Garth O. Vaz, MD
This paper presents Inattentive Learning Disorders (ILD) as a symptom and Attention Deficit and Hyperactivity Disorder (ADHD) without Impulsivity and Hyperactivity also known as Attention Deficit Disorder (ADD), as a diagnosis of exclusion. Conditions such as Absence Seizures (AS), Central Auditory Processing Disorder (CAPD), Childhood Depressive Disorder (CDD), and Obsessive Compulsive Disorder (OCD) are being inadvertently diagnosed as ADHD without Impulsivity and Hyperactivity. This leads to inappropriate administration of the stimulant drugs like Ritalin. When a child presents with inattention we now have a symptom that needs a diagnosis. We should exert every effort possible to rule-out AS, CAPD, CDD, and OCD, prior to arriving at the diagnosis of ADHD with Impulsivity and Hyperactivity. Stimulant drugs only works for ADHD with and without impulsivity and hyperactivity, and should only be prescribed for those conditions.
The child that presents with inattention happens to be one of the most difficult to remediate. First the correct diagnosis has to be determined. Secondly an effective method of remediation needs to be implemented. This paper groups 5 conditions that have inattention as a common symptom, thus, "The Inattentive Learning Disorders (ILD)". Too often, the inattentive child has been administered Ritalin or some form of stimulant drug inappropriately, thinking the child is experiencing inattention due to ADHD without Impulsivity and Hyperactivity. It is the intention of this paper to treat ADHD without Impulsivity and Hyperactivity (IH) as a diagnosis of exclusion, and approaching inattention merely as a symptom in the some manner one would treat a fever or a headache.
In order to arrive at the diagnosis of ADHD without IH 4 conditions need to be ruled out. These are, Obsessive Compulsive Disorder (OCD), Absence Seizure (AS), Central Auditory Processing Disorder (CAPD), and Childhood Depressive Disorder (CDD). The above conditions all present with inattention. The process of arriving at the correct diagnosis requires the employment of a number of disciplines. These include, psychology, neurology, audiology and a speech pathologist. It's the intention of this paper to bring the possible diagnosis of The ILD to the minds of the readers. We will describe each condition, suggest methods of the popular method of diagnosing each condition and recommend therapy for these conditions.
There are a million children in the United States that do present with OCD. The prevalence compares very closely to that of ADHD, the most common psychiatric disorder among children. It is very often missed, due to the sophistication of the victims.
Inattention is present when there is distraction due to obsessive illusions. They usually exhibit reduced performance in tasks that require high cognitive function. The onset is usually gradual, and exhibits its self more pronounced during time of stress or fatigue. It presents with a chronic waxing and waning course, affects male between the age of six and fifteen years of age and female between twenty and twenty-nine years of age.
Symptoms are more pronounced during activities that require increased concentration. Common obsessions include: fairs of contamination, fixation on lucky/unlucky numbers and the need for symmetry. Compulsive rituals include: frequent checking and re-checking; cleansing; touching; questioning and arranging objects in order. Compulsive rituals take different forms, and such behavior will always be recognized as being out of the ordinary.
Older children can be very sophisticated in their efforts to disguise their behavior. Parents have to observe effects such as, increased amount of soap being replaced, rashes on your child's hands, and increased number of useless objects in your child's room.
We will be discussing the typical Absence Seizures. AS accounts for 10% of all seizures among children. There is predominance among female. The condition is easily diagnosed and treated.
Ninety Percent Electroencephalograph (EEG) presents with regular and symmetric generalized discharges of 3-4 hertz spike and slow wave complexes while in the ictal phase. Ictal activity can be precipitated by hyperventilation. There is usually a normal background EEG. Asymmetric and focal waves are also common. AS previously known as Petite Mal Seizures presents with abrupt and brief impairment of consciousness with interruptions of on-going activity. These may last a few to 20 seconds. Neither auras nor post-ictal phase are present. Epileptics usually experience a sensation that cues them in on the fact that they are about to have a seizure. They also become very somnolent after the seizure. These does not occur with AS. Eye closure is the main precipitant. Myoclonic jerks, twitching of an eye, corner of the mouth or other muscles groups can be seen with this condition. Tonic activity leading to drooping of the head, slumping of the trunk, drooping of the arms, relaxation of grips, repulsion of the head or arching of the trunk, are also seen. Automatism includes lip liking, swallowing, fumbling with clothing and other articles or aimless walking is frequently seen. Autonomic component include paler, fleshing, sweating, dilation of pupils vomiting and incontinence can also be present. If the behavior is bazaar think AS.
CAPD presents with difficulty processing auditory in-put in the absence of peripheral auditory acuity deficit. There is also difficulty with sound recognition such as differentiating phonemes and the direction of the source of sounds. Distinguishing needed sounds from non-relevant background stimulus is the main source of difficulty with the condition. These children often occlude external ear canal because of noisy surroundings. They present with inattention seeming to be in different world. They are often mistaken for ADHD without Impulsivity and Hyperactivity and with Impulsivity and Hyperactivity since they usually have a different agenda because of their inability to follow the activities of a classroom. This is responsible for their failure to follow instructions. They are easily distracted and bothered by loud or sudden noises. Noisy environments are usually very upsetting to these children. They seem to be forgetful and very disorganized.
CDD is a diagnosis that parents like the least. They feel that if their child is depressed they are the cause. We do know that suicide secondary to depression ranks one of the leading causes of death among children and adolescents. And, this number has been increasing in recent years.
CDD presents with symptoms similar to those of adult depression. This includes sleep disturbances such as insomnia, hypersomnia, sleep latency, and sleep interruption. Somatic complaints such as headaches, abdominal pain, and chest pain are often seen. The patient also presents with suicidal ideations or suicidal attempts. Signs of CDD include tearfulness, anhedonia, impaired school performances and an excess of time spent alone.
ADHD without IH possesses many characteristics as those seen in CAPD, making the task of differentiating the two a difficult one. The degree of inattention seen in this condition is similar to those seen in the other 4 conditions already mentioned. Since there are no particular tests for this condition, OCD, AS, CAPD and CDD should all be ruled before arriving at the diagnoses of ADHD without IH. Making ADHA without IH a diagnosis of exclusion. This approach will aid in the prevention of inappropriate administration of stimulant drugs.
Symptoms of ADHD without IH need to present prior to age six years old lasting greater than six months. The Diagnostic and Statistical Manual IV (DSM IV) Suggests six or more symptoms of inattention be present before this diagnosis is applied.
These symptoms should be present in 2 or more settings. These include, making careless mistakes, failing to complete tasks, inattentive, easily distractible, difficult adhering to tasks that require sustained concentration, poor organizational skills, looses things frequently, and forgetful in daily activities.
As we can see, many of these symptoms are similar to those that have been assigned to the other 4 conditions.
Common errors include the following: AS being diagnosed as dyslexia, occurs due to pausing for seizures while reading.
A student that walks aimlessly, repeatedly over an area, is a behavior seen in Asperger's Disorder.
The child either sits still during thoughts of obsessive illusions or is often out of their seats while performing their compulsive rituals. CDD often mimics any of the above conditions.
Diagnosing The ILD range from simple observation of the student to high tech strategic methods. Several different disciplines are also required. OCD is one that requires mere observation, gleaning the diagnosis mainly from history, although a physical examination can be contributory, depends on the compulsive rituals. They cleanse frequently, over-anxious over serious illnesses, such as Cancer, tuberculosis, and heart attacks. They argue excessively over what's fair or unfair. Try their best to keep, and make things symmetric and they exhibits excessive doubts. AS on the other hand can be positively diagnosed utilizing an EEG machine during hyperventilation. This machine can identify 90% of the kids with AS. The school nurse also can identify these children with the schoolhouse test. Have the child stand with arms out-stretched breathing excessively while counting their breaths. This will precipitate an ictal phase 90% of the time. CAPD requires the employment of a speech pathologist and or an audiologist. There are sophisticated audiological equipment that are utilized and the skillful technologist is able to identify kids as young as four years of age. CDD can be identified greater than 90% of the time by using The Children's Depressive Inventory (CDI) by Marie Kovacs, P.H.D. published by Multi-Health Systems, Inc. A non-professional can utilize the short form, however, a professional in the field of psychology should administer the full test. The correct technique in diagnosing ADHD without IH is the purpose of this paper. This diagnosis only exists when all four of the other ILD have been ruled out. Keep in mind, however, several of these conditions could co-exist. Intervention should be in place before assessing for ADHD without IH.
Obsessive Compulsive Disorder can be treated using behavior modification. However, certain drugs have been very efficacious in the treatment of this condition. Although, has not been studied in this age group. The Selective Serotonin Reuptake Inhibitors (SSRI's) are the most popular. These include Zoloft, Paxil, and Luvox. Anafranil, a tri-cyclic drug has also been utilized in treating this condition.
Absence Seizures has two medications that have been efficacious in the treatment of the condition. There are others that have been used as supplement. These include Valproaic acid and Ethosuximide.
Central Auditory Processing Disorder presents with technological intervention and behavior modifications. The instructor wears a lapel mike with a transmitter while the student wears a headset or an earphone with a receiver. This technique allows information to reach the student without background contamination. There are also, some suggested behavior modifications that can be very helpful in remediation. Causing the child to look at the speaker while instructions are being given and having the student paraphrase instructions has proven helpful. Eliminate background noises via silencing the environment or utilizing earmuffs and earplugs are useful technique. Encourage the use of tape recorders. The multi-sensory mode of teaching is a must. Teaching should proceed from that which is known, adding new information. Above all, a good self-esteem should be established and maintained in interacting with the child with Central Auditory Processing Disorder.
Childhood Depressive Disorder is more responsive to counseling. However, when counseling has fails the SSRI'S have shown to be very efficacious. There is also a class of medications that is by itself it's an aminoketone. Wellbutrin is the only aminoketone presently on the market that is being used for this purpose.
One should be careful however, that it is not administered to students with seizure disorder since it lowers the threshold for seizures. Tricyclic anti-depressants such as Tofranil and Elavil have also been efficacious, especially in children who have been suffering from enuresis. These drugs can treat both conditions.
Attention Deficit Hyperactivity Disorder without Impulsivity and Hyperactivity have been responsive to low dose stimulant drugs.
In summary, we should be exerting in avoiding the inadvertent administration of stimulant drugs. There are such subtle differences between a number of these conditions making the task of distinction a large one. CDD is a great masquerader and often times co-exist further complicating the diagnostic process. All of the conditions have inattention as a common symptom, but we should avoid the temptation of treating for ADHD without IH too quickly. OCD, AS, CAPD and CDD should be ruled-out before giving the diagnosis of ADHD without Impulsivity and Hyperactivity.
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