ADHD, OCD, or Something Else in My Child?

Reader’s Question

My son is 8 years old. Last year he was diagnosed with ADHD. He was having trouble focusing, relaxing, sleeping and social interactions with other kids at school. He even falsely failed a hearing test at school because he couldn’t focus long enough to raise his hand at the beep. He tends to speak loudly and is easily excited. He has taken Focalin and is now on the Daytrana patch, 20mg. He seems to look a little “out of it” while on either medication, and I have noticed a few changes that are making me question his diagnosis. He’s very ritualistic, needs to know exactly when things will happen (down to the minute). For example, he asked his Dad to watch a movie with him tonight. Now he’s asked 20 times, repeats what time it’s on, what channel it’s on, etc.

If a subject interests him he will Google it and study it until he can repeat the info verbatim. We thought it was great at first — he is very smart — but now we’re thinking it’s more like an obsession. He also pushes chairs in, wipes things off the desk, touches his face repeatedly and repeats himself constantly. Even when he’s in his room alone. Usually I hear him saying…”ok, thank you, sorry”.

We will be telling his doctor these things next week, but I’d like to go to the appointment with a little knowledge about ADHD verses OCD in children. He is the youngest of four, the other kids are 20, 18 and 9. He is also the only boy.

Psychologist’s Reply

The symptoms of ADHD are just that — symptoms. Hyperactivity, distractibility, inability to focus, poor impulse control, etc., are found in several childhood conditions. When we first notice these symptoms it is almost always assumed that ADHD is the reason. In your situation, as in half of ADHD children, there are additional symptoms of concern.

Your son is exhibiting obsessive thoughts and compulsive behaviors. While a diagnosis of OCD is likely, there may be additional issues. Some disorders are found in pairs. For example, ten percent of children with ADHD have Tourette’s Disorder. In children with Tourette’s Disorder, 66 percent have ADHD and 50 percent have OCD features. Some of the options:

• Tourette’s Disorder: OCD features, inability to focus, amd frequent repetitive motor/vocal behaviors that have no purpose (touching his face, repeating himself) are some signs. If he has Tourette’s Disorder, look for motor tics (facial grimaces, head movements, touching, purposeless behavior that has a pattern, etc.), subvocal tics (throat clearing, stomach sounds, clicks, etc.), or vocalized tics (sounds, noises, repetitive comments). Tourette’s and OCD are closely linked and the symptoms you mention are not uncommon in children with this dual diagnosis.
• If your son has Tourette’s Disorder — his current medications will increase/exaggerate his tics and OCD behaviors. While psychostimulants work well for “true” and uncomplicated ADHD, they create significant problems with Tourette’s. If his behaviors increased with the ADHD medications — Tourette’s is a good possibility.
• Another possible diagnosis is Asperger’s Disorder. Compulsive searching and preoccupation with special topics is often found in this situation. Children with AD are preoccupied with sameness and may have motor (physical) behaviors that are odd and purposeless. AS children often have poor social skills.

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In doing your homework before seeing the physician, I’d research Tourette’s Disorder, OCD in Children, ADHD, and Asperger’s Disorder. What is clear from your articulate description is that more than ADHD is present in this case. While most ADHD treatment is provided by pediatricians, they are often not trained in dual diagnosis cases such as ADHD and OCD, Tourette’s and OCD, etc. I would consider consultation with a pediatric neurologist or pediatric psychiatrist. As you’ve noticed, traditional ADHD meds will not work well when two diagnoses are present.