Ending The Pattern Of Destructive Misdiagnosis

Is it ADHD? Anxiety? Giftedness?

Julie’s parents and teachers are worried. She is in the 4th grade and falling behind in her studies. Although she has a complex vocabulary, and demonstrates a high level of general knowledge, she is not performing up to her ability in the classroom. She has difficulty copying off the board, consistently falls behind in her class work, is unable to complete tests within time limits, and spends an inordinate amount of time on homework.

A doctor has diagnosed Julie with Attention Deficit Hyperactivity Disorder (ADHD). However, even after following proper treatment protocols and taking medication appropriate for ADHD, Julie shows no sign of progress. In fact, she appears even more distracted. Her parents desperately want to help her before these issues further impact her learning and self-esteem. How do we get Julie on the right track?

To get Julie on the right track, we must determine the root cause of her behavioral manifestations. In other words, we know that Julie is experiencing academic and social difficulties and appears inattentive. The question is why? The fact is that many of Julie’s symptoms can be attributed to any number of diagnoses, including ADHD, an anxiety disorder, or even giftedness. Thus, in order to put Julie on the right track, we must first accurately determine what it is that we are treating.

Is Julie’s inability to sustain attention due to her persistent distractions from worrisome thoughts? Does Julie have a hard time paying attention because she often gets bored easily? Or is Julie’s inattention due to her pure inability to attend to tasks? Each of these three possibilities gravitates toward different diagnosis. A proper diagnosis that allows for proper treatment is the first step to put Julie back on track to her full potential. On the other hand, a misdiagnosis or even a partial diagnosis – such as diagnosing ADHD alone when both ADHD and anxiety are present – can actually lead to treatment that may exacerbate Julie’s initial symptoms.

Let’s take a closer look at Julie’s symptoms, and break down the specific problems. She has difficulty completing tasks on time, such as copying from the board. Several reasons may contribute to this. For instance, an anxious child may spend a large amount of time perfecting her handwriting, checking repeatedly to see that nothing is misspelled, or writing everything on paper so that it looks exactly as the board. In particular, children with Obsessive-Compulsive-Disorder (OCD), which is a specific type of anxiety disorder, often spend an inordinate amount of time on rituals associated with writing to ensure that all the “rules” are followed exactly. They may feel compelled to make sure their handwriting slants a certain way, or erase and rewrite a certain number of times to feel “just right.”

On the other hand, a child with ADHD may have difficulty copying off of the board, because she loses focus during the lesson, and may not know what to copy. A gifted child may lose focus due to boredom, not know what to copy, and become disengaged from the classroom. The gifted child may also assume that she does not need to copy material from the board, only to realize later that she needs to reference those materials from the board. In each scenario, the simple task of copying off the board becomes a time-consuming process ultimately interfering with processing information from the lesson.

Because many anxious children spend an inordinate amount of time reviewing and perfecting their work, they fall behind. The anxious child may also doubt, and become worried that she fully understands the lesson taught, which results in time spent ruminating about a perceived ineptitude. Children with ADHD are often behind in class work because they do not work steadily on assignments to completion. The ADHD child may become distracted and start a different project, or become restless and abandon the assignment altogether. Gifted children often procrastinate; in part because they know that they generally require less time to complete projects. Unfortunately, this becomes problematic if the gifted child underestimates the time needed to complete the assignment. For the gifted child, procrastination may also signify anger for having to do the assignment, and may be a way of acting out.

Further, anxious children often disengage from lessons, because they are distracted by worries that may be unrelated to the lesson (e.g., ruminating over a poor test score just received, repeatedly checking for mistakes, mentally reviewing a previous interaction with a peer, etc.). A child with OCD, as noted above, may be fixated on a compulsion, and not be able to refocus on the material being taught. Children with ADHD are also less able to pay attention when the lesson is not interactive, or when the lesson is taught to a large classroom. For gifted children, the material being taught is often not challenging enough leading to boredom and disengagement. Nevertheless, paying little attention to the lesson plan can start a vicious cycle: The child is not engaged -> does not learn the material -> becomes discouraged because he/she now can not follow the lesson-> pays less attention/ becomes less engaged -> learns less.

We also noted that Julie often forgets her materials for projects. Anxious children may be so focused on a school project at the micro level that she becomes oblivious to the gestalt or “big picture”. For instance, an anxious child may be so completely concentrated on creating an exact replica of an Egyptian pyramid that other supplies necessary to present the project, such as note cards may be forgotton. Children with ADHD who are typically disorganized may also forget the necessary supplies. The child may even forget the homework assignment altogether if it’s not written down,. Gifted children will generally bring the proper materials to class for a project unless distracted by something more interesting.

Lastly, this case example highlights Julie’s difficulties with social interactions, specifically with making friends, leading activities, and discussing world events. Anxious children, children with ADHD, and gifted children may all have difficulties relating to their peers. Anxious children are often self-conscious and shy. They may appear introverted, because they are unsure of themselves in social settings and fear looking foolish. Some children with ADHD have under-developed social skills, which hinder their ability to interact in a way that fosters peer friendships. Also, children with ADHD are often oblivious to the social cues of others. They may blurt out inappropriate comments, and have problems waiting or taking turns. Gifted children, however, may have difficulty relating to peers, because they tend to be socially, emotionally, and or intellectually more mature and advanced than their same-aged peers. In fact, gifted children may downplay their intelligence in their struggle to make friends. Because of their emotional maturity, gifted children are also prone to mood swings.

Thus, the anxious child may be self-conscious leading an activity, because she fears making a mistake; whereas, the gifted child may be uncomfortable leading an activity due to her inability to relate to peers. A child with ADHD may not hesitate, or appear uncomfortable leading an activity; however, this child is unlikely to be effective in leadership skills due to a lack of organization and social skills.

To determine whether Julie’s discussion of world events is appropriate, we need to further explore the content of these conversations. Is Julie discussing worrisome events that concern her, such as wars, fires, or death? If so, she may be anxious. If she is discussing random world events that do not carry a theme, and she discusses them out of turn or at inappropriate times, she may have ADHD. If she discusses highly intellectual world news, and seeks to integrate her own thoughts with others’ opinions of the event, she may be gifted.

In summary, considering only the behavioral manifestation of her symptoms alone, Julie fits into several diagnostic patterns. To make the correct diagnosis, it is crucial to thoroughly explore the reasons behind Julie’s problems and understand why the behaviors occur. How can we achieve this?

• By carefully observing patterns in her behaviors and noting when they occur.
• By communicating with her parents about documenting the consistency of her behaviors.
• By coordinating with members of the school team who interact regularly with Julie.
• By framing questions, when talking directly with Julie, in a way that allow her to answer honestly without feeling ashamed.

Each of these will help to present a more thorough picture leading to the correct diagnosis. By taking these steps, we can uncover the root cause of Julie’s problems and determine the most effective treatment that will allow her to perform at her fullest potential inside and outside the classroom.

Understanding the Underlying Triggers of OCD in Children

The diagnosis of Obsessive-Compulsive Disorder (OCD) is usually quite straightforward in adults. However, symptoms of OCD in children often manifest in different ways, which can lead to detrimental misdiagnoses. The key is to understand the underlying cause of each child’s behavioral manifestations. Let’s take a look into Nick’s symptomology and how it was approached.

Nick was 10 years old at the time he began treatment with me. He had already been to several psychologists intermittently for talk and play therapy. He had begun seeing a psychiatrist, and was placed on a medication regimen of Luvox and Risperdal. Nick had been given various diagnoses since preschool, including Separation Anxiety, ADHD, Oppositional Defiant Disorder, Panic Disorder, and OCD. Due to his emotional outbursts and issues with anger, his family sought family therapy unsuccessfully, and was considering residential treatment at the family therapist’s suggestion. Nick also had difficulty paying attention in his classes, and always declined play dates with friends after school although he was socially interested and active during school.

When I first met Nick, he appeared to be a gentle boy with excessive fear and anxiety. He often smiled and nodded nervously in agreement with little much else to say. He expressed that his biggest fears were about being alone and “something bad happening” to him or his parents. He often worried about getting kidnapped or his parents getting into a car accident. He also had fears of contamination, and avoided any potentially contaminated items. To ensure that nothing “bad” would happen, Nick developed a set of behavioral and mental compulsions including: tapping a certain way; checking door locks, windows, stove, etc for safety measures; repeating “just kidding” to himself when he had an intrusive image of harm befalling his family; wearing the same two outfits over and over again because they felt safe.

Nick’s parents described their days as chaotic and debilitating. Getting Nick to school every morning was a struggle because of his emotional crying and pleading to let him stay home, which usually results in angry outbursts of threats. A detailed bedtime ritual of specific behaviors and words such as hugs, “goodnight” and “I love you” had to be performed in a particular way every night by each family member. If any part of the ritual was done incorrectly, it had to be repeated or Nick would have an emotional meltdown. These emotional outbursts worsened over time, and became so severe that the neighbors called the police at one time when they saw Nick jumping on the roof of his father’s car shouting “I hate you,” “I’m going to kill you,” “I want to shoot your head off.” Nick’s parents expressed waking up every morning in dread, because they felt helpless to help their child, and yet, frustrated by his unexplained behaviors.

At the outset of treatment at our program, Nick decided to call his OCD, “Mr. Worry.” Although he reported being very motivated to improve his behavior and relationship with his family, he appeared hesitant and uncertain. We developed a hierarchical list of all of the rules given by Mr. Worry. I educated Nick and his family on how Mr. Worry thrives when these rules are followed and how Mr. Worry weakens when these rules are broken.

I explained how we do not have direct control over our emotions, such as fears and anxiety, and can only redirect them through our defenses. I described how we do not have direct control over the specific thoughts going through our minds. Using his thought of being kidnapped as an example, I explained that at any given time we have a million tiny stimuli entering and exiting our minds. Helping him to understand that what we do have is “selective attention,” which allows us to focus on any one whole thought at any given time. This clarified how when we try not to think of something (i.e., getting kidnapped), we are actually selectively attending to that thought. Nick tested this theory when I said, “Now don’t think of the yellow duck.” He couldn’t, and his eyes lit up with more interest, which indicated our first breakthrough. I continued to explain that what we do have control over is our behaviors, including our actions and reactions to our thoughts and emotions. This means that we only have control over those behaviors that Mr. Worry instructs us to perform, such as checking and tapping.

From this very first psychoeducation of how OCD functions, Nick’s initial hesitation began to subside. We developed a strategy to beat Mr. Worry by selecting those rules (compulsions) to break that were at the bottom of the difficulty scale and worked our way up. Nick began acquiring tools to beat Mr. Worry by following this model:

We cannot control our emotions.
We cannot control our thoughts.
To beat Mr. Worry, we can only control our behaviors by not following his rules.

As for Nick’s behavioral outbursts, I explained to his parents how Nick himself did not comprehend what he felt. The anxiety from the obsessive fears of harm for a 10-year-old can be extreme and debilitating. Rather than feeling protected by his parents, Nick felt resentment toward them for making him go to school and experience his anxiety even more. I discouraged their consideration of residential treatment, which would only increase Nick’s resentment, and instructed them to audio tape his behavioral outbursts. This was used during sessions to increase Nick’s awareness of his emotional meltdowns. Additionally, we practiced graded exposures to his fears of being alone, such asseparating from his parents for brief moments by stepping just outside the front door for 2 minutes and taking 10-minute walks around the neighborhood.

To increase Nick’s motivation, we used a behavioral modification program for the Exposure and Response Prevention (ERP) part of treatment. This involved exposing Nick to his obsessive fears in a hierarchical level of difficulty without engaging in the compulsive behaviors. Nick was rewarded with his chosen privileges each time he was able to beat Mr. Worry and not give into the rules.

By that summer, 5 months from starting our treatment program, Nick was able to ride the school bus daily without anxiety, enjoy sleepovers at friends, participate in a weeklong camp away from home, and fly on a plane by himself. His mother even got into a minor car accident, which he stated, “was a good exposure.”

Although Nick’s behavioral symptomology may have initially appeared as ADHD or Oppositional Defiant Disorder, the underlying cause for his behaviors were clearly triggered by obsessive fears of harm to self and others, accompanied by the compulsive rituals to ensure safety. Had we entertained the other diagnoses, his symptoms would have been aggravated by the medications for ADHD, his anger would have worsened by his perception of his parents lack of understanding, and his overall functioning would have decreased by his inability to manage Mr. Worry.

Can your Child be Misdiagnosed? The Need for Child Anxiety Treatment

Timmy is an 8-year-old in the 3rd grade. He has always been known to be a shy, nervous kid who prefers to keep to himself and wait for others to approach him. He favors routine, and becomes anxious to change or when he is in a new, unfamiliar situation. When Timmy is in the classroom, he gets bored easily, often stares out of the window, and even dozes off at times. He is frequently late to school and often complains of having headaches and feeling nausea. Although his vocabulary is quite high for his age and grade level, his academic achievement is below what is expected. Timmy spends an inordinate amount of time on assignments, and always needs extra time to complete assignments and tests. He has problems copying off the board, sitting still, and just staying on track overall. On top of that, Timmy seems to be quite forgetful, as he usually does not have the materials he needs to complete tasks. Although, his teacher reports that he has a hard time paying attention and often gets behind in his work, Timmy does make astute comments and show a great deal of general knowledge. In fact, he often talks about world problems and events seen on the news, and displays great compassion and empathy for them. At this point, Timmy’s parents are frustrated that he is not reaching his potential. They have heard time and time again that Timmy is an ADHD kid and his primary problem is that he just has difficulty focusing. His parents’ frustration continues, as they are at a lost when medication and behavioral methods aimed at ADHD have minimal effects for Timmy, and he continues to have problems focusing and sitting still.
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Training Parents to Become Therapists: Crucial Strategies for Successful Child OCD Treatment

It cannot be stressed enough the necessity of involving parents and other caretakers into child OCD treatment. This is also essential for those adults with OCD who continue to live with and depend upon their parents.

OCD typically involve other family members of the patient suffering from this disorder. It significantly interferes with family dynamics, and has a significant impact on family functioning. In addition, families play a critical role in the child’s OCD treatment readiness, compliance, recovery rate, and relapse. Thus, consideration of the familial context, developing healthy collaborative relationships among the patient, his/her family, and the therapist, and integrating the family into treatment is vital to child OCD treatment outcome, since families are an integral part of the lives of individuals with OCD.
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State of Affairs in the World of BDD

Body Dysmorphic Disorder (BDD) is a disabling condition that until recently has been largely ignored. However, it is estimated that 1-2 % of the general population has BDD, nearly 5 million people in the US alone (Gorbis 2004b, Bohne et al. 2002, Otto et al. 2001).

Sufferers of BDD worry excessively and unreasonably about some flaw in their appearance that may be minimal or even nonexistent (Gorbis & Kholodenko 2005, Phillips et al. 1993). These excessive worries and fears prompt sufferers to ritualize their behaviors by constantly checking the supposed defects in mirrors, seeking reassurance of their images from others, obtaining unnecessary cosmetic and/or dermatological procedures, and even conducting self-surgeries (Rosen et al. 1995, Phillips et al. 2000, Veale 2000, Phillips et al. 2005). These obsessive concerns and compulsive behaviors cause significant emotional distress and often significantly interfere with global functioning (DeMarco 1998, Gorbis & Anan’Yev 2004).
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OCD-Anorexia

Obsessive-compulsive disorder (OCD) is the most common anxiety disorder, occurring in 40% of people suffering from anorexia nervosa (Kaye et al., 2004). Both disorders share many phenomenological similarities. The fears and obsessions of people with anorexia nervosa are similar to the obsessions that people with OCD experience. While the anorexic fears gaining weight and becoming obese, the person with OCD fears ingesting food that is contaminated with germs and bacteria and becoming sick. The compulsive behaviors exhibited by anorexics include excessive dieting, over-exercising, repeatedly evaluating themselves in mirrors, and stereotypical weight checking. Food-related rituals, such as cutting food into tiny pieces, are characteristic of both anorexia and OCD. For anorexics, compulsions serve to relief tension and fear of gaining weight, and reinforce ritualistic habits in an attempt to control weight gain.
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