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ADHD or Affective Disorder?
Q: My daughter is 14 years old. I recently had her tested for ADD at the ADHD Research Clinic at Indiana State University, Terre Haute, Indiana. The diagnosis and suggestions that I received baffle me. I am also concerned that I still have not found a way to help my daughter. I was interviewed and supplied information for a parent checklist. My daughter received a diagnostic interview for Children and Adolescents (DICA), an Intermediate Visual and Auditory Test of Attention (IVA), the Kaufman Biref Intelligence Test (K-BIT), the Weschler Individual Achievement Test-Screener (WIAT), and a Children's Checking Test. The information that I supplied indicated the possibility of ADD. The evaluation of my daughter did not. The assessment "suggested the possibility of an affective disorder which may account for problems with inattentiveness". I do not understand what an affective disorder is. I also would like to know if I should pursue testing with an individual who has specific expertise with ADD.
A: It does not sound like the team at the clinic contacted your daughter's teachers, which is surprising, since they spend so much time with her. If no one on the team observed your daughter in school, or at least asked the teachers to fill out ADHD rating scales, then I would say that the assessment was incomplete. Sometimes children do well on all clinic-based measures of attention, but still manifest the symptoms of ADHD in the classroom or in day to day life. (This is particularly true for adolescent girls who are not hyperactive, but who have difficulty focusing and sustaining attention). However, the clinic staff is suggesting that what appears to be inattention is really a symptom of a more serious condition called an affective disorder. Children and adolescents who have this condition have difficulty maintaining a positive mood and a productive way of dealing with life. The most common affective (or more simply, mood) disorders are depression and bipolar disorder (which is characterized by extremes of behavior ranging from excited and enthused to very depressed). Adolescents who are depressed have persistent sadness and/or irritability and a significant loss of interest or pleasure. They also exhibit several of the following symptoms; a sense of worthlessness, sleep disturbances, appetite disturbances, fatigue, either sluggish or agitated movements, suicidal thoughts or attempts, and finally, decreased concentration; which may be what the clinic staff was seeing in your daughter. Children may become seriously depressed for no apparent reason within a short period of time (major depression), or they may have a lower level of chronic depression which can last for over a year (called dysthymia). They may also become depressed in response to something that happens in their environment (for example, breaking up with a boyfriend or when someone close dies). This is called an adjustment disorder with a depressed mood. All of these are affective disorders.
I think you should go back to the clinic and ask them to help you understand why they feel your daughter's problem is not ADHD, but rather an emotional problem. If you are not satisfied, or confused by their answer, then you certainly should get a second opinion. I would suggest talking to a psychopharmacologist (a psychiatrist who specializes in the diagnosis and chemical treatment of emotional problems). Make sure you consult someone who has lots of experience with kids who have ADHD. Your daughter's pediatrician should be able to make a referral.
You should be aware that when teenagers are depressed, they commonly have difficulty focusing on schoolwork. When kids feel better emotionally, they can think more clearly and pay attention more easily. Depression in most children (and adults) can be effectively treated with a combination of therapy and medication, which the clinic may have recommended. This may have been hard news to hear, especially when you went in asking about ADHD. However, a treatment team is doing a good job when they consider all of the possible reasons for an attention problem. If you take your child to someone who only specializes in ADHD (e.g., a special educator), he or she may lack the expertise to diagnose depression.
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Jerome (Jerry) Schultz is the founding clinical director of the Learning Lab @ Lesley University, a program that provides assessment, tutoring, and case management services for children with learning challenges. Schultz holds a Ph.D. from Boston College, and has completed postdoctoral fellowships in both clinical psychology and pediatric neuropsychology.