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

A skilled psychologist or speech pathologist can help you determine the presence or absence of cognitive and language dysfunction and learning disabilities. Even before we interview the parents and child, we ask parents and teachers to rate the child’s attention, behavior, mood, PDD-like symptoms, and anxiety, using the Child/Adolescent Symptom Inventory (see Related resources). We use the youth version with children age 10 and older, then review the symptoms with the parents and child to make sure we understand all presenting comorbidities.

TREATMENT

Nonmedical interventions begin with an accurate diagnosis, where possible. Then the four steps of treatment are to:

• address each domain of dysfunction
  
• translate findings to parent, child, and teachers/school.
  
• provide settings and resources that allow the child to work most effectively
  
• develop a behavioral program for the most frequent problems, with consistent response by caretakers and educators.
  

The educational setting needs to be adapted for these children. This usually implies individualized attention in small classes or small work groups. Assigning an aide to the child may be effective in larger settings, but other support and expertise is needed. Otherwise, all the aide does is run interference for the child, which ultimately may be more isolating than a special education class.

A communication specialist interested in pragmatics is needed to make sure the child is understood and being understood in the classroom. Table 3, summarizes communications skills the child needs to learn. An educational specialist who serves a resource to other professionals may also help the child. Curriculum should be based on long-term goals rather than on inflexible credit schedules that teach worthless, unlearnable information and demoralize the student.

Finally, the education setting should provide opportunities for structured social interaction and less-structured but supervised—”bully-proofed”—interactions.

Medications. No systematic medical treatment data exist, as there is no way to classify these children. They are usually treated with multiple medications for their specific symptom cluster abnormalities (Table 4). Options include:

• atypical antipsychotics such as risperidone, quetiapine, aripiprazole, ziprasidone, or olanzapine
  
• mood stabilizers such as valproic acid, lithium, or lamotrigine
  
• stimulants such as methylphenidate, amphetamine salts, atomoxetine, or bupropion (a mild stimulant and an antidepressant)
  
• selective serotonin reuptake inhibitors, such as fluoxetine, sertraline, citalopram, paroxetine, or fluvoxamine.
  

Unfortunately, drug therapy may cause behavioral toxicity—tearfulness, irritability, disinhibition, activation, agitation, hallucinations and possibly even suicidal behavior. Stopping the medication usually reverses this kind of adverse effect.¹⁹

Medication side effects understandably frighten parents—who may be reluctant to have their children use any drug therapies. Counsel the parents in advance that side effects may occur.

Related resources

• Child/Adolescent Symptom Inventory. https://www.checkmateplus.com. Accessed Jan. 11, 2005.
  

Drug brand names

• Amphetamine • Adderall
  
• Aripiprazole • Abilify
  
• Atomoxetine • Strattera
  
• Bupropion • Wellbutrin
  
• Citalopram • Celexa
  
• Fluoxetine • Prozac
  
• Fluvoxamine • Luvox
  
• Lamotrigine • Lamictal
  
• Lithium carbonate • Lithobid, others
  
• Methylphenidate • Concerta, Ritalin
  
• Olanzapine • Zyprexa
  
• Paroxetine • Paxil
  
• Quetiapine • Seroquel
  
• Risperidone • Risperdal
  
• Sertraline • Zoloft
  
• Valproic acid • Depakote
  
• Ziprasidone • Geodon
  

Disclosures

Dr. Weisbrot receives grants from Pfizer Inc.

Dr. Carlson receives grants from or is a speaker for Janssen Pharmaceutica, Eli Lilly and Co., Shire Pharmaceuticals Groups, and Abbott Laboratories; is a consultant to Janssen Pharmaceutica and Eli Lilly and Co.; and is an advisor to Otsuka America Pharmaceutical, Pfizer Inc., and Ortho-McNeil Pharmaceutical.