When It's Not ADHD, What Is It, A Zebra?   Frank Barnhill M.D.
 

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Many diseases can masquerade as ADHD and many a doctor has made the diagnosis of ADHD without looking for these other Zebras. (A zebra is a horse hiding in tall grass that can’t be seen well because his stripes blend in with the background!) Zebras can be very easy to miss and the consequences can be terrible if a child is diagnosed with a behavioral disorder, yet has a more life-threatening problem.

Let’s take a look at a few zebras that can be mistaking for ADHD. One point I need to over emphasize is that all zebras can occur along with ADHD or behavioral problems and you won’t be able to get a good diagnosis before the Zebra is properly treated.
  1. Thyroid disease. I’ve seen many girls, who were diagnosed as ADHD without hyperactivity, because they daydreamed in class, were very shy and seemed too sleepy to pay attention. Fortunately, we found the hypothyroidism (low thyroid hormone) before it affected their growth and puberty. Within weeks, parents and teachers could see a big difference in energy levels, attention spans and of course grades. Likewise, I seen boys who were so hyperactive they disrupted the classroom and home-life so much that everyone wanted to get away from them. Some were hyperthyroid (high thyroid hormone levels) and responded within one month of treatment. These kids usually became very good students and rarely continued to cause problems at school and home.
  2. Anemia. Low hemoglobin or the oxygen (provides energy burning capability) carrying part of your blood can cause fatigue, irritability, mood swings, and of course the poor attention span that goes with these symptoms. One should be careful to supplement iron in the diets of kids who are on a vegetarian diet or avoid milk products.
  3. Hypoglycemia. A low blood sugar in a kid looks and acts just like one in an adult! Sometimes the symptoms of fatigue, lethargy and poor concentration are even more pronounced. Unfortunately, this Zebra goes undiagnosed a lot in kids, because they will bounce back fast and lead parents to believe they were just being lazy. I have several insulin requiring diabetics who were labeled ADHD when indeed it was just hypoglycemic episodes too mild to cause insulin reactions. How well do you process information and think clearly when your blood sugar is “low”?
  4. Diabetes mellitus. When your blood sugar is high, you will be on edge and others will perceive you as hyper. Sometimes ADHD can be “cured” by starting a diet, Insulin or other blood sugar lowering medicines. I’m sure you remember how wound up your kids can get on a heavy sugar load.
  5. Seizure disorders. This is a new topic in behavioral science. Some children labeled ADHD with or without hyperactivity actually suffer from mild seizures. Petit mal seizures (call absence seizures or staring episodes) can appear to be inattentive or spacey when they occur many times an hour. If the child becomes confused or scared, then periods of hyperactivity may follow. If you or any other member of your family has seizures, then you should have your ADHDer tested.
  6. Post concussion syndrome. Mild cases of trauma to the brain that leave no physical evidence of having occurred can lead to symptoms of ADHD. It is felt that brain cell pathways may have been damaged leaving the child poorly able to utilize higher brain cognitive and executive level thought processing abilities. When a child can’t interpret his or her sensory input properly, confusion and frustration may lead to hyperactive states. PET (Positive Emissions Tomography) scans of the brain are used to identify these “damaged” areas.
  7. Effects of other drugs. Prescription, over the counter, and legal-illegal. Many drugs, both over-the-counter and prescription can cause symptoms that mimic ADHD. For example pseudoephedrine found in cold and cough medicines can cause irritability, difficulty sleeping, inability to focus and concentrate and the appearance of being “hyper”. Some kids become hyper from smoking too many cigarettes. After all, nicotine and caffeine are first cousins. Cocaine use can cause mood swings, inability to concentrate or remain on task and states of agitation. Some kids actually self-medicate with amphetamines or speed to slow themselves down. Stimulants used to treat ADHD, such as Ritalin, are a form of amphetamine. See “Treatment Options For the ADHDer” for a discussion of stimulants.
  8. Effects of certain foods. Everyone knows how ‘hyper” kids get when fed a lot of sugar. But, have you ever thought about too much caffeine causing hyperactive states? Each and every child has a different metabolism. So some tolerate large amounts of sugar and caffeine without becoming hyper, while others can consume little of these stimulants and start bouncing off the walls.
  9. Depression. Mild forms of depression can cause irritability, attitude problems and poor concentration. Other symptoms may include sleepiness, insomnia, appetite changes, crying, and lack of energy and poor self-esteem. All of these can mistakenly lead to a wrong ADHD diagnosis.
  10. Manic depression. This disease is called the “rollercoaster of life” because one day the affected person will be on the highs of life and maybe the next day or two, will be on the lows. These people have wild mood swings and if not treated will disrupt classrooms, home life and workplaces.
  11. Anxiety, GAD. Anxious kids are almost always hyper in one way or another. It appears that Generalized Anxiety Disorder (GAD) is very common in young ADHD children and girls with ADHD without hyperactivity. If the anxiety isn’t treated with ADHD, then therapy is likely to fail.
  12. Mild psychosis. Most parents are surprised to discover that children can hallucinate. Usually, these problems have a sudden onset after a very stressful event in the family, such as a death, divorce or insecurity associated with a parent’s job loss and feelings of impending doom. There are cases where day terrors and night terrors occur very slowly and simply disrupt the child’s sleep pattern making them very moody. Teachers feel these children aren’t paying attention in class because they are always spacey.
  13. Sleep apnea is a condition where a person stops breathing multiple times during the night. It requires special diagnosis and treatment since it can lead to the same problems as psychosis. It has been associated with night terrors as a child (or even an adult) may awaken abruptly with a feeling of choking, drowning or being suffocated.
  14. Other Hormone problems such as Addison’s disease and Cushing’s disease can cause ADHD like symptoms. Thyroid and insulin related diseases are not the only endocrine disorders that can cause symptoms that “look” or “act” like ADHD. The adrenal gland sits on top of the kidneys and is responsible for everything from regulation of energy to how stable blood sugars remain after running the two-minute mile. When these disorders are present, a kid can have symptoms almost identical to ADHD, such as fatigue, restlessness, poor concentration, changes in weight, and mood swings. Your doctor would have to screen for these diseases with special blood tests based on findings from a good examination.
  15. Lead poisoning. Hopefully, your child has never been exposed to lead from paint or any other source. Lead damages bone marrows ability to make red blood cells, resulting in a terrible anemia. These kids can be lethargic and have weird hallucinations. Some can have seizures and eventual kidney failure.
  16. Inhalation poisoning. Inhalants such as permanent markers, airplane model glue, paint, fingernail polish and other solvents can cause wild mood swings, periods of intense hyperactivity, irritability and irrational combativeness and defiance. Kids who abuse inhalants may also suffer from paranoia, seizures, and hallucinations. When they’re just using a little, their symptoms will be mild and mimic many other conditions including ADHD.
  17. Malnutrition including multiple vitamin deficiencies. No child can adequately focus and concentrate when hungry. With prolonged periods of forced fasting, kids become tired, irritable, and unable to process visual-auditory-tactile sensory input correctly. In addition, vitamin B12 deficiency can cause fatigue, wasting and depression.
  18. Vision and hearing problems. It is sort of obvious that a child who can’t see or hear well will have problems integrating sensory input from his or her environment. It’s always surprised me how often parents and doctors fail to have these important aspects of learning assessed.
  19. Visual-tactile-auditory integration problems. These are very specialized problems that affect a child or adults ability to interact with one or more aspects of his sensory environment. Some children learn best when they hear and see what they are supposed to learn simultaneously. That’s why we advocate use of tape recorders for recording classroom lectures so the child can listen while reading later. Sometimes, students must touch and listen at the same time. This is the way most surgeons learn to operate.
  20. Other learning disabilities. These include minimal brain damages from birth trauma and low oxygen levels at birth. A child’s IQ may actually be affected in these circumstances and special training is usually indicated. They tend to have a variety of auditory-visual and sometimes tactile problems. These integration difficulties should be thoroughly assessed to provide a game plan for learning success specific to that child.

I trust this will give everyone an over-view of the complexity involved in making a diagnosis of ADHD. Remember, ADHD is a diagnosis of first exclusion as pertains to these “Zebras” and inclusion as it applies to matching the signs and symptoms with those required to make the diagnosis.
Good Luck!
Dr. Frank


These health tips are offered for your common sense use and are not intended to take the place of a visit to your doctor.  Your use of the materials implies your understanding that nothing herein contained represents individual medical advice.

drhuggiebear, drhuggiebear.com and contained materials are the copyrighted and/or registered properties of Frank Barnhill, M.D. and may not be reproduced for profit without the express written permission of the author.  All materials may be photocopied in whole for educational use.  For information please contact us at drfrank@drhuggiebear.com.

 
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