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Attention deficit hyperactivity disorder can be hard to diagnose, in part because so many other conditions can produce similar symptoms and your practitioner will want to try to rule them out. To make things even more complicated, it's not uncommon for children to have one or more of them in addition to ADHD. Read through the list below to see what else could be affecting your child's behavior.
Learning disabilities Like ADHD, learning disabilities can cause children to appear inattentive and restless in the classroom and to stall in their academic development. "The key is to determine why the child isn't paying attention: Is it because he's unable to pay attention or because he doesn't understand the material?" says Andrew Adesman, director of developmental and behavioral pediatrics at Schneider Children's Hospital in New Hyde Park, New York. In other words, a child with ADHD will slip behind in school not because he's incapable of learning but because he's too distracted to focus; a child with a learning disability will eventually tune out and possibly misbehave because he can't comprehend the material.
To determine what's going on, an expert will start by asking about a child's behavior outside the classroom. A child with a learning disorder usually doesn't have behavior problems outside of school or prior to being enrolled in school. A child with ADHD, especially one who is hyperactive, will probably have difficulty behaving at home or staying focused in a non-school group setting, like Little League softball. "Also, children with learning disabilities will often have a history of language problems," says Adesman. "They may have been late talkers or had speech problems. And they tend to confuse their prepositions or reverse numbers and letters, like seeing a 6 instead of a 9." To make matters more complicated, about 30 percent of children with ADHD also have a learning disability. If you or your child's teacher suspects him of having a learning disability, the school's psychologist together with a classroom teacher, special education teacher, or administrator should perform an evaluation. A neuropsychologist can also diagnose a learning disability.
Vision or hearing problems If your child can't see well enough to read the words on the chalkboard, he'll naturally start to slip behind in school. Likewise, if he can't see the expression on his teacher's face or hear her well enough, he may seem to be ignoring her. Hearing problems, even minor hearing loss in one ear, can make it hard for your child to hear directions. If your child is having trouble in school, ask your pediatrician about having his vision checked by an optometrist or ophthalmologist who works with children, and his hearing evaluated by a hearing specialist, says Meg Zweiback, a nurse practitioner and family consultant in Oakland, California. All children should be screened for hearing and vision problems before entering kindergarten, anyway. (Many states require this to be done by the public schools.)
Lack of sleep Some researchers have noted similarities in behavior between children who are sleep deprived and those who have ADHD. Kids who aren't getting enough sleep simply can't pay attention as well as they ought to in the classroom. One tip-off that your child may not be getting enough sleep is if he has trouble waking up in the morning. "Chart your child's sleeping pattern for a week or so and then ask your pediatrician whether he thinks he's getting enough shut-eye," says Zweiback.
Stress and anxiety All children cope with some degree of stress, and certain times of the day can be particularly taxing, such as bedtime or everyone's leaving the house in the morning. It's normal for children to become clingy or moody during these times. However, any situation that causes extreme or long-term stress, such as a divorce or the birth of a new baby, can cause a child to withdraw or act hyper. A chaotic home or school environment can also trigger symptoms of stress and anxiety. "Too much outer chaos will breed an inner chaos," says Patricia Quinn, M.D., a pediatrician on the board of the National Attention Deficit Disorder Association. "If there isn't a lot of structure and routine in your child's life, he's likely to feel and act out of control."
Up to 30 percent of children with ADHD have an accompanying anxiety disorder, which can mean excessive worry or preoccupation, extreme shyness, and separation anxiety, as well as episodes of heart pounding, dizziness, sweating, insomnia, and difficulty breathing. If you think your child may be overly anxious, ask your family doctor for a referral to a child psychologist or psychiatrist.
Depression The symptoms of depression in children — moodiness, irritability, and difficulty sleeping and concentrating — may also be noted in children with ADHD. Depression in children is often overlooked because the symptoms are easily confused with signs of normal developmental phases. (This is particularly true of girls). Depression can also be an elusive diagnosis in young children because they can't clearly communicate how they're feeling. If your child has unexplained outbursts of crying or yelling, complains frequently about vague physical pains (such as headaches, stomachaches or fatigue), shows a lack of interest in playing with friends, or engages in reckless behavior, he could be depressed and should be evaluated by a child psychologist or psychiatrist.
Bipolar disorder This mood disorder is quite rare, but it does share some symptoms with ADHD: extreme shifts in mood and energy, sleeplessness, distractibility, and risky or aggressive behavior. If your child has any of these particular symptoms, he should be evaluated by a child psychologist or psychiatrist. Up to 20 percent of children with ADHD may also have bipolar disorder, but putting a bipolar child on stimulants for ADHD may actually exacerbate his symptoms. This is why it's important to get an accurate diagnosis so you and your child's doctor can work on finding an appropriate treatment program.
Tourette syndrome (TS) Children with this neurological disorder may have involuntary tics, such as eye blinks and head movements, (or more rarely, arm thrusting, kicking movements, and jumping), uncontrollable vocalizations, and hyperactive, impulsive behavior similar to the kind that some children with ADHD exhibit. In fact, up to half of all children with TS also have ADHD (but only about 7 percent of kids with ADHD have TS). If your child does have TS, starting him on stimulants for ADHD can occasionally make the tics become more pronounced or may trigger them for the first time. If your pediatrician suspects TS, she'll refer you to a pediatric neurologist who can determine whether your child has one or both disorders.
Petit mal epilepsy This relatively mild form of epilepsy is tricky to spot because the seizures look more like staring spells than the muscle jerking people associate with epileptic episodes. A child with petit mal epilepsy may seem to be dreamy and "out of it" for several seconds at a time, just like some children with ADHD. "The difference is, a child with petit mal seizures will have these staring episodes in all settings — at the dinner table, while watching a video, at school," says Adesman. Kids with ADHD tend to "space out" at school or when they're supposed to be doing homework, but not while watching a favorite video or eating a meal. Petit mal epilepsy is much less common than ADHD, but if your child's doctor suspects it, she can refer you to a pediatric neurologist for an evaluation.
Central auditory processing disorder (CAPD) Children with this rare condition have difficulty processing language and filtering out extraneous background noise. Like children with ADHD, they may have difficulty learning in noisy environments (they tend to tune out when not taught one-on-one), may find it hard to follow directions, and are disorganized and forgetful. CAPD is generally diagnosed by an audiologist (hearing specialist) familiar with the disorder.