Overlapping Diagnoses in Children

Here's the link to the original document

Overlapping Behavioral Characteristics Chart
I thought this was a very interesting chart of the overlapping characteristics of the different diagnoses. We see a lot of overlap in behavioral characteristics in our children who have multiple diagnoses. 

{This chart was designed by a group with an FASD background, which is fine, and I agree that kids with FASD usually have all of those characteristics. I just disagree with the fact that they don't also have RAD checked off on most of the characteristics. I realize that how RAD affects children is different and that they may not check things off if the child only acts that way with certain adults (meaning family), but NONE of these were checked for RAD?!!! }

Multiple Diagnoses in Children

Comorbidity
Children with trauma issues usually have more going on than just one issue - attachment disorders, physical and sexual abuse, PTSD, RAD, bipolar disorder, ADHD, FAS/FAE...

Caseworkers will not or cannot tell you all of what caused these issues, and often symptoms overlap and appear to be other things. For example, I don't think I've ever heard of a child with RAD who didn't also have Complex PTSD. 

The simultaneous presence of two (or more) chronic illnesses or conditions in a patient.

"Comorbidity does not mean the simple addition of two illnesses that independently follow their usual trajectories. The simultaneous presence of two or more diseases will worsen the prognosis of all the diseases that are present, lead to an increasing number (and severity) of complications, and make the treatment of all of them more difficult and, possibly, less efficacious.

What is worse is that [at least] one of the comorbid illnesses is often overlooked. This is particularly true for mental illnesses which are frequently comorbid with physical illnesses. Non-psychiatric specialists and general practitioners are usually focused on the illness about which they know a great deal and which they wish to treat, often missing or underestimating the importance of mental disorders that might also be present."  

~ Comorbidity of Mental and Physical Diseases: A Main Challenge For Medicine of The 21st Century

Multiple diagnoses in children frequently lead to overwhelming frustration and a lack of services/ accommodations. The child's "Care Team" - medical and mental health providers, education professionals, therapists, case managers, parents' supports... each tends to focus on the area(s) where they have experience and training -frequently not understanding the child's other diagnoses and, more importantly, how those diagnoses interreact with each other. 

Each diagnosis not only has its own associated behaviors and behaviors that may overlap with the child's other diagnoses but the behaviors and symptoms frequently interreact and intensify minor or more serious issues exponentially.

For example, Kitty has many diagnoses - ADHD, C-PTSD, Cerebral Dysrhythmia (brain injury/ damage), well below average IQ (low average verbal IQ, well below average memory, lower extreme range processing speed), bipolar disorder, GAD, FASD, BPD, emotional/ developmental age approximately 10 years below her physical age... 

Most people on her "care team" recognize and/or have experience with only 2 or 3 of these diagnoses/ behaviors/ symptoms. They have no understanding of how her different diagnoses interreact with each other or how that interaction can change on a minute-by-minute basis based on what all is going on {Spoon Theory}.  They see my friendly child who "presents well"  and make assumptions as to what she needs and is capable of. (They also tend to assume I am an overemotional, overbearing parent with Munchausen by proxy).

{Unfortunately, many people in a child's life believe that telling a child the truth about his or her abilities and skills will damage his/her self-esteem. Personally, I believe that if you tell a child that he/she can do and/or be anything he wants to be and then the child fails, then the child assumes that the failure is his or her fault. {Dream Killer} 

I think children need encouragement to find the things that they enjoy but be gently directed away from unrealistic goals. A blind child who wants to be an artist might be guided away from watercolors and instead encouraged to become an amazing Sculptor or discover an interest in becoming an engineer.]

Like Attracts Like

One theory that explains why so many children have multiple diagnoses. People with mental illnesses are usually attracted to those who "get" them (meaning they understand and sympathize with the mentally ill person's issues - usually because they have personally experienced it. Kleenex Girls). 

People with issues are attracted to people with issues - creating babies with issues.

People with "issues" don't always make the best choices - which can lead to abused/ neglected children with genetic predispositions toward mental illnesses, who may have been "pickled in toxic soup" in utero (alcohol/ drugs/ adrenaline and anxiety hormones...). The combination of genetics and environment often leads to these children ending up in foster care.

People feel most comfortable with situations and people we know. My kids spend an inordinate amount of time trying to recreate the chaos they grew up with because those are the conditions they understand and know how to operate under. They know what to expect (even though that's usually abuse and more chaos)

DIAGNOSES

RAD and Trauma
I don’t believe the Overlapping Behavioral Characteristics Chart is entirely accurate (for example, it doesn’t include “Difficulty seeing cause & effect “ as a symptom of Reactive Attachment Disorder (RAD) when it most definitely is a very common one (Infants learn cause and effect from their primary caregiver. RAD is caused by the absence of the primary caregiver – whether emotionally or physically. Therefore most texts list this as a common symptom of RAD). 

I suppose it does depend on at what age the child developed RAD. For example, if the child was as an infant and the primary caregiver did not react consistently when the child cried (such as sometimes feeding the child or changing the child's diaper, sometimes ignoring the child, and sometimes beating him or her), then the child might not have learned "cause and effect." Whereas if the trauma began later then hopefully that stage would already be successfully completed. (Katharine Leslie Seminar - Infant Development)

Reactive Attachment Disorder Behavior Characteristics

• acts cute or charms others to get others to do what my child wants.
• often does not make eye contact when adults want to make eye contact with my child.
• overly friendly with strangers.
•  pushes me away or becomes stiff when I try to hug- unless my child wants something from me.
• argues for long periods of time about ev.ry.thing., often about ridiculous things.
• has a tremendous need to have control over everything, becoming very upset if things don't go my child's way.
• acts amazingly innocent or pretends that things aren't that bad when caught doing something wrong.
• does very dangerous things, ignoring that my child may be hurt.
• deliberately breaks or ruins things.
• doesn't seem to feel age-appropriate guilt when my child does something wrong.
• teases, hurts, or is cruel to other children.
• seems unable to stop from doing things on impulse.
• steals or shows up with things that belong to others with unusual or suspicious reasons for how my child got these things.
• demands things, instead of asking for them.
• doesn't seem to learn from mistakes and misbehavior (no matter what the consequence, the child continues the behavior).
• tries to get sympathy from others by telling them that I abuse, don't feed, or don't provide the basic life necessities.
• "shakes off" pain when hurt, refusing to let anyone provide comfort.
• likes to sneak things without permission, even though my child could have had these things if my child had asked.
• lies, often about obvious or ridiculous things, or when it would have been easier to tell the truth.
• very bossy with other children and adults.
• hoards or sneaks food, or has other unusual eating habits (eats paper, raw flour, baker's chocolate, etc. )
• can't keep friends for more than a week or so.
• throws temper tantrums that last for hours.
• chatters non-stop, repeatedly asks questions over and over about things that make no sense, mutters, or is hard to understand when talking.
• accident-prone (gets hurt a lot), or complains a lot about every little ache and pain (needs constant bandaids). (Even though he/she may not complain about serious injuries or illnesses) {Psychosomatic "Illnesses"}
• teases, hurts, or is cruel to animals.
• doesn't do as well in school as my child could with even a little more effort.
• sets fires or is preoccupied with fire.
• prefers to watch violent cartoons and/or TV shows or horror movies 
• was abused/neglected during the first two years of life or had several changes of the primary caretaker during the first several years of life. (This can include multiple or extended hospitalizations)
• was in an orphanage. 
• was adopted  (It is possible to have RAD even if the child was adopted at birth - if the child was "pickled" in utero with drugs, alcohol, and/or stress hormones...).

Triggered Behavior Characteristics
A child whose past trauma is triggered will likely exhibit several behavior characteristics/ symptoms/ signs at one time, and they may be even more exaggerated than usual.  Kids can be triggered by sights (violent TV shows, for example), smells (fried potatoes), sounds (a full laundry basket falling to the ground, a siren, a fire alarm at school, or a loud/sharp yell), and sensory feelings (a certain touch, a particular fabric, cold weather).   They can also be triggered by "traumaversaries" - anniversaries of significant events (like entering foster care), birthdays, and holidays. {Holidays, Birthdays, and Other Traumaversaries}


ADHD
ADD/ ADHD Behavior Characteristics

• Easily distracted by extraneous stimuli 
• Often does not follow through on instructions
• Often interrupts/intrudes 
• Often engages in activities without considering possible consequences 
• Often has difficulty organizing tasks & activities 
• No impulse controls
• Might act hyperactive (constantly active and sometimes disruptive behavior )
• Emotionally volatile, often exhibit wide mood swings
• Depression/ anxiety develops, often in teen years
• Over/under-responsive to stimuli 
• Difficulty initiating, following through
• Manage time poorly/lack of comprehension of time 
• Often blames others for his or her mistakes 

Stimulant Medications and the "ADHD Brain"
I've always wondered why giving a kid with ADHD the equivalent of speed seems to calm them down when it makes everyone else so hyper. Katharine explains it in terms I think I understand.

ADHD increases a person's impulsivity and causes them to hyperfocus on everything. Our frontal lobe normally is supposed to be saying, "Stop that!" It controls our actions. When we take speed it speeds up the frontal lobe so that it catches up to the "ADHD brain" and can think before it acts! 

Meds aren't slowing kids with ADHD down.

They're speeding up the rest of the brain.

Stimulant ADHD Medication vs Non-Stimulants 
Unfortunately, my children can't take stimulant medications because they cause major side-effects. Both my children have bipolar disorder and stimulant medications can trigger mania. My personal opinion is that non-stimulant ADHD meds don't work as well but they're better than nothing. 




PTSD or ADHD or Both?

We saw a lot of overlap in behavioral characteristics especially between ADD/ADHD and PTSD.  

When Kitty first came to us (at age 11), she showed signs of extreme ADHD (she was diagnosed at age 4).  She couldn't sit still for more than a few minutes.  Meals were torture for all of us if we insisted that she stay through the whole meal.  We assumed it was because her ADHD was unmedicated, and quickly had her put on medication.  Her academic skills improved greatly (went from a 2nd-grade level work to testing at a 4th-grade level almost immediately).  

Kitty's behavior at other times (especially dinner time) didn't improve much, but we blamed that on other things (meds wore off by evening, ADHD meds tend to kill the appetite, she wasn't used to sitting at the table and having conversations...).

PTSD often causes issues with hypervigilance (very similar to the hyperfocus you see in ADD/ ADHD) and when you're feeling like you're living in a "war zone," you have a lot of trouble focusing and using other executive functions.  In other words, most of the symptoms of ADD/ADHD.  

Both my children had QEEG testing which determined that they do have ADD (Bear) and ADHD (Kitty), but they also both have Complex PTSD and it wasn't until there was some improvement with their trauma and attachment issues that we began to see more of the "ADHD" symptoms lessening.

3 Main Symptoms of PTSD

1. Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares.
2. Avoidance of places, people, and activities that are reminders of the trauma, and emotional numbness.
3. Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.

Some examples of PTSD symptoms in Children

• irritable, angry, or aggressive behavior, including extreme temper tantrums
• hypervigilance
• exaggerated startle response
• problems with concentration
• difficulty falling or staying asleep or restless sleep

Bipolar Disorder in Children
When children develop bipolar disorder, it is usually called early-onset bipolar disorder (or Mood Disorder NOS because many medical professionals won't diagnose bipolar disorder in young children). Trauma has been known to trigger early-onset bipolar disorder in children that have a genetic predisposition to it.

Early-onset bipolar can be more severe than bipolar disorder in older teens and adults. Young people with bipolar disorder may exhibit symptoms more often and switch moods more frequently than adults with the illness. 


Bipolar mania, hypomania, and depression are symptoms of bipolar disorder. The dramatic mood changes of bipolar disorder do not follow a set pattern -- depression does not always follow mania. A person may experience the same mood state several times -- for weeks, months, even years at a time -- before suddenly having the opposite mood. Moods can rapid cycle too - minutes, hours. Also, the severity of mood phases can differ from person to person.

Child Mania Rating Scale - 

• periods of feeling super happy for hours or days at a time, extremely wound up and excited, such as feeling "on top of the world"
• feel irritable, cranky, or mad for hours or days at a time
• think that he or she can be anything or do anything  (e.g., leader, best basketball player, rap singer, millionaire, princess) beyond what is usual for that age
• believe that he or she has unrealistic abilities or powers that are unusual, and may try to act upon them, which causes trouble
• needs less sleep than usual; yet does not feel tired the next day
• have periods of too much energy
• have periods when she or he talks too much or too loud or talks a mile-a-minute
• have periods of racing thoughts that his or her mind cannot slow down, and it seems that your child’s mouth cannot keep up with his or her mind
• talk so fast that he or she jumps from topic to topic
• rush around doing things nonstop
• have trouble staying on track and is easily drawn to what is happening around him or her
• do many more things than usual, or is unusually productive or highly creative
• behave in a sexually inappropriate way (e.g., talks dirty, exposing, playing with private parts, masturbating, making sex phone calls, humping on dogs, playing sex games, touches others sexually)
• go and talk to strangers inappropriately, is more socially outgoing than usual 
• do things that are unusual for him or her that are  foolish or risky (e.g., jumping off heights, ordering CDs with your credit cards, giving things away)
• have rage attacks, intense and prolonged temper tantrums
• crack jokes or pun more than usual, laugh loud, or act silly in a way that is out of the ordinary
• experience rapid mood swings
• have any suspicious or strange thoughts
• hear voices that nobody else can hear
• see things that nobody else can see

Brain Injuries/ Brain Damage
Both my children have brain injuries (called Cerebral Dysrhythmia - the cause and time of injury is unknown - could be birth defects, could be from abuse).  The temporal lobe is definitely damaged in both children, Bear also has damage in the parietal lobe.  I always thought it explained a lot, and I believe more than a few of "our kids" have these issues.  

I always include their brain injuries when mentioning their issues to people who need to know, because I think it helps them understand that this is PERMANENT not something that therapy or medication is going to "fix." 

We are often told that brain damage can be "fixed," and honestly, I believe that to a certain extent that is true, but at some point we have to acknowledge that some of it isn't going to get better or we'll be blaming ourselves (or allowing others to blame us) for our child not healing.


Fetal Alcohol Spectrum Disorders (FASD)

Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term describing the range of effects that can occur in an individual who is prenatally exposed to alcohol. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term FASD is not intended for use as a clinical diagnosis.

FASD Behavior Characteristics

• difficulty with memory
• slow information processing
• impaired executive functioning
• problems generalizing
• problems connecting cause and effect
• poor repetitive language skills
• perseveration
• confabulation
• difficulty setting/ reaching goals
• trouble understanding abstract concepts
• problems with social skills
• trouble reading social cues
• mood swings
• lack of inhibitions
• reacting poorly to changes
• poor understanding of ownership
• unrealistic expectations
• poor expression of emotions
• easily overwhelmed
• interpersonal struggles
• impulsive actions
• inflexibility
• repeated mistakes
• vulnerable to peer pressure

Puberty

Puberty sucks. Those hormones rushing around adds a whole new layer of fun. The good news is that while ages 13 and 14 were horrible for my kids (biokids and adopted kids), things got better after that. More info in this post - The Teen Years

TREATMENT

Does It Matter What's Causing the Behavior?

The answer is, sometimes. Treatment can be different for different diagnoses. Some issues are biologically based, like the chemical imbalance leading to bipolar disorder. Treating bipolar disorder with therapy alone would be fairly ineffectual.

Neuropsychological Evaluations
The first step is a thorough neuropsychological assessment. This will give you a good picture of your child's physical, mental, and family history.  Assessments are critical because a thorough evaluation can provide recommendations used to create an individualized plan of care. 

Do remember that no one knows your child better than you do. The more information you can provide the neuropsychologist, the more accurate your child's evaluation will be.

Most important to understand is the necessity that comorbid disorders be treated concurrently. Mental illness and comorbid addiction disorders are intimately connected. Healing both means healing both as opposed to one or the other.

Why Won't My Child Just Behave?
We don't always know why children (especially children of trauma) act the way they do.  It’s possible that they just want to watch adults get all agitated, maybe they want adults to fight to distract them from the child (and thus avoid conflict), or maybe they're trying to recreate the chaos that their brains are used to and therefore it feels comfortable and familiar - often they were "pickled" in adrenaline (or alcohol) in utero.... 

Discipline vs Behavior Problems

Discipline problems (noncompliance, misbehavior) occur when the caregivers have not structured the child's environment for success or when parents are inconsistent (expectations or consequences), non-responsive, or inaccessible. When adults adjust their behaviors and attitudes, often children with discipline problems can be brought under control in as few as 3 to 7 days.

Behavior problems on the other hand lie within the child. These are persistent behaviors that do not disappear even with the best parenting (although good parenting can help to control the behaviors). These can include impulsivity, inattentiveness, and other behaviors like ADHD, FASD and immature behaviors associated with missing capacities in object relations.

YOU CANNOT EXPECT PUNISHMENT OR DISCIPLINE

TO "FIX" BEHAVIOR PROBLEMS!

Having behavior problems is like being born with poor eyesight. No amount of punishing or controlling is going to fix this problem. Glasses will help. However, the parent will be responsible for taking the child for regular eye check-ups, teaching him how to care for his glasses, and restricting activities where glasses might break. The goal is that by the time the child is 18, he will be ready and able to take full responsibility for the care of his own eyes and glasses.

Medication

Many of our children's major issues cannot be "fixed" by medication (C-PTSD, RAD...), and are trauma-based, not biologically-based. So why give them medication?

Alleviating Symptoms
I know a lot of times there is huge resistance to giving children meds, and while I agree that there are times some children are over-medicated (particularly those in foster care), I believe that it often means kids with trauma issues are struggling more than most. 

For kids with trauma-based issues, I believe meds are not healing or correcting the child's brain, but they can calm down all the outside/extra input, so that the brain can focus on building those new pathways. 

Children can't heal if they feel they are living in a war zone or they are struggling with basic coping skills, unable to function.

In my opinion, you can't work on healing trauma if you can't sleep, focus, sit still, react normally to external stimuli (like someone saying, "you dropped jelly on the counter," which, in my opinion, should not trigger a screaming rage but has)... Handling Dysregulation/ Meltdowns

There's a reason doctors prescribe pain medications after major injuries - it's because people heal faster when they are not in pain.


Therapy 

On the other hand, you can't just treat with meds. Meds control the symptoms, but it takes a lot of work to retrain your brain to function in a new way. This is where therapy and therapeutic parenting come in. To help our kids you must have both.

Get a good therapist who understands and has experience working with adopted/foster kids with trauma. We love our EMDR therapist for our daughter but still use a good attachment therapist too. Don't be afraid to "fire" the therapist if it's not a good personality match.
Questions to Ask a Potential Therapist

Therapeutic Parenting
Therapeutic Parenting is the term used to describe the type of high structure/high nurture intentional parenting that fosters the feelings of safety and connectedness so that a traumatized child can begin to heal and attach. 

Structure and Caring Support
When I realized this behavior was caused by anxiety, it made it easier to provide Calming Techniques and fight to make her world smaller and less overwhelming (by providing Structure and Caring Support). 

Age-Appropriate Parenting
Trauma can cause significant delays in development (emotionally, socially, intellectually...).  Frequent moves and other traumatic life events can also cause delays or even get them stuck at the age the trauma occurred.  Emotionally "triggering" events can cause a child to regress to a much younger age.  Most kids with PTSD (and brain damage from RAD) have a tough time with processing, memory, object permanence, emotional regulation...  

Expecting a child to "act his/her age," can cause frustration and anger for both of you.

EMDR therapy is the most recommended therapy for people with PTSD. It is most often used by soldiers and victims of trauma (like rape or being in a natural disaster), and usually only requires 2-3 sessions.  Obviously, people who have suffered from long-term trauma (Complex PTSD), such as child abuse, would most likely require more sessions.  

There are no medications specifically for treating PTSD, but with good therapy and meds that help with the symptoms, the child can recognize the effects of the trauma, learn to cope, and move on to dealing with the cause of the trauma.

Helpful Documents
Current Meds and Diagnoses 
New School Year Letter