models this same self-defeating pattern of blaming and complaining, children tend to follow suit. Here are a few coaching points to help the "reluctant recoverers" in your family:
Empathize with their struggles. There is little to enjoy when your child is sulking. Yet, this period of nursing wounds can be an opportunity to express empathy. I suggest that you offer some "symbolic satisfactions" at this time, such as surprising them with a favorite drink or snack. The intent is to say with actions what is sometimes better not to say with words: "You see, the world is not all bad - there are some good things left in it." One warning: don't use this as an opportunity to urge them to get over it.
Don't try to talk them out of their perceptions. One frequent mistake that family members make is to use reason to challenge the blame-focused perceptions of those stuck in the ditch. This can make them dig their heels in more, and leave you feeling frustrated with them! Although your own guilt about their unhappiness may prompt you to debate the issues, you're better off explaining, "It makes me unhappy to see you this way but I can't change the way you see things." It's hard to accept that sometimes we can't relieve the suffering of those we love, and that only they can do it for themselves.
If discussion is not too antagonistic, focus on the future, not the past. Children with this problem tend to collect their grievances and air them during the most recent setback. Don't fall into the trap of reviewing their past disappointments where evidence of all the unfairness of life is piled up. Encourage them to look ahead and not behind. Point out how keeping their mind open to future opportunities creates future satisfactions.
Don't forget that parents lead the way. We can't afford to neglect our responsibility to model the behavior we wish to see reflected in our children. Parents are wise to recognize where we might be sending the wrong message to our kids. Look for opportunities to "self-correct" or demonstrate how we can put bad feelings behind us in order to make room for the good ones to come.
(c)Dr. Steven Richfield's column appears monthly. Richfield, of Plymouth Meeting, PA can be contacted at www.parentcoachcards.com or 610-275-0178
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