What Is the Differential Diagnosis of Attentional Problems?

Patient Presentation
A 7-year-old male came to clinic for his health supervision visit. His mother noted that over the 2nd grade school year he seemed to be having more problems with reading and the teachers noted that he had more inattention in the afternoon when they did language arts.
He had been previously diagnosed with attention deficit hyperactivity disorder (ADHD) in kindergarten. She said that otherwise he was his energetic self and that the teachers didn’t complain of other behaviors.
The teachers had not done any specific evaluations that the mother was aware of.
The past medical history showed a healthy male with an unremarkable past medical history ADHD that was diagnosed after parent and teacher evaluations, a psychosocial assessment and normal hearing, vision and laboratory screening. He had done well in school and home with some behavioral modification.
The family and social history showed the father was described as “energetic” and had had some difficulties reading as a child. He graduated from college and was a businessman with steady employment. Other paternal relatives were described as “energetic” also.
There were no recent medical or psychosocial changes in the family. There were no mental illness reported in the families.
The review of systems was negative.

The pertinent physical exam showed a healthy 7 year old with normal growth parameters and vital signs. His examination was negative except that he was very verbal in the office describing his school and after-school activities.
The work-up included a fuller interview with the patient who said that he liked school, had friends, and denied bullying or other problems at school or home. He said that he didn’t read as well as most of the other kids and found it hard to pay attention to the reading.
The diagnosis of a possible learning problem in addition to the ADHD was made but the pediatrician suggested that he be re-screened for vision and hearing problems that may not have been picked up previously.
She suggested that the school may also want to do some basic cognitive testing in addition to specific educational testing.
The patient’s clinical course showed that he was found to have an average to above average intelligence quotient, but was borderline for his age in reading skills.
He started a special reading program in the regular classroom and was making good progress by the end of the school year. Over the summer, the family was gong to do extra reading with him.

Attentional problems are a clinical diagnosis.
Some people use a functional definition of attentional difficulties that disrupt the normal activities of the patient and/or family.
Attention Deficit Disorder (with or without hyperactivity, i.e. ADD, ADHD) has specific criteria for its diagnosis using the Diagnostic and Statistical Manual (version IV).

Children with attentional problems present in a wide variety of ways, including poor school performance, behavioral problems, personality changes, and inappropriate or antisocial behavior. History is very important and should include school history with results of other evaluations, typical day activities and behaviors, birth history (including possible teratogens and substance abuse), developmental history (including possible loss of milestones), social history including use of discipline and possible abuse, and family history (including learning disabilities, mental illness and genetic abnormalities).
Family members impressions of strengths, weaknesses, and if the child reminds them of another family member are often revealing.
ADD/ADHD can exist alone, be co-morbid or be mistaken for another problem. Co-morbid conditions include various developmental disorders (including learning disorders), anxiety disorders, conduct disorder, oppositional defiant disorder, and mild mental retardation.
Physical examination should include a thorough neurological examination for subtle or overt neurological abnormalities (for immaturity or gross abnormality of the CNS, and sensory deficits).
The evaluation should include an extensive history and physical examination, vision and hearing testing (for sensory deficits), academic assessment including observations from classroom teachers (for learning disabilities), and psychological screening (for psychological/social assessment).
Parental observations by structured questionnaires may reveal other information not gathered by interview.
The initial evaluation may necessitate further workup with cognitive testing (for mental retardation), EEG (for seizures), blood testing (for substance abuse, lead, hyperthyroidism), etc.

Treatment depends on the underlying cause. Often, acknowledgment of the problem and appropriate educational, psychological, and social supports will improve the attention of the child. Supporting the parents in understanding the problem and supporting their efforts with the patient are very important.
Treatment of primary ADD/ADHD requires a multimodal approach. The mainstays are the understanding of the problem by parents, family, and teachers, behavioral modification, appropriate educational placement, and psychological support. Stimulant medication may also be used for certain patients but is not effective by itself and should only be used in addition to other services. Stimulant medication should never be viewed as a “magic pill.” Consultations with psychiatrists, psychologists, developmental pediatricians or other qualified consultants are often also helpful.

Learning Point
The differential diagnosis for attention problems includes:

  • Normal Development
  • Prematurity
  • Developmental Disorders
    • Autism/Pervasive Developmental Disorder
    • Language Disorder
    • Learning Disabilities
    • Primary Attention Problems, i.e. ADHD, ADD
    • Sensory Deficit – hearing, vision
  • Metabolic Disease
    • Iron Deficiency
    • Heavy Metals – lead
    • Hyperbilirubinemia
    • Medication Side Effects
  • Congenital/Genetic/Neurological Disease
    • Congenital Infection
    • Fetal Alcohol Syndrome
    • Genetic Disorders, i.e. Fragile X, Turner Syndrome
    • Inborn Errors of Metabolism
    • Neurotrauma
    • Mental Retardation
    • Seizures, i.e. petite mal, temporal lobe
  • Other
    • Boredom
    • Fatigue
    • Hunger
    • Hyperthyroidism
  • Psychiatric Problems
    • Anxiety
    • Attachment Disorder
    • Bipolar Disorder
    • Conduct Disorder
    • Dissociative Disorder
    • Depression
    • Disruptive Behavior Disorder
    • Mood Disorder
    • Oppositional Defiant Disorder
    • Personality Disorder, i.e. aggression, antisocial behavior
    • Post-traumatic Stress Disorder
    • Psychosis, i.e. schizophrenia
    • Substance Abuse
    • Tourette Syndrome
  • Social Problems
    • Abuse
    • Family Stress (including Attachment Disorder)
    • Normal communication problems – i.e. different languages, cultural and ethnic differences
    • Parenting, Ineffective
    • Poverty
    • Teaching, Ineffective

Questions for Further Discussion
1. What standardized parent and teacher questionnaires are available for evaluating attentional problems?
2. What types of behavior modifications are often recommended in educational settings for children with attentional problems?
3. What mental health professionals are available in your local community to help co-manage children with attentional problems?
4. What educational professionals are available in your local community to help co-manage children with attentional problems and learning problems?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Learning Disorders and Attention Deficit Hyperactivity Disorder.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Wender E. Hyperactivity in Behavioral and Developmental Pediatrics. Parker S and Zuckerman B. eds. Little Brown and Co. Boston, MA. 1995;185-94.

Borowsky, IW. Attention Deficit/Hyperactivity Disorder, in Pediatrics A Primary Care Approach. Berkowitz CD, ed. W.B. Saunders Co. Philadelphia, PA. 1996;404-407.

American Academy of Pediatrics. Clinical Practice Guideline: Diagnosis and Evaluation of the Child With Attention-Deficit/Hyperactivity Disorder. Pediatrics. 2000;105(5):1158-1170.

Behavenet Clinical Capsule. Bellevue, WA.
Available from the Internet at http://www.behavenet.com/capsules/disorders/dsm4TRclassification.htm (rev. 2009, cited 12/7/2009).

Wilms Floet A, Scheiner C, Grossman L, Attention-Deficit/Hyperactivity Disorder. Pediatrics in Review. 2010;31:56-69

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Systems Based Practice
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.


    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital