Some ADHD diagnoses are more difficult to make than others. Because many disorders "look like" ADHD, it is not always easy to determine whether the hyperactivity and/or inattention and/or impulsivity is caused by ADHD or another condition.
Thirty to 50 percent of individuals with ADHD also have a learning disability, difficulty regulating emotions (anxiety disorder, depression), anger, obsessive-compulsive disorder), and/or a tic disorder. It is essential to identify each problem and treat it appropriately.
Here is what you need to know about obsessive-compulsive disorder and its symptoms in order to differentiate the two.
Franklin's OCD Story
Franklin’s symptoms highlight the diagnostic difficulties of discerning between OCD and ADHD.
I consulted with the 15-year-old and his parents when he was in tenth grade. Franklin couldn’t stay on task and fidgeted in class, and while doing homework. At a recent school meeting, a teacher suggested that Franklin may have ADHD. Franklin’s parents had him examined by his family doctor, who started him on a trial of methylphenidate. His problems got worse.
When Franklin visited with me, I discovered that his teachers and doctors had never asked him why he acted the way he did. He told me that he could not stop his behaviors.
"I can’t start schoolwork until everything is in its place," he said. He told me that his pen had to be at the top of, and parallel with, the desktop. The paper he wrote on had to be positioned at a 45-degree angle. He stacked books only on the right corner of his desk. He "had to" do these tasks.
"Sometimes it takes so long to get everything where I need it to be that I run out of time," he said.
When he writes, each letter and word has to be formed perfectly. If it isn’t, he erases it and writes it again -- and again. Sometimes the paper tears, and he has to start over. "Doing schoolwork in class or at home is exhausting," Franklin said.
He went on to describe another frustration when he did homework. "I keep wondering whether I locked the front door before coming upstairs. I have to go down and see that it is locked -- even if I know that I already checked." Franklin told me that these behaviors started in fourth grade. He managed them well until high school, when written work started to overwhelm him.
Franklin's OCD Diagnosis
Even though the minutes from his teachers’ conference strongly suggested that he had ADHD, I was fairly certain he had obsessive-compulsive disorder (OCD), a neurologically based disorder that causes anxiety.
Classroom teachers often interpret inattention and poor classroom performance as ADHD. Many teachers are familiar with the symptoms, but they may not know that a diagnosis requires that the observed behaviors be chronic and pervasive. Franklin’s behaviors were first noticed in middle school, and they occurred only when doing written work in class or homework.
When I met with Franklin and his parents to discuss my impressions, his mother was surprised. His father smiled and admitted that he had some of the same symptoms. I explained that the stimulant medication Franklin was taking for his misdiagnosed ADHD could make his OCD symptoms worse. I took him off the stimulant and put him on a selective serotonin reuptake inhibitor (SSRI). I also recommended that he see a cognitive behavioral therapist.
What to Know About OCD
OCD is a neurologically based disorder characterized by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (compulsions) that the child realizes are senseless. OCD may start at age five or six, sometimes even earlier. OCD results from a deficiency of a neurotransmitter, serotonin, in specific areas of the brain. (New research suggests that the more severe forms of the condition, in which obsessive thoughts “lock” and cannot be relieved, involve more than a neurotransmitter shortfall.) OCD is treated with an SSRI, which increases serotonin levels in the brain.
Obsessions can take many forms: repetitive words, thoughts, fears, memories, pictures. Compulsive behaviors, such as hand-washing, counting, checking, or cleaning, are performed in hope of preventing obsessive thoughts or making them go away. Obsessions and compulsions are often viewed as being unnecessary, but they can’t be stopped. Although doing these “rituals” provides only temporary relief, not doing them dramatically increases anxiety.
ADD/ADHD and OCD
It is not uncommon for someone to have both ADHD and OCD. Since the presenting behaviors might look the same, it is important to know whether both problems exist.
For reasons that are not known, stimulant medications may exacerbate an existing case of OCD. Or, if the OCD behaviors are minimal and not obvious to parents, a stimulant may make them clinically apparent. The first clue that someone has ADHD and OCD -- or may have OCD rather than ADHD -- is a significant increase in OCD behaviors after taking a stimulant medication.
If you or your child has both conditions, it is best to treat the OCD first. Once these behaviors are under control, the stimulant can often be reintroduced without causing a flare-up of the OCD behaviors. If you think that your son or daughter may have ADHD and OCD, see a professional who understands the concept of treating someone with more than one disorder.
Common OCD Obsessions
The most frequent worries in children and adolescents are about picking up germs and becoming sick or dying, or about getting sick and throwing up. Other fears include: If I don’t act/do a specific behavior, I will lose someone’s love; I will fail a test; God may punish me; a natural disaster will occur.
Common OCD Compulsions
Counting or repeating: the need to touch something a certain number of times; the need to repeat a specific behavior or pattern of behaviors
Checking or questioning: the need to check and recheck something (e.g., whether the stove is off, the car keys are on the key rack, the closet light is off)
Arranging and organizing: the need to tie shoes or to dress or undress in a certain sequence; the need to organize toys, dolls, or other items in a certain way; becoming upset if anything is changed
Collecting or hoarding: saving books, magazines, ticket stubs, birthday cards, or other items in the belief that they are important and cannot be thrown away
Cleaning and/or washing: the need to lather and rinse an exact number of times in the shower or to brush one’s hair a certain number of times in a pattern
“Preening”: behaviors that “must be done,” even if the result is discomfort or pain. Examples are nail or cuticle biting, picking at sores or scabs, twirling or pulling hair, eye-brows, or eyelashes, “cleaning off” dry skin.
More About Conditions Related to ADD/ADHD
Is It Anxiety or ADD/ADHD?
Is It Asperger's Syndrome or ADD/ADHD?
Is It Auditory Processing Disorder (APD) or ADD/ADHD?
Is It Autism or ADD/ADHD?
Is It Bipolar Disorder or ADD/ADHD?
Is It Depression or ADD/ADHD?
Is It Executive Function Disorder (EFD) or ADD/ADHD?
Is It a Learning Disability or Inattentive ADD/ADHD?
Is It Oppositional Defiant Disorder (ODD) or ADD/ADHD?
Is It Sensory Processing Disorder (SPD) or ADD/ADHD?
This article appears in the Fall 2009 issue of ADDitude.
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To discuss ADHD and Obsessive Compulsive Disorder with others, visit the OCD and ADHD support group on ADDConnect.