“Diagnostically homeless” Is it ADHD? Mania? Autism? What to do if no diagnosis fits

NOS diagnoses also don’t adequately address children with marked anxiety, unusual fears, and perseverative behaviors who are socially clumsy but manage reciprocal social interaction. These children are substantially disabled by:

• attention difficulties
  
• mood dysregulation (including anxiety and/or manic symptoms)
  
• trouble with transitions/change
  
• motor problems (not infrequently)
  
• pragmatic language/social difficulties.
  

Few tests exist for pragmatic language skills, which include being able to maintain a reciprocal conversation, stay on topic, understand the listener’s needs, and use correct body language and voice tone. Children with PDD, ADHD, and other language disorders are most often disabled in this area of communication.

Diagnostic terms that have tried to classify these children (Table 1) include:

• childhood-onset PDD, described in DSM-III. This category was dropped in DSM III-R to be included in PDD, then largely ignored in DSM-IV when autism criteria were refined.
  
• multiple complex developmental disorder (MCDD),^7-9 which appears to describe children within the autism spectrum (such as PDD NOS)
  
• multidimensionally-impaired (MDI) syndrome, whose atypical psychosis has been called “psychosis NOS”^10-11
  
• schizotypal personality disorder, which addresses similar symptoms (although mental health professionals are loathe to use a personality disorder diagnosis in a child).¹²
  

These designations all include psychopathology in four domains: anxiety, affect regulation, communication, psychosis, and relatedness.

At this time, however, diagnostic conclusions about this heterogeneous group of children are premature. Our classification system does not do them justice, and we need to study them for what they have, rather than forcing them into our current alternatives.

Prevalence. To find out how many patients in our university-based, tertiary-care clinic do not fit DSM-IV-TR nosology, we examined data from faculty evaluations of 624 children and adolescents.¹³ These included semi-structured interviews of parent and child, rating scales from parents and teachers, and testing information from the schools in two-thirds of cases.

The result: nearly 25% of our child and adolescent psychiatry outpatients are “diagnostically homeless.” Like the rest of our patient population, these children are:

• 80% male
  
• 60% under age 12
  
• 86% Caucasian
  
• 85% living with their biological mothers.
  

These children are referred to psychiatrists for many reasons:

• ADHD (16%). They have great difficulty with executive functions, such as paying attention, inhibiting impulsive responses, planning and organizing, making transitions from one activity to another, and controlling emotion. Their problems, however, go much beyond ADHD.
  
• Bipolar disorder (15%) or depression/anxiety (16%). They have catastrophic anxiety and/or frightening rages triggered by apparently trivial circumstances. They balk or “shut down” when people want them to move or act faster than they can move or act.
  
• To “rule out autism” (19%). More than one-half (56%) of these children have a diagnosable speech or language disorder, compared with 35% among our other child psychiatry outpatients.
  
• For educational assessment (23%). School systems request guidance for educational interventions because these children are possibly psychotic and disturbing to teachers and children. They may be unable to execute homework assignments and fail their courses but surprisingly do grade-level work on achievement tests.
  

ASSESSING FOUR DOMAINS

We can consolidate the domains needing assessment into mood/anxiety problems, possible psychosis, language/thought disorder, and relationship/socialization problems. Although evaluating and treating some of these domains may be beyond the psychiatrist’s purview, we must make sure that other professionals attend to them.

Anxiety and mood. Understanding these children’s anxieties is important. A routine fear of bees is a simple phobia, whereas catastrophic anxiety over a highly unlikely impending tornado and perseverative interest in the weather may be more common in a PDD spectrum disorder. Anxiety about going to sleep because a monster is going to suck out one’s brains does not easily fit into the rubric of generalized anxiety.¹⁴

Irritability is these youngsters’ most disabling mood symptom. Volcanic anger and rage that prompts referral occurs in numerous conditions, including mania. Many of the children described in Ross Greene’s book, The Explosive Child,¹⁵ have conditions other than bipolar disorder. Although parents and teachers often describe these events as occurring without provocation, a good functional behavioral assessment will usually reveal a precipitant.

Table 2

Assessing children’s social and language skills

Social assessment	Seen in…
Are the child’s social abilities delayed?	ADHD
Is he uninterested in social situations?	Autism
Is he clueless about social interaction?	Autism spectrum disorders including MCDD, MDI, PDD NOS, nonverbal learning disability
Are social interactions deviant?	Schizotypal personality disorder/schizophrenia
Does child appear shut down/behaviorally inhibited in unfamiliar settings, with greater comfort at home or with familiar people?	Social phobia
Language assessment (can be done by psychiatrist)
Age at first word use; age at first use of short sentences Early interest in language? Nonverbal communication? Communication for sharing?
Useful questions	Seen in…
Was communication delayed but then progressed “normally”?	Developmental language disorder
Did it begin normally and stop?	Autism
Was/is it egocentric and/or unidimensional?	Asperger’s disorder; nonverbal learning disability
Was/is it bizarre or paranoid?	Schizotypal personality disorder
Pragmatic language problems?	All of the above, MCDD, MDI, ADHD
Communication domains (may require speech pathologist assessment)
Expressive and receptive language
Pragmatic language (the child’s ability to communicate in the real world; see Table 3)
Written language
Audiology (hearing and auditory processing)
ADHD: attention-deficit/hyperactivity disorder
MCDD: multiple complex developmental disorder
MDI: multidimensionally impaired syndrome
PDD NOS: pervasive developmental disorder not otherwise specified