From Parenting New Mexico April 1999

ARTICLE TWO OF FOUR ARTICLES ON
ATTENTION DEFICIT/HYPERACTIVITY DISORDER

Look-Alikes and
Accompanying Disorders

In last month's article on Attention Deficit/Hyperactivity Disorder we discussed the symptoms and behaviors of the disorder, and the basics of correctly diagnosing it. This month we take a look at the several mental health disorders which often coexist with ADHD or have symptoms which can mislead us into believing that they represent ADHD.

Behavior Problems

In children and young adolescents the most common coexisting condition is certainly poor conduct - including oppositional behavior, rule breaking, and a defiant attitude. This pattern is referred to by mental health professionals as Oppositional-Defiant Disorder (ODD) except when it progresses to outright delinquent behavior in the community and then becomes known as Conduct Disorder. Approximately 50% of children with ADHD also show distinct ODD. This is especially true for ADHD sufferers having the Impulsive-Hyperactive Type or the Combined Type with strong hyperactive symptoms. Poor impulse control (trouble with waiting and patience, for example) and hyperactivity are strong risk factors for the development of behavior problems.

Behavior problem children and adolescents are often automatically assumed inappropriately to have ADHD. Poor attention span, being impulsive, and being restless seem in many ways to fit the child who doesn't "pay attention" to school or other "socially acceptable" activities and who seems "on the go" constantly in an effort to aggravate others. Diagnostically and with regard to treatment, however, the two disorders have many distinct and different features. What is important is whether the child has the capability to attend to tasks when motivated, can show restraint when desiring to, and can be still and calm during periods of good behavior. If yes to these three, then ADHD is not likely present. If not, ADHD is probably concurrent with the behavior problems.

Difficult for many families is the fact that even when ADHD does coexist with behavior problems successful treatment of the ADHD, especially in older children and adolescents, may not bring about corresponding reductions in defiant, oppositional, and delinquent behaviors. Especially as children grow older, behavior problems take on their own habitual nature, self identity, and reinforcing patterns which make them very resistant to change. The ability to use poor conduct to control others, including making adults angry, and manipulate situations is a powerful reinforcer which many children with or without concurrent ADHD find very attractive even in the face of severe consequences. Hence, improved self control which occurs in successful ADHD treatment often does not automatically result in a child being willing to use their improvement toward better behavior. I often describe it this way: ADHD is like having poor brakes; fixing the brakes won't necessarily make you a good driver - you have to be willing to use the brakes. Behavioral programs and often family therapy are necessary to achieve better behavior.

Learning Disorders

There are many specific learning disorders, also commonly referred to as learning disabilities (LD). The most common are focused reading problems (Dyslexia), spelling and writing disorders, impaired mathematical reasoning (Dyscalculia), and several language and perceptual processing problems. While a discussion to these many forms is beyond the scope of this article, it is well established by research that between a third and one half of all children with ADHD also have one or more distinct learning disorders.

A learning problem can often be mislabeled as ADHD. It is very easy to not recognize a LD but rather to simply assume that poor academic work and frustration-related avoidance of work are best explained by distractibility due to ADHD. It is generally true that children with a learning disorder avoid the pain of focusing on their work by turning their attention to other activities at hand. The question becomes, are they distracted by things around them (the inattention of ADHD) or are they avoiding work which is highly frustrating for them (the behavior of a learning disordered child). Correctly diagnosing the difference, especially in child with both ADHD and one or more learning disorders, can be a very challenging task even for the professional skilled in the subtleties of both types of problems.

A common LD, poor auditory sequential memory, can be especially difficult to distinguish from ADHD. Someone with this memory deficit has difficulty remembering verbal requests and commands which require memory for things in order or sequence. These individuals have problems with lecture style teaching and oral directions, and are easily assumed to be showing ADHD-like distractibility or even just laziness.

Depression

Among older adolescents and adults, depression is the most common mental health problem worldwide. And among ADHD sufferers, clinical (organically-based) depression is, for unknown reasons, even more common than in the general population. Depression in preteen children is fortunately fairly rare. While clinical depression and ADHD often coexist in adolescents and adults, it is very common for depressed individuals to believe that they have ADHD when in fact the symptoms of concern are actually a part of their depression. This is because two common symptoms of depression may mimic ADHD. The first is trouble with sustained attention. Depressed people find it very hard to concentrate on tasks, just like someone with ADHD. However, there is a difference between the two; in ADHD environmental distracters interfere with attention while depressed persons are usually distracted by their own thoughts and daydreaming.

A second depression symptom overlapping with ADHD is insomnia. Fitful bedtimes are notoriously associated with depression, and in many ways appear similar to the ADHD sufferer who just can't "wind down." Both can look like the ADHD boy whose mother described his bedtime to me as, "He flops in there like a fish." The main differences between the insomnia of ADHD and depression are the onset of the problem - in ADHD sleep problems usually go back to childhood - and the course of sleep through the night - depression sufferers are often additionally plagued by waking up later in the night.

Substance Abuse

There has been a great deal of research on whether there is a relationship between taking drugs or drinking and ADHD. The most surprising finding is how variable the research results have been, often producing conflicting results.

With regard to whether ADHD is a precursor to drug use, the findings are very mixed. The best evidence suggests that ADHD sufferers, especially those with strong hyperactive and impulse control difficulties, seem somewhat more likely to experiment with drugs, but heavy drug use does not seem to be strongly related to a history of ADHD. Some ADHD sufferers use sedating drugs in an attempt to self medicate away their ADHD symptoms or take excitatory drugs as an excuse to explain their wild and impulsive behavior. We do know that a childhood history of medication treatment for ADHD does not predispose adolescents or adults toward drug use.

Personality Disorders

There are a number of personality disorders, several of which have symptoms overlapping with ADHD. Like learning disorders, a full discussion is beyond the scope of this article. In brief, personality disorders are ongoing dysfunctional patterns of daily behavior which typically begin in adolescence (unlike ADHD which begins in early childhood). The specific personality disorders most often having features which look like ADHD are the Borderline Personality and the Histrionic Personality. In both, the individual, most commonly girls and women, has frequent mood swings and tends to be very over reactive to daily events. They are quite melodramatic in their behaviors and tend to precipitate frequent crises in their lives. Repeated suicidal gestures and many medical complaints are also common.

Individuals with these personality disorders are generally very impulsive, a symptom they share with ADHD. While ADHD and these personality disorders can coexist, the common reasons for ADHD to be suspected in individuals who truly have a personality disorder comes from their impulsivity and their exaggerated, often dramatic responses to events which can look like hyperactivity.

Anxiety Disorders

People with ongoing, low level anxiety problems often look to others as if they cannot attend to tasks due to distractibility and seem hyperactive because of their agitation. While the anxiety sufferer feels internal nervousness which is totally uncharacteristic of ADHD, the similar outward appearance to ADHD can be very misleading to others. With young children and others who cannot express their anxiety it is easy for parents and others to assume that they have ADHD. A child who is quite anxious about life events or learning problems can in fact look quite distractible and hyperactive. And if one already suffers from ADHD, anxiety certainly worsens the symptoms.

In the big picture, ADHD is not a neatly separate and simply diagnosed disorder. Rather it is a complex problem which can relate to or involve many other problems as discussed here. The complicated relation of ADHD and ADHD-like symptoms to a host of other problems is another reason that the diagnosis of ADHD requires a thorough evaluation, not just casual observations of behavior.

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Dr. Zieman is an Albuquerque psychologist who specializes in the evaluation of child and adolescent disorders. He also works with adults having ADHD and learning disabilities such as Dyslexia.

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ADHD Articles
Part 1 | Part 3 | Part 4

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Copyright by Parenting New Mexico and Gayle L Zieman PhD. This article may not be published in part or in its entirety in any medium without written permission from Gayle L Zieman PhD or Parenting New Mexico magazine. Links to this page are welcome.