Is it Severe ADHD, or is it Asperger's? The Case for a Good Assessment

Charlie is seven years old. He hates school; he has no friends. Charlie is aggressive and angry most of the time, but particularly when his parents set a limit. A pediatric neurologist diagnosed him with Asperger’s syndrome and told the parents that he was an “odd duck.” Charlie was then evaluated in a tertiary care setting (a medical school). They agreed. Charlie was put on Risperdal, an antipsychotic. Charlie got “better” according to the parents, but he still did poorly in school and he still had no friends.

Charlie’s parents were reluctant to pursue educational testing. Not only was the price high, they did not want Charlie to think that his entire life was about going from one medical appointment to another. I understood that, but I said this is the most important step you can take in terms of understanding Charlie’s brain. Reluctantly, the parents agreed. Meanwhile, I explored the family history. Charlie’s dad, Tony, never did well in school either. Now, he works as a fire fighter. Charlie’s mom, Gaby, was a good student, as were her six siblings. I wondered about Charlie’s attention span. Gaby explained to me that “he could never sit on the circle, like the other kids could in preschool. He was always running around.”

The neuropsychological evaluation confirmed my suspicion. Charlie had severe ADHD. He could not focus; he has no frustration tolerance. Hence, he could not engage in a dialogue with other children, so he had no friends. He could not wait his turn in games. He blurted out what he was thinking. He had no ability to inhibit his thoughts, so other kids found him to be a “a bit strange” according to Gaby. I stopped the Risperdal, gave him a stimulant (Concerta), and within days, he was doing his work at school, he was no longer a behavior problem and he was getting along with other children. As Charlie said “that medicine really makes my friends nice to me.”

Social skills are dependent on attention. In order for Charlie to make friends, he has to be able to listen, wait, and think before he speaks. If his ADHD makes it so that he has no control over his brain, he will come across as odd, intrusive, and uncooperative. On the other hand, if he takes a stimulant, he will then be able to ponder his next move and thereby prevent the embarrassing moment of saying something that other kids will laugh about. In other words, he will have a space between thought and action. This space is critical for social success.

Untreated ADHD looks like Asperger’s Disorder. That is a simple, yet often missed, truth. The treatment for ADHD is stimulants. The treatment for Asperger’s Disorder ranges from special education to antipsychotic medication. These are very different paths. Diagnosis is essential. A comprehensive approach to assessment demands that the clinician consider all conditions, factoring in the statistics which reinforce the obvious; common diseases are common. ADHD is one out of twenty kids. Asperger’s is hard to pinpoint, but it is roughly one in a hundred kids. Those numbers alone make it so that ADHD should be a leading contender in the mystery of Charlie’s behavior. Adding on, Charlie has a potential family history of ADHD, as his dad might have it as well. This data, combined with the neuropsychological testing, combined with Charlie’s long history of hyperactivity makes the diagnosis straight-forward.

Charlie’s parents have gone through what so many parents suffer from. Charlie has behavior problems. Who should he see? A pediatrician? A pediatric neurologist? A child psychiatrist? Who should pay? Insurance? Out-of pocket? Should they go to a University for an “expert” opinion? There is no road map for these questions. Parents are understandably confused. Child psychiatrists are the experts at diagnosing behavior problems in children, yet the public does not understand that; pediatricians do not understand that either. Universities can be very helpful, but because the patient sees someone in training, there is variability in quality. Once again, the fault lies in my profession. We have not presented our expertise to the public in such a way that it is clear how we can be helpful. Shame on us for not helping more kids like Charlie. Shame on us for putting families through multiple evaluations with confusing answers.

Child psychiatrists need a public relations firm to announce our skill set. We should use the money from our dues in the American Academy of Child and Adolescent Psychiatry  Association to pay for this public education.  Maybe we can figure out a way to make it happen. For the sake of our “children” we must.