Differential Diagnoses Worksheets

Diagnoses matter. As indicated in the table on the following page, most common child psychiatric diagnoses have numerous overlapping symptoms. As the treatment implications of the different diagnoses vary significantly, careful differential diagnosis is essential. For example, the symptom of inattention is associated with the diagnoses Attention Deficit Hyperactivity Disorder (ADHD), Major Depression (MDD), Bipolar Disorder, and Posttraumatic Stress Disorder (PTSD). However, as indicated in the table below, each of these diagnoses are associated with different recommended clinical interventions. The last page of this document includes probes to elicit information which will help to facilitate differential diagnoses, including information about: 1) the episodic or chronic nature of symptoms; 2) patterning of symptoms with other symptoms; and 3) context (e.g., home vs. school) where the symptoms are most problematic. The screen interview of the KSADS-COMP and probes which are built into the instrument are designed to facilitate differential diagnoses. For example, if a child has longstanding inattention problems associated with ADHD, and a new onset of depression symptoms, a question will automatically be included in the KSADS-COMP interview depression supplement to determine if concentration problems got worse with the onset of mood problems. If there was no worsening of longstanding concentration problems with the onset of mood difficulties, the symptom is not counted toward the diagnosis of MDD.

Diagnosis Recommended Treatments ADHD Stimulant treatment, parent training, teacher consultation, social skills training MDD Antidepressants, Cognitive Behavior Therapy, Interpersonal Psychotherapy, Behavioral Activation Bipolar Mood stabilizer, Multifamily Psychoeducation Group PTSD Trauma-focused therapy, safety planning

Mania Major Depression Attention Deficit Disorder Oppositional Defiant Disorder PTSD

Distinct period of Meets criteria for: Meets criteria for at least 6 Meets criteria for 4 symptoms Criterion A trauma plus: Abnormally Elevated, Inattention symptoms: Depressed Mood Expansive or Irritable/ Loses temper One Re-Experiencing item: Irritable Mood, or Irritable Mood and Makes Careless Mistakes Argues a lot with adults increased goal directed Anhedonia Difficulty Sustaining Disobeys rules One Avoidance items: activity Plus 4 symptoms Attention Easily annoyed or angered Doesn't Listen Plus 3 symptoms Angry or resentful Two of the following: Worthlessness/Guilt Difficulty Following Spiteful or vindictive Inability to recall aspects of (four if mood is only Sleep Disturbances/ Instructions Annoys people on purpose the traumatic event(s); irritable) Insomnia Difficulty Organizing Tasks Persistent and exaggerated Fatigue Blames others for own Avoids Tasks Requiring negative beliefs and Grandiosity Concentration Disturbance mistakes

Sleep Disturbance/ Appetite/ Weight Changes Attention expectations (e.g., I am Psychomotor Agitation or bad, the world is unsafe); Decreased Need for Sleep Loses Things Duration: Minimum of 6 Psychomotor Retardation Distorted cognitions about Easily Distracted months Pressured Speech Recurrent Thoughts of causes or consequences of Forgetful in Daily Activities Racing Thoughts Death/Suicidality the traumatic event (e.g. Distractibility blame self);

Psychomotor Agitation or OR Persistent negative emotional Increased Goal Directed Duration: Minimum of 2 states (e.g., anger, fear, guilt, Activity weeks Meets Criteria for at least 6 of shame) Excessive Involvement in the hyperactivity/ impulsivity Anhedonia High-Risk Activities symptoms: Feelings of detachment; Persistent inability to experience positive Psychomotor agitation/ emotions (e.love,) Duration: At least one Fidget week (or any duration if Driven by a Motor Two Increased Arousal items: hospitalized). Difficulty Remaining Seated Irritability Runs or Climbs Excessively Reckless or Self-Destructive Difficulty Playing Quietly Behavior Talks Excessively Hypervigilance Blurts Out Answers Exaggerated Startle Difficulty Waiting Turn Difficulty Concentrating Often interrupts or intrudes Sleep disturbance/Insomnia

Duration: Minimum of 6 months Duration: Minimum of 1 month Mania Major Depression Attention Deficit Disorder Oppositional Defiant Posttraumatic Stress Disorder Disorder Presence of some symptoms Manic children often present For the diagnosis of ADD and Avoidance is a core feature of uniquely associated with ADHD, the symptoms must Presence of some symptoms PTSD. Children do not like to with severe irritability or depression: have had an onset prior to age uniquely associated with talk about past traumas. It is mixed states. 12. If the ADHD-like ODD: therefore imperative that Depressed Mood symptoms were not present in multiple sources be tapped to Appetite/Weight Changes Presence of some symptoms grade school to some extent, obtain a complete trauma Psychomotor Retardation Resentful uniquely associated with they likely represent history of children prior to Recurrent Thoughts of Spiteful or Vindictive mania: manifestations of another surveying PTSD symptoms Death/Suicidality Annoys People on Purpose disorder. (e.g. parents, workers). Blames others for own Abnormally Elevated or mistakes Expansive Mood If child had pre-existing Many of the symptoms of PTSD overlap with MDD (e.g., Grandiosity ADHD with history of ADD/ADHD symptoms are irritability, guilt, anhedonia, concentration disturbances relatively chronic through Decreased Need for Sleep and psychomotor agitation, concentration disturbance, early childhood. If the Exhibits a disregard for there should have been a insomnia), ADHD (e.g., worsening of these long- symptoms wax and wane rules. While manic symptoms may significantly, alternate concentration disturbances), standing difficulties if these mania (e.g., concentration appear prior to the age of 7/12, symptoms are to also be diagnoses (e.g. mania, disturbance, recklessness, they most frequently emerge counted toward a diagnosis depression) later in development. The of MDD. Relatively chronic presence irritability), and ODD (e.g., should be considered. new onset of ADHD-like of symptoms. The waxing irritability). The presence of a symptoms in adolescence and waning of symptoms complete trauma history is should raise concerns of should raise red flags about essential for making the MDD cannot be diagnosed differential diagnosis. bipolar or another disorder. without a direct assessment ADD and ADHD symptoms other possible diagnoses. of the child. Parents are appear worse in school and often poor informants of The diagnosis of PTSD requires The development of psychotic unstructured settings than at depressive symptoms. the presence of re-experiencing symptoms in response to home. They may be Symptoms must be present symptoms. Nightmares need stimulant treatment or mania across settings. Typically completely absent in highly not be trauma specific to count with antidepressant treatment symptoms are worse in the Self-report questionnaires structured one-on-one testing toward the diagnosis of PTSD is considered by some a red home environment. are an important adjunct to situations. flag for mania. in children. the clinical interview when assessing depressive symptoms in general, and The presence of trauma-related Manic symptoms are most If the symptoms are severe suicidality in particular. Teachers are critical hallucinations can further often more severe in the home at home and completely complicate this diagnosis. setting. For diagnosis, some informants in finalizing an absent at school, rule-out Trauma-related hallucinations evidence of symptoms should ADD/ADHD diagnosis and are associated with dissociative be present across settings. in monitoring treatment parent-child relationship response. problem(s). symptoms (e.g. trance-like states) and are frequently Manic symptoms must occur nocturnal. Children with within the context of distinct PTSD and trauma related episodes not as part of a hallucinations usually have chronic course of illness. good social relatedness and no They should represent a formal thought disorder. change from baseline.