A case presenting the obstacles to accurate diagnosis of pediatric mental health disorders

Background: The diagnosis of psychiatric disorders in children presents unique obstacles, including parental perceptions of mental health disorders, failure of providers to address behavioral concerns, and limited report of symptoms due to limited history from child and caregivers. The most common mental health disorder diagnosed in children in the United States is ADHD, with the CDC estimating the national prevalence is 6.1 million in those aged 2-17 years. The importance of accurately diagnosing a mental health disorder can greatly impact a child's outcomes, including access to resources. Case information: A 9-year old African-American male presented for a follow up visit for ADHD at an outpatient clinic. Past medical history included ADD/ADHD, intellectual disability, and asthma. The patient had been diagnosed with ADHD combined type, with initial testing being performed at the office of a primary care provider five years previously. ADHD medication had been trialed with no improvement of symptoms. In addition, patient's symptoms (including hyperactivity, excessive verbal repetition, and difficulty concentrating) had been prevalent at home, but had not been demonstrated at school. Family history included paternal intellectual disability. Physical examination, focused on neurological exam, revealed no abnormalities. Despite the previous diagnosis of ADD/ADHD, the case warranted further workup due to presence of symptoms in only one setting, and co-diagnosis of intellectual disability. The patient was referred for further psychological testing in order to ensure that the correct diagnosis is made, and was connected to community resources. Conclusion: This case illustrates the unique presentation of mental health disorders in children, and the obstacles to appropriate diagnosis and treatment. This case also illustrates the importance of appropriately diagnosing mental health disorders when there are multiple diagnoses; despite the diagnosis of ASD and intellectual disability, it is possible the patient may have an entirely different disorder, such as Autism Spectrum Disorder, and full psychological evaluation is warranted.