These "Pearls" were published by Current Psychiatry in 2002:
Five Red Flags to Rule Out ADHD
By Manuel Mota-Castillo, MD.
In a Consensus Statement The National Institutes of Health concluded that there is not an independent diagnostic test for Attention Deficit hyperactivity disorder (ADHD).1 Furthermore, the American Academy of Child & Adolescent Psychiatry (AACAP) issued a Treatment Guidelines classifying the ADHD diagnosis as a clinical one.
The physician is left with his or her clinical skills to figure out a diagnosis for a hyperactive and/or inattentive child. With the time constraint imposed by Managed Care, our questioning and history gathering need to be precise and aimed to specific information. Over the years I have come up with “pearls” that can help to separate ADHD from mood problems,2 anxiety, psychosis, obsessions, etc.
Moodiness is not part of ADHD.
If we look at the criteria set forth by DSM-IV, elevated mood is not an element of ADHD. The presence of “mood swings,” persistent clowning or angry affect should prompt further questioning about the presence of similar features in other relatives. Frequently we hear that “his father was never diagnosed with anything but he was a class clown.” Another red flag is a father that was “hyper” as a child but later on abused cocaine. I would doubt that a cocaine-dependent father had ADHD because ADHD patients don’t get a “high” with cocaine and it is very unlikely they can become addicted to that substance.
ADHD is not an intermittent condition.
By asking if the child has “good days and bad days” we can obtain valuable information. ADHD has a biological basis and should be present every day, as Parkinson Disease or Diabetes. Obviously, some days can be more challenging than others, but if a parent says, “some days she is a perfect child” the possibilities of diagnosing ADHD become very scarce.
Symptoms should be present in Kindergarten.
The child with ADHD begins to show signs of this condition very early in life and parents are frequently call by the pre-school and kindergarten teachers. The usual complains are the inability to stay in task and disrupting the class. The start of these symptoms in first or second grade should be a red flag to question the ADHD diagnosis.
More than one diagnosis probably means “none of the above.”
When a child is giving the diagnosis of Conduct Disorder (CD) and/or Oppositional-Defiant Disorder (ODD) along with ADHD chances are that we are missing the real diagnosis. I have seen cases of Social Anxiety Disorder diagnosed as ADHD/ ODD because the child was inattentive, secondary to nervousness. For what is worth, the DSM-IV does not allow diagnosing ODD in the presence of CD.
Worsening of symptoms is not an expectected outcome from stimulants.
Lack of response to psychostimulants or only mild improvement may occur in ADHD. Frequently, however, we see children with a history of getting worse after being starting medication for presumed ADHD. A clarifying question to the child can be, “Can you think better on this medication?”3
We usually get an affirmative answer when the ADHD diagnosis is correct. Another hint could be to discover if the child feels that his mind goes “faster” or “slower” with the medication. If a psychostimulant increases the speed of the mind we should question the validity of such diagnosis. Finally, a follow up appointment within 2 weeks and being available by phone to obtain feedback from parents, and listening to the patient, can be the best tools to find the real diagnosis.
NIH Consensus Statement. Volume 16, number 2, November 16-18, 1998
Joseph Biederman, MD, “Childhood Mania, it does Exist and Coexist with ADHD,” American Society of Clinical Psychopharmacology Progress Note, 1995.