Ending The Pattern Of Destructive Misdiagnosis

August 30th, 2009 | Leave a comment »
Published by Dr. Yip

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.

Her teacher is concerned because, although Julie seems to have much potential, she appears disengaged during lessons, and often stares out the window. She shows an interest in school projects; however, she often forgets to bring the necessary supplies to complete them. Julie, herself, reports that she gets bored easily.

Julie’s parents and teachers have noticed that she also has difficulties in social interactions. She tends to keep to herself, and her parents note that she rarely brings friends home. Her teacher reports that she appears uncomfortable when given tasks that require her to lead the class in activities. Although she maintains a high interest in world events and will often talk about such events with adults and peers, she does not initiate social interactions and often waits to be approached.

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.