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Attention Deficit Hyperactivity Disorder: Differential Diagnoses & Workup

Author: Susan Louisa Montauk, MD, Medical Director, The Affinity Center, Cincinnati; Professor, Departments of Family Medicine and Public Health Science, University of Cincinnati College of Medicine
Coauthor(s): Christine A Mayhall, PhD, Clinical Psychologist, The Affinity Center
Contributor Information and Disclosures

Updated: Feb 27, 2009

Differential Diagnoses

Anxiety Disorder: Generalized Anxiety
Mood Disorder: Bipolar Disorder
Anxiety Disorder: Obsessive-Compulsive Disorder
Mood Disorder: Depression
Anxiety Disorder: Separation Anxiety and School Refusal
Oppositional Defiant Disorder
Conduct Disorder
Pervasive Developmental Disorder
Eating Disorder: Anorexia
Pervasive Developmental Disorder: Asperger Syndrome
Eating Disorder: Bulimia
Sleep Disorder: Night Terrors
Learning Disorder: Mathematics
Sleep Disorder: Nightmares
Learning Disorder: Reading
Sleep Disorder: Problems Associated With Other Disorders
Learning Disorder: Written Expression

Other Problems to Be Considered

Dissociative disorder
Mood disorder
Panic disorder with or without agoraphobia
Post traumatic stress disorder (PTSD)
Psychotic disorders
Social phobia
Substance-related disorders
Tourette syndrome or other tic disorders

Workup

Laboratory Studies

Workup in attention deficit hyperactivity disorder (ADHD), previously termed attention deficit disorder (ADD), includes the following:

  • Liver function tests
    • Liver function tests (LFTs) may be indicated if the patient has a history of hepatic dysfunction.
    • Amphetamines, methylphenidate, atomoxetine, and tricyclic antidepressants are metabolized hepatically and excreted mainly in the urine.
    • A cause-and-effect relationship has been established between the use of atomoxetine and reversible hepatic failure. However, no evidence suggests that baseline LFT results assist care with atomoxetine in any way.
    • Consider checking LFTs if a patient who is taking atomoxetine presents with signs of hepatitis including early signs, such as nausea, vomiting, diarrhea, and muscle aches lasting longer than 5 days.
  • Determination of CBC counts
    • A coincident relationship has been reported, but no cause-and-effect relationship has been established between use of methylphenidate and blood dyscrasias.
    • A few clinical authorities recommend periodic determination of the CBC counts, but their necessity is not generally endorsed, even for patients receiving long-term treatment.
  • Drug screening
    • Consider periodic random drug screening by means of urine testing (witnessed) or serum testing (if witnessing of urine testing is not possible) in all patients with a history of chemical abuse or suspected chemical abuse.
    • Any suspected substances should be investigated.

Imaging Studies

  • Evidence suggests that MRI and positron emission tomography (PET) may be useful as future diagnostic methods. Current use is appropriate for research purposes only.
  • At present, no laboratory studies, imaging studies, or procedures help with the diagnosis of ADHD (ADD), unless the patient's history suggests that other pathology must be ruled out.

Other Tests

Psychometric and educational testing is often important for the diagnosis of ADHD (ADD). The patient's initial history may indicate a need for additional tests, as follows:

  • Examine children by using the Conners' Parent and Teacher Rating Scale and examine adolescents according to the Brown Attention Deficit Disorder Scale (BADDS) for Adolescents and Adults.2
  • Assess impulsivity and inattention using timed computer tests such as the Conners Continuous Performance Test (CPT), the Integrated Visual and Auditory (IVA) CPT, or both.
  • Assess girls using the Nadeau/Quinn/Littman ADHD Self-Rating Scale for Girls.
  • Assess the patient's executive function by using various neuropsychologic tests.
  • Perform a learning disability evaluation (intelligence quotient [IQ] vs achievement).
  • Several well-validated IQ tests are available.
    • The Wechsler tests are the standards.
    • Many believe that untimed tests are most appropriate for persons with ADHD (ADD).
    • A large discrepancy between the patient's IQ and other measures, such as visual or auditory abilities or an ability to work with numbers, is not uncommon, particularly in older children and adolescents 
  • Baseline ECG to access the QT interval may be indicated before a tricyclic antidepressant is prescribed.

More on Attention Deficit Hyperactivity Disorder

Overview: Attention Deficit Hyperactivity Disorder
Differential Diagnoses & Workup: Attention Deficit Hyperactivity Disorder
Treatment & Medication: Attention Deficit Hyperactivity Disorder
Follow-up: Attention Deficit Hyperactivity Disorder
References
Further Reading
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References

  1. APA. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association Press; 1994:78-85.

  2. Brown TE. Brown ADD Scales. San Antonio, TX: Psychological Corp; 1996:5-6.

  3. Elia J, Ambrosini PJ, Rapoport JL. Treatment of attention-deficit-hyperactivity disorder. N Engl J Med. Mar 11 1999;340(10):780-8. [Medline].

  4. Hunt RD, Paguin A, Payton K. An update on assessment and treatment of complex attention-deficit hyperactivity disorder. Pediatr Ann. Mar 2001;30(3):162-72. [Medline].

  5. Johnson TM. Evaluating the hyperactive child in your office: is it ADHD?. Am Fam Physician. Jul 1997;56(1):155-60, 168-70. [Medline].

  6. Millichap JG. Etiologic classification of attention-deficit/hyperactivity disorder. Pediatrics. Feb 2008;121(2):e358-65. [Medline].

  7. Nadeau KG, Littman E, Quinn P. Understanding Girls With AD/HD. Springfield, MD: Advantage Books; 2000.

  8. Ramchandani P, Joughin C, Zwi M. Attention deficit hyperactivity disorder in children. Clin Evid. Jun 2002;262-71. [Medline].

  9. Rappley MD. Clinical practice. Attention deficit-hyperactivity disorder. N Engl J Med. Jan 13 2005;352(2):165-73. [Medline].

  10. Reeves G, Schweitzer J. Pharmacological management of attention-deficit hyperactivity disorder. Expert Opin Pharmacother. Jun 2004;5(6):1313-20. [Medline].

  11. Spencer TJ, Biederman J, Wilen T. Pharmacotherapy of ADHD with antidepressants. In: Barkley RS, ed. Attention Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment. 2nd ed. New York, NY: Guilford Press; 1998:552-63.

  12. Wolraich ML, ed. The Classification of Child and Adolescent Mental Diagnoses in Primary Care: Diagnostic and Statistical Manual for Primary Care (DSM-PC) Child. Elk Grove, IL: American Academy of Pediatrics; 1996.

  13. Wilens TE. Straight Talk about Psychiatric Medications for Kids. New York, NY: Guilford Press; 2002.

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Further Reading

Additional resources on attention-deficit/hyperactivity disorder (ADHD) are available at Medscape's Attention Deficit/Hyperactivity Disorder (ADHD) Resource Center.

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Keywords

attention deficit hyperactivity disorder, AD/HD, ADD, ADD/ADHD, ADHD, attention deficit disorder, attention deficit disorder with and without hyperactivity, attention–deficit/hyperactivity disorder, attention-deficit hyperactivity disorder, hyperkinetic impulse disorder, hyperactive syndrome, hyperkinetic reaction of childhood, minimal brain damage, minimal brain dysfunction, undifferentiated attention deficit disorder, learning disorders, restless-legs syndrome, ophthalmic convergence insufficiency, depression, anxiety disorders, antisocial personality disorder

substance abuse disorder, conduct disorder, inattentive ADHD, inattentive ADD, pervasive developmental disorder, premenstrual dysphoric disorder, schizophrenia, psychotic disorder, mood disorder, anxiety dissociative disorder, personality disorder, major arterial disease, narrow-angle glaucoma, heart disease, heart palpitations, hepatic disease, hypertension, orthostasis, renal disease, seizure disorder, generalized anxiety disorder, GAD, obsessive-compulsive disorder, OCD, panic disorder, social phobia, oppositional defiant disorder, dissociative disorders, eating disorder, enuresis, encopresis, Asperger syndrome, posttraumatic stress disorder, PTSD, sleep disorder, Tourette syndrome, physical abuse, sexual abuse

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Contributor Information and Disclosures

Author

Susan Louisa Montauk, MD, Medical Director, The Affinity Center, Cincinnati; Professor, Departments of Family Medicine and Public Health Science, University of Cincinnati College of Medicine
Susan Louisa Montauk, MD is a member of the following medical societies: American Academy of Family Physicians and Society of Teachers of Family Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Christine A Mayhall, PhD, Clinical Psychologist, The Affinity Center
Christine A Mayhall, PhD is a member of the following medical societies: American Psychological Association
Disclosure: Nothing to disclose.

Medical Editor

Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

CME Editor

Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD, Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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