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

Current Psychiatry. 2005 February;04(02):24-42

February 1, 2005|Current Psychiatry

Deborah M. Weisbrot, MD;Gabrielle A. Carlson, MD

This approach for children with ‘much more than ADHD’ can help them function better in school and at home

Possible psychosis. These children may have impaired reality testing that can be difficult to assess; thus, deciding whether the child is experiencing psychotic symptoms can be a challenge. The child may be intensely involved with fantasy characters or imaginary companions to such a degree that he or she insists the character is real.^16,17 Developmentally normal fears—as of the dark, monsters, or images from dreams—may preoccupy him or her during the day. Quasi-psychotic symptoms such as these are easily missed if:

we don’t ask about them
we assume the child is “just pretending” or has a “great imagination”
the child does not volunteer the information spontaneously.¹⁸

Table 3

Communication skills children need to learn

Rules of conversation (for example, who is likely to be interested in what) Topic management (when to expand, shift, end a conversation) Awareness of nonverbal cues Social expectations in various settings Operational knowledge of the language of emotions and mental states (how to express feelings and the different ways we experience ourselves) How to monitor a listener’s relative interest The meaning of eye contact, voice tone, and voice inflection Awareness of how social settings affect communication, such as voice volume (whisper in the library, shout on the soccer field) and speech style (slang with peers, formal style for classroom recitation) Body proximity (how to avoid invading someone’s space) Decoding facial expression (such as what it means when someone rolls his eyes) Special instruction to help decipher nonliteral communication, including teasing, irony, sarcasm, emotional tones of speech

Rules of conversation (for example, who is likely to be interested in what)
Topic management (when to expand, shift, end a conversation)
Awareness of nonverbal cues
Social expectations in various settings
Operational knowledge of the language of emotions and mental states (how to express feelings and the different ways we experience ourselves)
How to monitor a listener’s relative interest
The meaning of eye contact, voice tone, and voice inflection
Awareness of how social settings affect communication, such as voice volume (whisper in the library, shout on the soccer field) and speech style (slang with peers, formal style for classroom recitation)
Body proximity (how to avoid invading someone’s space)
Decoding facial expression (such as what it means when someone rolls his eyes)
Special instruction to help decipher nonliteral communication, including teasing, irony, sarcasm, emotional tones of speech

In assessing psychotic symptoms, the first goal is to get a detailed picture of unusual thoughts or images the child is experiencing in different settings, including school, home, and with peers. Then evaluate these symptoms in the broader clinical context of how the child is functioning in other domains.

Language/thought disorder. Parents may not recognize that their child has a thought or language disorder because they have filled in the blanks and interpreted for him or her for so long. Asking the child “yes” and “no” questions will not elucidate these disorders, either. The examiner must talk to the child to determine his or her ability to:

sustain an extended narration that makes sense
stay on the topic
care whether the listener understands what the child is talking about
make a point.

Distinguishing between a thought or and language disorder in a child is difficult, although the more illogical the communication, the less likely it is to be a language disorder. If the child connects ideas that don’t make sense, ask him or her to explain how the subject shifted or what he or she meant. Children with language disorders may have misunderstood the question or may have expected the examiner to make connections, but the explanation usually makes sense. When it doesn’t, we become more concerned that the child has a thought disorder.

Nonverbal communication realms include eye contact, appropriate hand gestures and facial expression, tone of voice, and vocal inflection. Other important areas of language to assess are summarized in Table 2.

Relationship/socialization problems. It is important to know whether the child has friends, wants friends, or prefers being with younger children. Peer relationships may be absent, delayed, or deviant.

Other assessments. The diagnostically homeless children we see have complicated family histories of psychopathology. Their first-degree relatives have a higher number of heritable disorders—including bipolar disorder, panic disorder, ADHD, learning disabilities, and “nervous breakdowns”—than do those of children with uncomplicated ADHD, bipolar disorder, or anxiety disorders. Ask about these conditions when taking the family history; if a family member is said to be bipolar, get a description of the person’s symptoms.

Table 4

Targeting drug therapies to treat children’s symptoms

Drug class	Efficacy by symptom domain
Atypical antipsychotics	Psychosis/thought disorder: Can reduce psychotic symptoms
	Anxiety symptoms: Can reduce extreme anxieties
	Affect regulation: Improved by mood-stabilizing effect
	Socialization problems: Appear to modify affective aggression, hyperactivity, and impulsivity, which can improve socialization and pragmatic communication
Mood stabilizers	Psychosis/thought disorder: Not primary area of effectiveness
	Anxiety symptoms: May be helpful; not primary area of effectiveness
	Affect regulation: Address mood dysregulation
	Socialization problems: May reduce aggressive outbursts and mood, which can improve socialization
Stimulants*	Psychosis/thought disorder: Can produce or intensify psychotic symptoms and agitation
	Anxiety: Usually do not improve anxiety; can intensify anxiety and agitation
	Affect regulation: Not a primary effect in severe cases; address impulsive aggression via mood stabilization
	Socialization problems: Can improve functioning via decreased impulsivity, inattention, and aggression
SSRI antidepressants†	Psychosis/thought disorder: Do not directly address
	Anxiety: Can be effective in decreasing anxiety
	Affect regulation: Can improve depressed mood
	Socialization problems: Can be improved as a result of improved mood and decreased anxiety
* Stimulants often increase agitation and disinhibition.
† Watch for behavioral disinhibition, possible increase in suicidality, with selective serotonin reuptake inhibitors (SSRIs).

References