On the Differential Diagnosis of Reading, Attentional and Depressive Disorders Jonathan Cohen Teachers College, Columbia University and The Institute for Child, Adolescent and Family Studies New York City

Children may present with reading and~or attentional and~or affective (depressive) disorders in childhood. Although reading problems are more readily identifiable, childhood attentional and affective disorders can be difficult to recognize and diagnose. Here are discussed a number of complex and potentially confusing ways in which reading, attentional and affective disorders may be related: a primary problem in one area may result in problems in another; one disorder may look like another; and~or a child may simultaneously present two or all three primary disorders. Current clinical practice and recent and ongoing research is presented to clarify the changing definitions and potential relationships of these three childhood disorders to aid the process of differential diagnosis.

Annals of Dyslexia, Vol. 44, 1994 Copyright©1994 by The Orton Dyslexia Society ISSN 0736-9387 Address for Correspondence: 300 Central Park West, New York, New York 10024, (212) 877-7328, FAX (212) 316-2643 I want to thank Dr. Anne E. Fowler for her valuable comments and suggestions with this paper.

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There are complex and sometimes confusing relationships between childhood reading disabilities, attention deficit hyperactivity disorder, and affective (depressive) disorders. Some children present with only one of these difficulties. However, there are many instances when children present with overlapping or comorbid reading a n d / o r biologically based attentional and/or affective disorders. Sometimes one disorder can lead to secondary symptomatology that looks like another disorder. For example, a primary phonologically based reading disability can lead to distractibility and impulsivity as well as dysthymic (e.g. mild depressive) disorders. Or, an Attention Deficit Hyperactive Disorder (ADHD) can interfere with learning to read as well as contribute to disparaging feelings about oneself. Or, depression may interfere with memory and concentration, making it harder for children to learn in school. Finally, some children may present with a phonologically based reading disability, an ADHD, and a major depressive illness. In other words, the disorders may not be a psychological/behavioral reaction but instead three primary disorders that are all affecting the child. It is essential that clinicians, educators, and parents understand the specific nature of the child's difficulties. Clinically, it is important to be able to begin to diagnose differentially the nature of a child's reading a n d / o r attentional and/or depressive concerns. Our understanding should determine intervention and treatment planning and will affect efficacy. For example, a reading "problem" that is actually a reaction to or symptom of ADHD in a six-year-old child may not require educational therapy for a reading problem. Instead, intervention and treatment may need to focus on the attentional a n d / o r impulsive problems. In this case, remedial reading instruction may inadvertently increase the child's, parent's and teacher's frustration because the actual problem is not understood and treated. Alternatively, distractibility that is due to depression needs to be understood by parents and educators and treated therapeutically differently than distractibility resulting from ADHD. In addition, a better understanding by educators and parents of the specific nature of the problem(s) should help to create a better "fit" between the child and the world and, importantly, allow them to empathize with the child. To be able to understand and empathize is always one of the most powerfully helpful things that we can do to help and truly support a child. This paper is not a research endeavor. It is rather an attempt to make a clinical statement about the differential diagnosis of reading, attentional, and depressive problems in childhood that

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integrates recent research. It is my hope that this discussion will clarify the complex and changing definitions of attentional and depressive disorders in childhood and how they may be related to reading disabilities.

Reading Disabilities: As readers of these Annals know, the terms learning disability and reading disability are used in various ways. I find it useful to think of learning disabilities as specific neuropsychologically based cognitive weaknesses. For example, reading disabilities typically reflect impaired phonological processing skills (Pennington 1991; Shepherd and Uhry 1993). According to this logic, a biologically or neuropsychologically based attentional disability (e.g. an attention deficit hyperactive disorder which I shall discuss below) can also be conceptualized as one type of a learning disability. Verbal (or language-based) and nonverbal learning disabilities are two other major classifications of learning disabilities (Shepherd 1991). To contrast with the term disability, here I use the term learning disorder or attentional disorder to refer to a difficulty of unknown origin. Because readers of the Annals tend to be familiar with the diagnosis, intervention, and treatment programs related to reading disabilities, I will not review this issue here. Instead, I focus on how reading disabilities may actually be or appear to be related to attentional and affective disorders. I consider three major ways in which reading disabilities may be related to attentional a n d / o r depressive problems: (1) a reading disability can result in attentional a n d / o r depressive problems; (2) an ADHD a n d / o r primary depressive problem can result in reading problems (but not an actual phonologically based reading disability); and, (3) a child may evidence a reading disability and in addition may be suffering from ADHD a n d / o r depression. There are several ways that a reading disability can result in or seem to result in attentional and depressive problems. Problems with phonological processing may be misinterpreted by a teacher or parent as being due to the child "not paying attention." This is not at all uncommon with children who present with receptive language disabilities that may make it difficult for the child to understand verbalizations. In a similar manner, when a child is struggling to decode a word, teachers a n d / o r parents may misunderstand the child's struggle as being due to "not paying attention." In these instances, initially, the child's attentional functioning will appear be affected only when the

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child is attempting to utilize the specific cognitive function that is relatively weak (e.g., reading or listening). In addition, to the specific task being difficult due to an underlying weakness, it tends to be frustrating and eventually anxiety producing to engage and then, to anticipate engaging in the task. The child's psychological reactions to the frustration and failure that verbal and nonverbal learning disabilities engender is one common way that these cognitive weaknesses may inadvertently and indirectly cause distractibility and/or impulsivity. The experience of being learning disabled may also result in anxiety, decreased motivation, and a poor self image/esteem that can profoundly undermine our ability to attend and learn (Silver 1974; Rourke and Fuerst 1991). In addition, mild to moderately severe cognitive disabilities tend to result in intermittent, and hence unpredictable negative moments and this seems to have a subtle but profound effect on behavior, self experience, and emotional life in a number of ways. When a difficulty (e.g., a word finding a n d / o r reading difficulty) is intermittent, it engenders a sense of unpredictability and helplessness that quite naturally leads to further anxiety and helplessness ("when is it going to happen again?"). Often this experience seems to engender the emergence of low level anxiety and a chronic, low level depressive sense of having "lost a part of myself." The repeated experiences of helplessness (i.e., the child not being able to predict the difficulty and do much about it) is sometimes an emotionally wounding experience as well as being quite anxiety provoking, demoralizing, and depressing. In other words, there are a series of psychological reactions and internal experiences that can result in mounting strain, anxiety, and low level depression for the child (Cohen 1985). This anxiety a n d / or depression in conjunction with school difficulties or failure can in turn result in strain for parents and siblings. These family dynamics often create further anxiety for the child and may contribute to still further emotional concerns, distractibility, impulsivity, and other behavioral disturbances. There are many reasons biologically based attention deficit disorders are overdiagnosed. One reason has to do with the fact that although verbal and nonverbal learning disabilities initially appear to complicate attention only in the domain being affected, the experience of being learning disabled can lead to more generalized anxiety as well as a chronic low level depression (Cohen 1985). Generalized anxiety and/or low level chronic depression can easily result in inattention, impulsivity, and/or overactivity. Recent research by Pennington and his co-workers (Pennington,

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Groisser, and Welsh 1993) shows that primary phonologically based reading disabilities can lead to distractibility, impulsivity, a n d / o r hyperactivity. In other words, all of the symptoms that are required to make a diagnosis of ADHD may be a reaction to a reading disability. It is easy to imagine how an ADHD a n d / o r a primary depressive problem can result in reading problems but not an actual phonologically based reading disability. If we are distractible (be it due to a constitutional vulnerability a n d / o r sad and upsetting thoughts/feelings) it will naturally be more difficult to listen in a sustained manner and learn. What is not always so simple to recognize and understand are the many potential signs of an ADHD or depression in childhood. I will be detailing these signs and symptoms below. Some children may present with reading disabilities and in addition may be suffering from ADHD a n d / o r depression. Denckla and Hughes were perhaps the first to suggest that some children may evidence a reading and an attentional disability, which they called dyslexia-plus (Denckla 1979). A dyslexia-plus child shows clear phonologic deficits and attention deficits which may or may not be a "full blown" ADHD but impairment along the attention/executive function dimension of cognition (Denckla 1993). It is clear that many children who seem to evidence an ADHD a n d / o r depression also do show reading and spelling/written language problems (Cantwell and Baker 1992; Elbert 1993; Shaywitz, Fletcher, and Shaywitz 1994). However, the fact that there are so many definitions for these disorders makes it difficult for researchers as well as parents, educators, and health care professionals to understand the relationship between reading, attentional, and depressive problems in childhood (Shaywitz and Shaywitz 1992; Stavrakaki 1992). And, it is to these issues of definition and the diagnosis of attentional and then depressive disorders that we now turn.

Attention Deficit/Hyperactive Disorder Inattention, impulsivity and hyperactivity may represent the most common reason youngsters are referred to mental health practitioners in the United States. These behavioral difficulties are also the most common reason children are labeled behavior problems in the classroom. However, attention is not a unitary process and there are many psychological as well as biological factors that can contribute to attentional disorders in childhood. As noted above and below, it is quite common that anxiety and depression can result in attentional difficulties. Many aspects of

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attending are learned automatically and schools reinforce certain attentional patterns (e.g., sustained attention). It is also my clinical impression that certain environments (e.g., very chaotic families) not only cause a child to be understandably anxious, but also inadvertently interfere with that child's learning to sustain attention. There are numerous biologically based factors that can cause a child to be distractible. For example, it is surprisingly common how many children have concentration difficulties because they simply do not get enough sleep. In addition, there are a host of medical problems (e.g., undiagnosed ear or vision problems, developing diabetes, eye tracking problems, certain seizure disorders, hyperthyroidism, iron deficiency anemia, allergies, and medication reactions) that can disrupt attentional processes a n d / o r appear to be an attention problem (see Goldstein and Goldstein 1990 for a recent review). Finally, there is growing evidence to support the idea that there are relatively chronic and pervasive attentional disorders that are biologically based (e.g., Shaywitz and Shaywitz 1992; Zametkin et al. 1990). Attention deficit/hyperactive disorder (ADHD) is the most recent label for children who evidence a relatively chronic and pervasive pattern of difficulties with attention, irnpulsivity, a n d / or overactivity. It is unclear how many children diagnosed with ADHD will continue to be plagued into adolescence and adulthood, but the numbers are high. Various professionals believe that 50 to 80 percent diagnosed in early and middle childhood will evidence the disorder in adolescence and 25 to 70 percent of these adolescents may continue to manifest the disorder into adulthood (Barkley 1990; Shaywitz and Shaywitz 1992; Weiss and Hechtman 1993). The key diagnostic dimension of ADHD is the relative chronicity and pervasiveness of attentional, impulse control, and overactive behavior. However, children diagnosed with ADHD are a heterogeneous group who show significant variations in the severity and pervasiveness of their symptoms. There are many recent and excellent reviews on the diagnostic and treatment considerations of ADHD (e.g., Barkley 1990; Goldstein and Goldstein 1990; Shaywitz and Shaywitz 1992; Silver 1992; Weiss and Hechtman 1993). Hence, I will only briefly describe some of the general issues surrounding this much diagnosed disorder. And, I will then focus on some new and important research that has the potential to shed further light on the heterogeneous nature of ADHD.

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General Issues

The relatively chronic and pervasive nature of ADHD is diagnostically critical, but complicated. It is diagnostically critical because these attentional, impulse control, and hyperactive problems tend to be relatively chronic and pervasive in a way that is not so with purely psychologically based, cognitively based, and even, many other biologically based attentional problems. For example, attentional problems that are secondary to a psychological problem and/or a language disability tend to evidence themselves in a non-chronic and non-pervasive manner: they are expressed only when the emotional 'wound' or cognitive weakness is being affected. In contrast, children with ADHD evidence attentional, impulsive, and/or hyperactive difficulties at home, school, and with friends from infancy on across a whole range of activities (e.g., at both emotionally laden and neutral moments). However, the dichotomy between interrnittent and chronic symptomotology is not always so clearcut: moderately severe and severe psychopathology sometimes do result in relatively chronic and pervasive cognitive impairment (e.g., Bettelheim and Zelan 1982). Similarly, as noted above, reading disabilities often do contribute to a diagnosis of ADHD. What further complicates this diagnostic evaluation is the fact that motivation (e.g., how much the youngster wants to do a given task) and structure (e.g., the extent to which a situation is defined and monitored) profoundly affect symptom presentation in children who really do seem to evidence ADHD. Children with biologically based attentional problems typically perform much better on a one-to-one basis than they do in a group situation. Group settings are more stimulating and these youngsters may not have the physiological mechanisms to manage this. In addition, one-to-one settings tend to be emotionally safer, more secure and structured than group situations. Thus, an individualized tutoring or clinical situation may not elicit the typical behavior evident in group settings. To help determine the youngster's pattern of functioning it is always essential to have parents and teachers report behavioral patterns over time. Hence, I believe that clinicians who arrive at the diagnosis of ADHD without having consulted with the child's teachers and remedial experts have acted irresponsibly and should be questioned. There are two other, overlapping factors that make the diagnosis of ADHD complicated: determining "normalcy" and differential diagnosis. We all have difficulty paying attention sometimes. And, this raises the basic question of what is normal

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and how do we define the problem. In extreme clinical cases (e.g., severe ADHD), identification is typically not a problem. But, our perception of what is "distractible" or "hyperactive" behavior varies dramatically (e.g., Mann et al. 1992). Especially in more marginal situations ("mild ADHD"), knowing what to call normal can be difficult. In fact, how parents and professionals label a child's problem is always a critical process that effects what can be done and how the child comes to view the problem and themselves. Barkley (1990) suggests that ADHD kids have most difficulty on tasks that are repetitive and boring. But, what does this mean? All children have some (if not a lot) of difficulty on repetitive and boring tasks, unless they have been successfully "beaten" into the "school mold." Emotional concerns and being distracted for any number of reasons (psychological, social or biological) will increase difficulty on repetitive and boring tasks. What is further complicating is that ADHD in childhood (after the age of 7 or 8) virtually n e v e r exists in isolation. Most older children who evidence attentional problems have other problems as well. This is not so for younger children: in the preschool years we can see children who clearly present chronic and pervasive attentional, impulsive, a n d / o r hyperactive problems with no other significant difficulties. What importantly determines whether this is labeled a problem is the "fit" between the child and his environment: how empathically acceptingly a n d / o r frustratingly/angrily do the parents, siblings, and peers respond? As the child grows up, when we are assessing attentional problems we must watch for disorders that overlap and may be confused with attentional problems. In fact, having an attentional problem predisposes one to having educational and psychological problems. Therefore, the clinical challenge is not to isolate a single trait but to ensure that we account for the multiple sources and complications often associated with these traits. Currently, the only way to make this differential diagnosis is for the clinician to talk directly with the child, parents, teachers, and other professionals who have been working with the child. Meeting with the child and his/her whole family is also invaluable. This direct clinical contact and comprehensive understanding of all facets of the child's life provides the basis for understanding the youngster's cognitive strengths and weaknesses as well as how psychological and family dynamics help a n d / o r hinder cognitive functioning. This kind of integrative evaluation allows clinician and parents to develop an impres-

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sion over time and across situations to determine whether the attentional problems are relatively chronic and pervasive in nature as well as the extent to which psychogenic factors are causative a n d / o r problematic. The current Diagnostic Statistical Manual (the DSM-III-R) of the American Psychiatric Association (1987) diagnostic guidelines do not require this kind of integrative understanding and hence, are inadequate. However, it is important to be familiar with these guidelines as they represent research findings and, to some extent, important clinical understanding. I am not going to review the recent American Psychiatric Association's DSM-III and III-R diagnostic guidelines as many readers are familiar with them and they have been well reviewed in the recent texts on ADHD noted above. This year a new diagnostic manual has been published: the DSM-IV (American Psychiatric Association 1994). In the DSMIV, the symptoms of ADHD are differentiated into two categories: developmentally inappropriate degrees of inattention on the one hand and impulsivity/overactivity on the other hand. This distinction represents a return to the DSM-III distinction of an attention deficit disorder with hyperactivity and an attention deficit disorder without hyperactivity, which was removed in DSM-III-R. Many professionals believe that ADHD has been over diagnosed. And, as a result the DSM-IV diagnosis of an attention deficit disorder is contingent on symptoms being " m a l a d a p t i v e and inconsistent with d e v e l o p m e n t a l level" (page 83). In addition, ADHD symptoms must be present in two or more settings (e.g., school and home). Heterogeneity and the Sub-typing of ADHD

Another fact that makes diagnostic efforts difficult is that ADHD does not seem to be a single disorder: it is heterogeneous. The most interesting and potentially the most useful research on ADHD now underway is the attempt to distinguish different types of the disorder. Five areas of research illustrate current efforts to clarify the various sub-types of ADHD: (1) ADHD versus ADHD without hyperactivity, (2) inattentive/ cognitively impaired versus impulsive/aggressive, (3) medication response (positive or negative) in conjunction with patterns of neurological findings, (4) underfocusing versus overfocusing, and (5) a group of children who meet the diagnostic criteria for ADHD, with right hemisphere problems and depressive symptoms who may in fact be biologically depressed.

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(1) ADHD Versus ADHD Without Hyperactivity: Recent research supports the idea that one valid nosological distinction for attention deficit disorders is an attention deficit with hyperactivity (ADHD) on the one hand and an attention deficit without hyperactivity on the other hand (Barkley 1990). This distinction is akin to the past DSM III criteria (American Psychiatric Association 1980) and apparently, in accord with the upcoming DSM IV criteria noted above. There is mounting evidence that ADHD and ADHD without overactivity may in fact be two distinct disorders. For example, the Shaywitz's have found spinal fluid differences between these two groups of children and this is one of a number of biologically based differences that supports this notion (Shaywitz and Shaywitz 1988). The more classic and more studied group of youngsters who evidence ADD with H overlap much more with the so called "conduct disordered" children and adolescents. Although the ADD without H group of youngsters do not seem to manifest the intrusive, externalizing behaviors of the ADHD kids, they do perform poorly in school and are at serious risk for long-term academic and social problems. These children and adolescents seem to have more trouble with focused attention and cognitive processing speed, rather than sustained attention and impulse control problems. They do not evidence a pattern of behavioral self control problems: they are not so impulsive, intrusive and, unable to delay gratification to a degree that is abnormal for their mental age. This is the less well studied group of youngsters. (2) Inattentive/Cognitively Impaired Versus Impulsive/Aggressive: Distinguishing children who are "inattentive/cognitively impaired" from these who are impulsive/aggressive overlaps with research using the Continuous Performance measures. This research has begun to reveal a dual diagnostic discrimination between two groups of children and adolescents who present with attentional problems: inattentive/cognitively impaired versus impulsive/aggressive. Spearheading recent efforts to develop objective measures of attention, the Continuous Performance Test (CPT) is one instrument increasingly being used to assess inattention, impulsivity, and dyscontrol (e.g., Matier et al. 1992). In this task, letters are typically presented visually for 200 msec. with a 1.5 second interstimulus interval; children are told to respond whenever they see an "A" followed by an "X." Although we do not yet know how diagnostically useful or even h o w valid this measure is, m a n y researchers agree that CPT omission errors reflect an attentional

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disorder. It is unclear whether errors of commission are an indication of impulsivity. In a series of studies utilizing CPT measures, researchers have found support for the idea that there may be two subgroups of ADHD youngsters: a group that can be characterized primarily by inattention and cognitive problems (high incidence of omissions), and another group that can be characterized more by aggressive behavior, without significant attentional or cognitive dysfunction on the CPT measure (August and Garfinkel 1989; Halperin, Newcorn, and Sharma 1991). In a series of past and ongoing studies based in part on CPT responses, Halperin and his co-workers are investigating the finding that there do seem to be these two distinct groups of children who meet teacher report profiles of evidencing ADHD (Halperin et. al. 1993). They are looking at presenting symptoms, antecedent predictors, neurobiological disturbances, treatment response, and long-term outcome from a variety of perspectives (e.g., biological, behavioral, neuropsychological, pharmacological). Halperin and his co-workers are now discovering that the impulsive/aggressive sub-group is dramatically different from the inattentive/cognitively impaired sub-group when the former group's aggressive behavior is actually physically assaultive (Halperin 1994). At present, it is unclear whether the subgroup that can be characterized as having conduct problems (as opposed to the other group that evidences inattention and learning problems) is simply psychogenically troubled. Sometimes, psychopathology expresses itself as a "conduct problem" and these children can meet DSM III-R criteria for ADHD even though there is no underlying biological disorder. Nonetheless, the attempt to utilize psycho-physiologically based measures of attention in conjunction with comprehensive evaluations will potentially be quite fruitful.

(3) Medication Response (Positive or Negative) in Conjunction with Patterns of Neurological Findings. Another interesting and quite important line of subtyping research is being conducted by Dr. Urion at Children's Hospital in Boston. He has done a study with 176 boys (9 to 11 years old) to appear in the Journal of Child and Adolescent Psychopharmacology. In his first retrospective study, Urion (1989) looked at youngsters' ritalin response in conjunction with neurological findings (patternings of soft and hard signs) to identify three sub-groups among youngsters who had met diagnostic criteria for ADHD: (1) One group of youngsters who responded positively to ritalin (e.g., alleviation

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of distractibility) and whose reticular activating system may be affected as seen on a neurological exam (he termed this group the the "low risk, high yield group" meaning low risk of adverse medication effects and very therapeutic); (2) A second group, in which only one fifth of the youngsters responded to ritalin and evidenced mild frontal lobe findings on a standard neurological exam (the "low risk, low yield group"); (3) A third group which included youngsters who quickly experienced complicating side effects to Ritalin and evidenced an abnormal neurological exam with parietal lobe dysfunction (this was called the "high risk, low yield group"). Due to the negative side effects (the "high risk") these children's Ritalin medication was immediately discontinued. Urion is now replicating and extending these retrospective study findings with three additional studies: a prospective study (with 150 children) again focusing on Ritalin response, a brain scan study (with 40 children), and a comparative study using another stimulant medication (desipramine) which in some important way seems to work on neural transmitters that are related to the frontal lobes and not the reticular activating system. Preliminary results from the desipramine study and the prospective study reportedly replicate the three sub-groups described above (Urion 1994). (4) Children with ADHD Who Underfocus Versus Overfocus. It has been suggested that distinguishing between youngsters who overfocus as opposed to underfocus may be another subtype classification of attention deficit/hyperactive disorders (Kinsbourne 1991). Kinsborne suggests that both subgroups are inattentive to ongoing instruction. More typically, the impulsive and sensation seeking temperament of many ADHD youngsters causes inattention due to rapid attentional shifting or "underfocusing." On the other hand, it is suggested that overfocusers become "stuck" or overly focused on an earlier stimulus. Based on a series of studies using Kinsbourne's Focus of Attention Rating Scale and the DSM-III diagnostic criteria, the overfocuser tended to show the following patterns in contrast to the more usual underfocusers: overfocusers will finish things that they start, but may still be doing it "tomorrow"; they tend to evidence preservative trends and hence do not often "act before thinking"; they act impulsively only when trapped in situations in which they cannot avoid becoming overstimulated; they do not have "difficulties waiting their turn in games or group situations" tending instead to hang around the fringes, waiting longer than necessary; they do not show characteristic ADHD

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impulsive and hyperactive behavior (e.g., difficulty staying seated, fidgeting when seated, running and climbing excessively). In short, they do not really have difficulty sustaining attention because they sustain it to excess. In addition to these difficulties, Kinsborne has identified a number of additional characteristics of the overfocused group of "attentionally disordered" youngsters. They tend to be shy and withdraw socially, and are unskilled interpersonally (especially with strangers). They prefer sameness and are upset by changes in routine; they tend to work slowly and may be compulsive. They resist being hurried or told to do more than one thing at a time. They evidence organizational difficulties, especially at the beginning of tasks. They are bothered by loud noises, they evidence a narrow scope of interest, they are worried and anxious, they have difficulty reading nonverbal cues (e.g., faces), they have difficulty remembering more than one thing at a time, they are quite vulnerable to explosive outbursts, and they tend to engage in repetitive movements. This sub group of youngsters does not appear to evidence simply an attentional disorder. As can be seen from Kinsbourne's description, these youngsters display a number of social/communicative and right hemisphere related difficulties. Kinsbourne postulates that the attentional disorder of overfocusing may be an attempt to correct for an underlying, unstable arousal system. This may in fact be true. However, attention is only one of the difficulties these youngsters experience. In fact, overfocusing youngsters may very well evidence a high level autistic disorder or a form of what has been labeled a nonverbal learning disability (Allen 1988; Denckla 1989). (5) "ADHD" Resulting from Depression. Some investigators suggest that there is a subgroup of children diagnosed with ADHD who in fact evidence an underlying biological depressive disorder (see Brumback and Weinberg 1990 for a recent review). Brumback and his colleagues suggest that there is interesting evidence from a number of studies that depression may be involved when the child presents with an array of right hemisphere-related problems (e.g., visual-motor disabilities, developmental apraxia or dysgraphia, developmental Gerstmann syndrome, a n d / o r developmental dyscalculia). They suggest that the pharmacological treatment of the disorder with anti-depressant medication results in the eradication of the attentional symptoms as well as the depression and associated right-hemisphere-related learning disabilities. Although this may account for but a small subset of children diagnosed with ADHD, what is dear is that there can be

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and often is a complicated relationship between attentional disorders and depressive disorders. Attentional disorders can and often do result in (understandable) reactive depressive concerns. And, biological depressive illness (uni-polar or bi-polar disorders) can result in attentional problems. It is to these issues that we now turn. Affective Disorders

Depression is a word that has many meanings and in fact, there is a spectrum of types of depression that children and adults may experience. On the one hand, most children and all adults normatively feel a bit "down" or "blue" sometimes. At the other end of the spectrum is severe, debilitating, and even life threatening depressive illness. Here I will not be focusing on normative moments of feeling "down." Rather, I refer to the range of depressions that include a variety of behaviors (e.g., listlessness, loss of energ~ tearfulness, and loss of interest for playing), symptoms (e.g., depressed mood/sadness, little capacity for pleasure, self-deprecatory thoughts, low self-esteem, hyperactivity, distractibility, and suicidal thoughts and attempts) and signs (e.g., sad, dejected faces, loss or increase of appetite, and weight loss or gain) (Stavrakaki 1989). The term affective disorder is usually used to describe pathological mood states in which depression or elation are significant and problematic. Many parents and professionals think, and understandably wish, that it is rare for children to present with affective disorders. However, recent research and clinical practice suggest that various types of depressive disorders are in fact much more common than we had realized. For example, although epidemiological studies yield varied estimates, a recent study found that 8 to 9 percent of children from 10 to 13 years old experience a major depression in the course of a year; roughly 4 percent of the children showed a more mild or dysthymic depression (Cohen et al. 1993). Importantl~ researchers have also found that depressed children are at risk for suffering further depressions in the years to come (Kovacs et al. in press; Kovacs et. al. 1984). As children move into the adolescent years, the rates of depression dramatically increases. Hence, it is important that parents, educators, and health care providers be attuned to the signs and symptoms of depression in childhood and understand how it may be related to attentional, reading, and other learning problems. It is clinically and educationally important to recognize when a child is depressed and what the nature of the depres-

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sion is. As noted above, learning disabilities place children at risk for developing a low level depression and related concerns about having lost a part of themselves (Cohen 1985). And, depression--regardless of the cause can interfere with concentration, memory, thinking, learning, and social interaction in myriad complicating ways (Bettleheim and Zelan 1982; Kovacs et al. in press). Finally, as I detail below, certain depressive illnesses can also result in symptoms that look like ADHD. Attenfional disorders and affective disorders can be confusing for differential diagnosis (e.g., Brumback and Weinberg 1990; Jenson, Burke, and Garfinkel 1988). They share symptoms and they may co-exist within a given child. My own clinical experience indicates that childhood ADHD sometimes seems to convert into a major depression in late adolescence or young adulthood and this is supported in other clinical anecdotal reports (e.g., Popper 1990; Schmidt and Fredson 1990). This pattern, however, has not been supported in the few research studies that have looked for it (e.g., Barkley 1990; Mannuzza et al. 1991). Nonetheless, other investigators are beginning to believe that ADHD may be a form of an "affective spectrum disorder." In particular, there is evidence that there may be a common underlying physiological basis to major depression and ADHD as well as the following six disorders: bulimia, panic disorder, obsessive compulsive disorder, migraine, irritable bowel syndrome, and cataplexy (Hudson and Pope 1990). This point of view overlaps with Brumback's idea noted above, that certain biological depressive disorders--particularly when there is a pattern of right hemisphere-related problems--results in ADHD symptoms. In my own experience, it is often difficult to tell whether a child has ADHD a n d / o r an affective disorder. All of the features of ADHD can be seen in mood disorders at times, so ADD is a diagnosis that we reach after ruling out a mood disorder (e.g., Kestenbaum 1992; Popper 1989). Here, I summarize the major similarities, slight differences, and significant differences between ADHD and affectively disordered children (youngsters with a bi-polar illness or a major depression) based on clinical evidence: (1) Similarities: Both ADHD and affective disordered children can show problems with attention, impulsivity, hyperactivity, labile emotional and behavioral control, and low energy level (although ADHD youngsters can also show normal or increased energy level). Motor restlessness during sleep may be seen in both groups (bipolar children are physically restless at night when "high" though they may have little physical motion

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during sleep when "low"). Both groups present self-image problems and problems with school learning. Stimulant and antidepressant medications are often helpful for both groups and the family history often includes mood disorders. (2) Slight differences: In general the mood of the affectively disordered children tends to be sad whereas the ADHD child is more likely to be labile and intermittently dysphoric. Both groups of children can act destructively, but the mood disordered youngster tends to do so in anger and the ADHD is destructive not only when angry, but when careless as well. The appetite of the ADHD children tends to be normal or increased, whereas the mood disordered child's appetite tends to be poor or increased. In bi-polar cases, we see marked fluctuations. (3) Significant differences : The sleep difficulties of the mood disordered child tend to take the form of insomnia or too much sleep, sometimes with severe nightmares.With the ADHD youngster, we can see sleep arousal imbalances with occasional difficulty falling asleep. The interest in children with ADHD often seems inconsistent, whereas the interest of a mood disordered youngster is lessened with a loss of interest or pleasure in usual activities. Suicidal intent or thought is common with the mood disordered child and much more rare for the ADHD youngster. Finally, psychotic symptoms and primary process thinking sometimes occurs in the mood disordered child but is extremely rare in the ADHD child. Another major diagnostic marker that usually aids in differential diagnosis is frequency of symptoms. Whereas ADHD is marked by relatively chronic and pervasive symptomatology, mood disorders tend not to be chronic, but cyclical a n d / o r recurrent a n d / o r increasing in severity. When ADHD is a factor, we sometimes see a positive family history for this disorder. The parent (more often the father) often does not realize that he too, evidenced (and may still evidence) ADHD until the diagnosis of his child is underway. The consequences of ADHD (lack of control, frustration, and often academic and social difficulties) do diminish opportunities for pleasure, and can result in a psychogenic depressive disorder, which is referred to as a "dysthymic disorder" or "dysthymia." The fact that this is often not recognized and addressed is one of the reasons so many of these children go on to develop moderately severe-to-severe character pathology and maladaptive behavioral patterns. However, in considering the diagnosis of dysthymia, the clinician must be aware that a key diagnostic issue may be de-

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termining whether irritable mood stems from symptoms of helplessness and depression or is simply a characteristic of the ADHD child's overarousal and impulsivity. ADHD youngsters with significant overarousal and hyperactivity problems and long histories of environmental failure appear to be at greater risk to develop symptoms of dysthymia (Weiss and Hechtman 1993). In fact, DSM-III-R notes that ADHD is a predisposing factor for dysthymia. In summary, there are a variety of complex ways that reading, attentional and depressive problems in childhood may be interrelated. A significant and primary problem in one of these areas may result in symptomotology in another area. One disorder may produce signs and symptoms that look like another problem. Or, a child may present with two or even three primary problems that potentially will all intensify each other. This paper has primarily been an attempt to present current clinical and research findings about differential diagnosis which may be helpful to parents, educators, and heath care professionals. The more parents and professionals can understand the specific nature of a child's difficulties, the more we can intervene in the most helpful manner. Specific understanding also allows us to be more empathic to a child's experience, which is always one of the single most important things we can do. Let me close with a word of caution. Differential diagnosis and the specification of a child's problems should be one of the first steps in understanding and attempting to help children who are having trouble learning. Too often this process is not only a first step but also the last step: the process ends with labels that in and of themselves are not actually helpful to teachers, parents, and child (Cohen 1994). Clearly, we must move beyond labels to consider intervention and treatment implications of childhood reading, attentionaI a n d / o r affective difficulties. Although it is beyond the scope of this paper to detail these implications, it is worth underscoring several basic principles to put the present discussion in a useful context. It is usually only when we understand a child's developmental phase and stage, strengths as well as weaknesses and work with the "whole" child, his or her parents and the school that we can be helpful in the long run. For example, pharmacological treatment (e.g., ritalin) can often eradicate the primary symptoms of ADHD (distractibility, impulsivity, a n d / o r hyperactivity). And yet follow-up research suggests that medication alone is not sufficient (Weiss and Hechtman 1993). Children who were treated with medication alone (which w a s sympto-

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matically effective) tended to do poorly ten and twenty years later. Children whose treatment also included work with the family, the school and their emotional life fared dramatically better. This is not surprising given the complex interactions discussed in this paper. Regardless of the source of the difficulty, a youngster will attribute conscious and unconscious meanings to the problem (and how others have labeled and treated the problem), and family members will be (dis)stressfully affected. School performance, peer and teacher's perceptions, and other reactions can also have important effects on the course of a child's life. In sum, effective treatment needs to integrate a specific understanding of the problem, the child's strengths and psychological, as well as community and family, dynamics.

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