Current p S Y C H I AT R Y
Is it ADHD? Mania? Autism?
What to do if no diagnosis fits
This approach for children
with ‘much more than ADHD’
can help them function better
in school and at home
Deborah M. Weisbrot, MD
Assistant professor of psychiatry
Director, child and adolescent psychiatry
outpatient clinic
Gabrielle A. Carlson, MD
Professor of psychiatry and pediatrics
Director, child and adolescent psychiatry
Stony Brook University School of Medicine
Department of psychiatry and behavioral science
Stony Brook, NY
© Jill Greenberg / Photonica
C hildren with developmental prob-
lems and serious psychopatholo-
gies often do not fit neatly into DSM diagnoses.1,2
These “diagnostically homeless” children—
handicapped by hyperactivity, volcanic rages,
extreme anxieties, and other complex problems—
need assessment and treatment that address four
domains of dysfunction:
• mood/anxiety problems
• possible psychosis
• language/thought disorder
• relationship/socialization problems.
This article offers snapshots of four children
with undetermined diagnoses, explores the dilem-
ma of treating such patients without knowing
what they really have, and recommends a treat-
ment approach to help them function better in
school and at home.
WHO ARE THE ‘DIAGNOSTICALLY HOMELESS’?
Devon is 5. He is extremely hyperactive and impul-
sive, with a normal IQ but significant language delay.
He exhibits little but not absent interest in peers and
rages when changes are imposed on him.
continued
VOL. 4, NO. 2 / FEBRUARY 2005 25
 ‘Diagnostically homeless’

Table 1

Criteria describing impairments in ‘diagnostically homeless’ children

Multidimensionally
Multiple complex impaired (MDI) Schizotypal
Domain developmental disorder (MCDD)* syndrome† personality disorder

Anxiety Intense generalized anxiety, Unspecified Excessive social

symptoms diffuse tension or irritability; anxiety associated
unusual fears and phobias, with paranoid fears
peculiar in content or
intensity; recurrent panic
episodes, terror, or flooding
with anxiety

Affect Significant, wide, emotional Nearly daily periods Inappropriate or

regulation variability out of proportion of emotional lability constricted affect
to precipitants disproportionate to
precipitants

Psychotic-like Magical thinking; illogical Poor ability to separate Ideas of reference;

symptoms confusion between reality reality from fantasy unusual perceptual
and fantasy; grandiose experiences;
fantasies of special powers suspicious; eccentric

Thought/language Thought problems including Thought disorder Odd thinking; vague,

disorder irrationality, sudden intrusions specifically excluded circumstantial,
on normal thought process, metaphorical speech,
neologisms or nonsense words overelaborate or
repeated over and over; stereotyped
blatantly illogical, bizarre ideas

Problems Social disinterest, detachment; Impaired interpersonal Lack of close friends

with social instrumental relatedness; high skills despite desire or confidants other
functioning degrees of ambivalence to adults, to initiate social than relatives
manifested by clinging, overly interactions with
controlling, needy behavior and/or peers
aggressive, oppositional behavior;
limited capacity to empathize

* PDD NOS (pervasive developmental disorder, not otherwise specified) is the closest DSM-IV-TR designation.
† Psychosis NOS is the closest DSM-IV-TR designation.
Source: References 1, 3, 8-13.

Devon says he can run faster than cars and swim
across the ocean. He has “more than ADHD,” less
than autism/pervasive developmental disorder (PDD).
Were he older, his grandiosity might seem manic but
his age and language delay make this suspect.
Steven is 11, referred “to rule out bipolar disorder”
and to evaluate hyperactivity, explosiveness, and
nightmares. He didn’t speak until he was 22 months
old. He worries that bad people are chasing him,
fears skeletons under his bed, has nightmares of
vampires, and believes that cartoon characters are
real and that Sponge Bob is his protector. He says
he sees “scary stuff” out of the corner of his eyes.
He does not have a thought disorder; psychotic

26 Current
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VOL. 4, NO. 2 / FEBRUARY 2005

symptoms are more than an overactive imagination
or anxiety.
Lauren, age 12, has been diagnosed with attention-
deficit/hyperactivity disorder (ADHD) but now pre-
sents with withdrawn, depressed, and defiant
behaviors. She is described as a “loner” who has
never related well to other children. Lauren speaks
about being tortured by her peers to the point of
sounding paranoid. Her conversation is extremely
circumstantial and rambling.
Richard, age 8, has motor coordination, attachment,
and disinhibition problems. He hears voices telling
him to do bad things, such as hurt people, steal
things, and “break stuff.” He doesn’t mind the voic-
es much, and they don’t pervade his life the way
hallucinations do in schizophrenia.
Children such as these are common, and it is
unclear whether they have a developmental disor-
der, the prodrome of a psychotic or mood disorder,
or idiosyncratic personalities. They
don’t meet criteria for many disor-
ders, including autism, bipolar dis- NOS diagnoses
order, schizophrenia, and obsessive- fail to adequately
compulsive disorder (OCD). They address these
have more-extensive difficulties than children’s multiple
those seen in ADHD, generalized impairments
anxiety disorder (GAD), or OCD.
Clinically, they are either forced
into a category someone thinks they resemble
(such as mania in Devon’s case) or are given a “not
otherwise specified” (NOS) label (such as PDD
NOS, psychosis NOS, or mood disorder NOS),
the severity of which goes unacknowledged.
Problems with ‘NOS.’ Some might consider
“NOS” a less-severe problem than a specific diag-
nosis, but these children are very impaired. They
are excluded from treatment studies because they
do not meet formal criteria for the designated dis-
order or they get included erroneously because
the structured diagnostic interview doesn’t assess
what they really have.
Meaningful psychoeducation for their par-
Current p S Y C H I AT R Y
ents is impossible because no Web site or book
exists to help them help their child. Finally, no
follow-up studies have been done of this group of
children because no one can agree on a diagnosis.
Small studies have addressed some of these con-
cerns, but outcomes—not surprisingly—are
wide-ranging.3-6
NOS diagnoses also don’t adequately address
children with marked anxiety, unusual fears, and
perseverative behaviors who are socially clumsy
but manage reciprocal social interaction. These
children are substantially disabled by:
• attention difficulties
• mood dysregulation (including anxiety
and/or manic symptoms)
• trouble with transitions/change
• motor problems (not infrequently)
• pragmatic language/social difficulties.
Few tests exist for pragmatic language skills,
which include being able
to maintain a reciprocal con-
versation, stay on topic, under-
stand the listener’s needs, and use
correct body language and voice tone.
Children with PDD, ADHD, and other
language disorders are most often dis-
abled in this area of communication.
Diagnostic terms that have tried to clas-
sify these children (Table 1) include:
• childhood-onset PDD, described
in DSM-III. This category was dropped in DSM
III-R to be included in PDD, then largely ignored
in DSM-IV when autism criteria were refined.
• multiple complex developmental disorder
(MCDD),7-9 which appears to describe children
within the autism spectrum (such as PDD NOS)
• multidimensionally-impaired (MDI) syn-
drome, whose atypical psychosis has been called
“psychosis NOS”10-11
• schizotypal personality disorder, which
addresses similar symptoms (although mental
health professionals are loathe to use a personality
disorder diagnosis in a child).12
continued
VOL. 4, NO. 2 / FEBRUARY 2005 27
 ‘Diagnostically homeless’
These designations all include psycho-
pathology in four domains: anxiety, affect regula-
tion, communication, psychosis, and relatedness.
At this time, however, diagnostic conclusions
about this heterogeneous group of children are
premature. Our classification system does not do
them justice, and we need to study them for what
they have, rather than forcing them into our cur-
rent alternatives.
Prevalence. To find out how many patients in our
university-based, tertiary-care clinic do not fit
DSM-IV-TR nosology, we examined data from fac-
ulty evaluations of 624 children and adolescents.13
These included semi-structured interviews of par-
ent and child, rating scales from parents and teach-
ers, and testing information from
the schools in two-thirds of cases.
The result: nearly 25% of our Irritability, often with
child and adolescent psychiatry volcanic anger,
outpatients are “diagnostically is these youngsters’ of these domains may be beyond the psy-
homeless.” Like the rest of our most disabling
patient population, these children mood symptom
are:
• 80% male
• 60% under age 12
• 86% Caucasian
• 85% living with their biological mothers.
These children are referred to psychiatrists for
many reasons:
• ADHD (16%). They have great difficulty
with executive functions, such as paying atten-
tion, inhibiting impulsive responses, planning
and organizing, making transitions from one
activity to another, and controlling emotion.
Their problems, however, go much beyond
ADHD.
• Bipolar disorder (15%) or depression/anx-
iety (16%). They have catastrophic anxiety
and/or frightening rages triggered by apparently
trivial circumstances. They balk or “shut down”
when people want them to move or act faster
than they can move or act.
• To “rule out autism” (19%). More than
28 Current
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VOL. 4, NO. 2 / FEBRUARY 2005
one-half (56%) of these children have a diagnos-
able speech or language disorder, compared with
35% among our other child psychiatry outpa-
tients.
• For educational assessment (23%). School
systems request guidance for educational inter-
ventions because these children are possibly psy-
chotic and disturbing to teachers and children.
They may be unable to execute homework assign-
ments and fail their courses but surprisingly do
grade-level work on achievement tests.
ASSESSING FOUR DOMAINS
We can consolidate the domains needing assess-
ment into mood/anxiety
problems, possible psychosis,
language/thought disorder, and
relationship/ socialization problems.
Although evaluating and treating some
chiatrist’s purview, we must make sure that
other professionals attend to them.
Anxiety and mood. Understanding these
children’s anxieties is important. A rou-
tine fear of bees is a simple phobia,
whereas catastrophic anxiety over a highly unlikely
impending tornado and perseverative interest in
the weather may be more common in a PDD spec-
trum disorder. Anxiety about going to sleep because
a monster is going to suck out one’s brains does not
easily fit into the rubric of generalized anxiety.14
Irritability is these youngsters’ most dis-
abling mood symptom. Volcanic anger and rage
that prompts referral occurs in numerous condi-
tions, including mania. Many of the children
described in Ross Greene’s book, The Explosive
Child,15 have conditions other than bipolar disor-
der. Although parents and teachers often describe
these events as occurring without provocation, a
good functional behavioral assessment will usu-
ally reveal a precipitant.
Possible psychosis. These children may have
impaired reality testing that can be difficult to
continued on page 35
 Current p S Y C H I AT R Y

continued from page 28

Table 2

Assessing children’s social and language skills

Social assessment Seen in…

Are the child’s social abilities delayed? ADHD

Is he uninterested in social situations? Autism

Is he clueless about social interaction? Autism spectrum disorders including MCDD, MDI,
PDD NOS, nonverbal learning disability

Are social interactions deviant? Schizotypal personality disorder/schizophrenia

Does child appear shut down/behaviorally Social phobia

inhibited in unfamiliar settings, with greater
comfort at home or with familiar people?

Language assessment (can be done by psychiatrist)

• Age at first word use; age at first use of short sentences

• Early interest in language? Nonverbal communication? Communication for sharing?

Useful questions Seen in…

Was communication delayed but then Developmental language disorder

progressed “normally”?

Did it begin normally and stop? Autism

Was/is it egocentric and/or unidimensional? Asperger’s disorder; nonverbal learning disability

Was/is it bizarre or paranoid? Schizotypal personality disorder

Pragmatic language problems? All of the above, MCDD, MDI, ADHD

Communication domains (may require speech pathologist assessment)

Expressive and receptive language

Pragmatic language (the child’s ability to communicate in the real world; see Table 3)
Written language
Audiology (hearing and auditory processing)

ADHD: attention-deficit/hyperactivity disorder

MCDD: multiple complex developmental disorder
MDI: multidimensionally impaired syndrome
PDD NOS: pervasive developmental disorder not otherwise specified

assess; thus, deciding whether the child is experi-
encing psychotic symptoms can be a challenge.
The child may be intensely involved with fantasy
characters or imaginary companions to such a
degree that he or she insists the character is real.16,17
Developmentally normal fears—as of the dark,
monsters, or images from dreams—may preoccu-
py him or her during the day. Quasi-psychotic
symptoms such as these are easily missed if:
• we don’t ask about them
continued

VOL. 4, NO. 2 / FEBRUARY 2005 35

 ‘Diagnostically homeless’
Table 3
Communication skills children need to learn
• Rules of conversation (for example, who is likely
to be interested in what)
• Topic management (when to expand, shift,
end a conversation)
• Awareness of nonverbal cues
• Social expectations in various settings
• Operational knowledge of the language of emotions and
mental states (how to express feelings and the different
ways we experience ourselves)
• How to monitor a listener’s relative interest
• The meaning of eye contact, voice tone, and voice inflection
• Awareness of how social settings affect communication,
such as voice volume (whisper in the library, shout on
the soccer field) and speech style (slang with peers,
formal style for classroom recitation)
• Body proximity (how to avoid invading someone’s space)
• Decoding facial expression (such as what it means when
someone rolls his eyes)
• Special instruction to help decipher nonliteral
communication, including teasing, irony, sarcasm,
emotional tones of speech
• we assume the child is “just pretending” or
has a “great imagination”
• the child does not volunteer the informa-
tion spontaneously.18
In assessing psychotic symptoms, the first
goal is to get a detailed picture of unusual
thoughts or images the child is experiencing in
different settings, including school, home, and
with peers. Then evaluate these symptoms in the
broader clinical context of how the child is func-
tioning in other domains.
Language/thought disorder. Parents may not recog-
nize that their child has a thought or language
36 Current
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VOL. 4, NO. 2 / FEBRUARY 2005
disorder because they have filled in the
blanks and interpreted for him or her
for so long. Asking the child “yes” and
“no” questions will not elucidate these
disorders, either. The examiner must
talk to the child to determine his or her
ability to:
• sustain an extended narration
that makes sense
• stay on the topic
• care whether the listener
understands what the child
is talking about
• make a point.
Distinguishing between a thought
or and language disorder in a child is
difficult, although the more illogical
the communication, the less likely it is
to be a language disorder. If the child
connects ideas that don’t make sense,
ask him or her to explain how the sub-
ject shifted or what he or she meant.
Children with language disorders may
have misunderstood the question or
may have expected the examiner to
make connections, but the explanation
usually makes sense. When it doesn’t,
we become more concerned that the
child has a thought disorder.
Nonverbal communication realms
include eye contact, appropriate hand gestures
and facial expression, tone of voice, and vocal
inflection. Other important areas of language to
assess are summarized in Table 2, page 35.
Relationship/socialization problems. It is important
to know whether the child has friends, wants
friends, or prefers being with younger children.
Peer relationships may be absent, delayed, or
deviant.
Other assessments. The diagnostically homeless
children we see have complicated family histories
of psychopathology. Their first-degree relatives
have a higher number of heritable disorders—
continued on page 39
 Current
p S Y C H I AT R Y

continued from page 36

Table 4

Targeting drug therapies to treat children’s symptoms

Drug class Efficacy by symptom domain

Atypical antipsychotics Psychosis/thought disorder: Can reduce psychotic symptoms

Anxiety symptoms: Can reduce extreme anxieties
Affect regulation: Improved by mood-stabilizing effect
Socialization problems: Appear to modify affective aggression, hyperactivity,
and impulsivity, which can improve socialization and pragmatic communication

Mood stabilizers Psychosis/thought disorder: Not primary area of effectiveness

Anxiety symptoms: May be helpful; not primary area of effectiveness
Affect regulation: Address mood dysregulation
Socialization problems: May reduce aggressive outbursts and mood,
which can improve socialization

Stimulants* Psychosis/thought disorder: Can produce or intensify psychotic symptoms

and agitation
Anxiety: Usually do not improve anxiety; can intensify anxiety and agitation
Affect regulation: Not a primary effect in severe cases; address impulsive
aggression via mood stabilization
Socialization problems: Can improve functioning via decreased impulsivity,
inattention, and aggression

SSRI antidepressants† Psychosis/thought disorder: Do not directly address

Anxiety: Can be effective in decreasing anxiety
Affect regulation: Can improve depressed mood
Socialization problems: Can be improved as a result of improved mood
and decreased anxiety

* Stimulants often increase agitation and disinhibition.

† Watch for behavioral disinhibition, possible increase in suicidality, with selective serotonin reuptake inhibitors (SSRIs).

including bipolar disorder, panic disorder, ADHD,
learning disabilities, and “nervous breakdowns”—
than do those of children with uncomplicated
ADHD, bipolar disorder, or anxiety disorders. Ask
about these conditions when taking the family his-
tory; if a family member is said to be bipolar, get a
description of the person’s symptoms.
A skilled psychologist or speech pathologist
can help you determine the presence or absence of
cognitive and language dysfunction and learning
disabilities. Even before we interview the parents
and child, we ask parents and teachers to rate the
child’s attention, behavior, mood, PDD-like
symptoms, and anxiety, using the Child/
Adolescent Symptom Inventory (see Related
resources, page 40). We use the youth version with
children age 10 and older, then review the symp-
toms with the parents and child to make sure we
understand all presenting comorbidities.
TREATMENT
Nonmedical interventions begin with an accurate
diagnosis, where possible. Then the four steps of
treatment are to:

VOL. 4, NO. 2 / FEBRUARY 2005 39

 ‘Diagnostically homeless’
• address each domain of dysfunction
• translate findings to parent, child, and
teachers/school.
• provide settings and resources that allow
the child to work most effectively
• develop a behavioral program for the most
frequent problems, with consistent
response by caretakers and educators.
The educational setting needs to be adapted for
these children. This usually implies individualized
attention in small classes or small work groups.
Assigning an aide to the child may be effective in
larger settings, but other support and expertise is
needed. Otherwise, all the aide does is run interfer-
ence for the child, which ultimately may be more
isolating than a special education class.
A communication specialist interested in
pragmatics is needed to make sure the child is
understood and being understood in the class-
room. Table 3, page 36, summarizes communica-
tions skills the child needs to learn. An educa-
tional specialist who serves a resource to other
professionals may also help the child.
Curriculum should be based on long-term goals
rather than on inflexible credit schedules that
teach worthless, unlearnable information and
demoralize the student.
Finally, the education setting should provide
opportunities for structured social interaction
Diagnostically homeless children do
not meet criteria for a mood disorder,
autism, or psychosis, but their complex
handicapping symptoms overlap these
disorders. Until we understand what
these children have, assess and treat
their mood/anxiety problems, possible
psychosis, language/thought disorder,
Line
and relationship/socialization problems.
Bottom
40 Current
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VOL. 4, NO. 2 / FEBRUARY 2005
Related resources

Child/Adolescent Symptom Inventory.
http://www.checkmateplus.com. Accessed Jan. 11, 2005.
DRUG BRAND NAMES Lithium carbonate • Lithobid, others
Amphetamine • Adderall Methylphenidate • Concerta, Ritalin
Aripiprazole • Abilify Olanzapine • Zyprexa
Atomoxetine • Strattera Paroxetine • Paxil
Bupropion • Wellbutrin Quetiapine • Seroquel
Citalopram • Celexa Risperidone • Risperdal
Fluoxetine • Prozac Sertraline • Zoloft
Fluvoxamine • Luvox Valproic acid • Depakote
Ziprasidone • Geodon
Lamotrigine • Lamictal
DISCLOSURES
Dr. Weisbrot receives grants from Pfizer Inc.
Dr. Carlson receives grants from or is a speaker for Janssen Pharmaceutica,
Eli Lilly and Co., Shire Pharmaceuticals Groups, and Abbott Laboratories;
is a consultant to Janssen Pharmaceutica and Eli Lilly and Co.; and is an
advisor to Otsuka America Pharmaceutical, Pfizer Inc., and Ortho-McNeil
Pharmaceutical.
and less-structured but supervised—”bully-
proofed”—interactions.
Medications. No systematic medical treatment
data exist, as there is no way to classify these chil-
dren. They are usually treated with multiple
medications for their specific symptom cluster
abnormalities (Table 4, page 39). Options include:
• atypical antipsychotics such as risperidone,
quetiapine, aripiprazole, ziprasidone, or
olanzapine
• mood stabilizers such as valproic acid, lith-
ium, or lamotrigine
• stimulants such as methylphenidate,
amphetamine salts, atomoxetine, or bupropi-
on (a mild stimulant and an antidepressant)
• selective serotonin reuptake inhibitors,
such as fluoxetine, sertraline, citalopram,
paroxetine, or fluvoxamine.
Unfortunately, drug therapy may cause behav-
ioral toxicity—tearfulness, irritability, disinhibi-
tion, activation, agitation, hallucinations and pos-
sibly even suicidal behavior. Stopping the medica-
tion usually reverses this kind of adverse effect.19
Medication side effects understandably
frighten parents—who may be reluctant to have
their children use any drug therapies. Counsel
the parents in advance that side effects may occur.
continued on page 42
 ‘Diagnostically homeless’
continued from page 40
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J Am Acad Child Adolesc Psychiatry 1995;34(8):1096-106.
Have a case from which
other psychiatrists can learn?
Check your patient files for a case that teaches valuable lessons
on dealing with clinical challenges, including:
• sorting through differential diagnoses
• getting patients to communicate
clinical needs
• catching often-missed diagnoses
Send a brief (limit 50 words) synopsis of your case to
pete.kelly@dowdenhealth.com.
Our editorial board will respond promptly. If your synopsis is accepted, we’ll ask
you to write about the case for a future issue of CURRENT PSYCHIATRY.
10. McKenna K, Gordon C, Lenane M, et al. Looking for childhood-
onset schizophrenia: the first 71 cases screened. J Am Acad Child
Adolesc Psychiatry 1994;33:636-44.
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impaired disorder”: is it a variant of very early-onset schizophre-
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12. Nagy J, Satzmari P. A chart review of schizotypal personality dis-
orders in children. J Autism Dev Disord 1986;16(3):351-67.
13. Carlson GA. Unpublished data.
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and parenting easily frustrated, chronically inflexible children (2nd
ed). New York: Harper Collins, 2001.
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13(2):153-63.
Current p S Y C H I AT R Y
• avoiding interactions
with other treatments
• ensuring patient adherence
• collaborating with other clinicians.