Establishing a differencial diagnosis

Differential diagnosis is the outcome of the process of "determination of which of two or more diseases with similar symptoms is the one from which the patient is suffering, by a systematic comparison and contrasting of the clinical findings"(WebMD).

Establishing a differential diagnosis for an internationally adopted child who may demonstrate several contradictory symptoms at a time is especially difficult due to the unknown developmental history of the child, typically including intensely traumatic events and complete culture and language switch among other causes. In the majority of cases, a differential diagnosis established on the basis of the child's comprehensive and sometime even multidisciplinary assessment is critically important.

Tatyana Elleseff MA CCC-SLP
Differential diagnosis of AD/HD and Auditory Processing Disorders in Internationally Adopted School Age Children

Corinne is an adorable 8 year old girl with an infectious smile, who has been adopted from Russia at the age of 15 months. She sits quietly by the bookshelf; completely absorbed by the book in her lap, while her distraught mother is quietly telling me in the hallway why Corinne has come to visit me today. Corinne has numerous listening difficulties. She is very inattentive and frequently mishears verbal messages. She is very distractible and tends to act impulsively at home and in school. She has trouble organizing her verbal output when speaking and is constantly forgetting what has been told to her, even if it was only moments ago. Corinne has never had a speech and language assessment before, but she does have a documented diagnosis of ADHD, for which she is currently taking medication. The trouble is that this medication does not seem to be helping Corinne one bit. She is just as distractible, impulsive and inattentive as she was before. Not only that, but this is not the first medication or the lowest dosage that Corinne has been taking for her ADHD. According to Corinne’s mother, Corinne’s medications and dosages have been adjusted multiple times by several doctors, but so far it has not really affected anything. Corinne’s parents’ are at their wit’s end! Corinne is desperately struggling with her studies despite working very hard and getting a lot of help at home, but she is doing so poorly - that her school has been hinting very strongly that Corinne ought to be held back in 3rd grade.

Fast forwarding several assessment sessions later, I am not so convinced that ADHD is Corinne’s primary deficit, or even if it’s an appropriate diagnosis for Corinne at all. Testing has revealed that Corinne has a severe language processing difficulty and requires a referral to an audiologist for a comprehensive auditory processing testing battery. Corinne’s mom is bewildered at the news: “But no one has suggested anything like this at all before!”

Sadly, Corinne’s case is far from unique. The incidence and prevalence of AD/HD (the slash is used to denote both subtypes with and without the hyperactivity component) in internationally adopted children is very high and continues to be on the rise.

What further complicates the situation is lack of valid statistical data. At this time there are no reliable statistics to cite! However, parents of internationally adopted children and those professionals who work with this unique population know just how frequently this label is used. AD/HD prevalence in internationally adopted children is so highly alarming that it begs a number of important questions:

Attention Deficit/Hyperactivity Disorder is one of the most commonly diagnosed disorders of childhood. As a speech language pathologist, who works in a pediatric psychiatric hospital setting, I see many children, including a large number of internationally adopted children, who have the diagnosis of AD/HD in conjunction with other comorbidities including psychiatric disorders as well as speech-language and learning deficits.

However, after the initial screening and assessment period when these children are seen by our multidisciplinary team (psychiatrist, psychologist, nurse, occupational and speech therapists, as well as a learning specialist) in a number of cases, the AD/HD diagnosis is ruled out.