DIFFERENTIAL DIAGNOSIS — The symptoms of ADHD overlap with a number of other conditions, including

developmental variations, neurologic or developmental conditions, emotional and behavioral disorders,

psychosocial or environmental factors, and certain medical problems (table 1) [1,2,94-96]. Some of these
conditions can coexist with ADHD and may or may not be responsible for some of the symptoms (eg, children
who have learning disabilities may develop inattention as a result of an inability to understand new information)
[97]. These conditions usually can be differentiated from ADHD with a thorough history and/or the use of a
broadband behavior rating scale. If the diagnosis remains uncertain, psychometric testing or a mental health
evaluation may be necessary. (See 'Coexisting disorders' above.)

●Developmental variations – Developmental variations include intellectual disability, giftedness, and

behaviors that are within the normal range for the child's level of development and do not impair function
(eg, a short-attention span or increased motor activity in a preschool child; occasional impulsivity in a
school-age child) [94,95,98]. (See "Intellectual disability in children: Definition, diagnosis, and assessment
of needs" and "Intellectual disability in children: Evaluation for a cause".)

When considering behaviors that are within the normal range for the child's level of development, age and
maturity are more important than grade level [99]. In observational studies, younger age for a particular
grade level has been associated with increased diagnosis of ADHD [95,100-103], suggesting that
developmental immaturity may account for some behaviors that are attributed to ADHD.

Children with developmental variations do not meet the full criteria for ADHD. (See 'Diagnostic
criteria' above.)

●Neurologic or developmental conditions – Neurodevelopmental conditions that can mimic or co-occur

with ADHD include [94,104,105]:

•Learning disabilities (see "Specific learning disabilities in children: Clinical features")

•Language or communication disorders (see "Etiology of speech and language disorders in children")

•Autism spectrum disorders (ASD); it is particularly important to consider ASD in preschool children
with symptoms of ADHD [105] (see "Autism spectrum disorder: Clinical features")

•Neurodevelopmental syndromes (eg, fragile X syndrome, fetal alcohol syndrome, Klinefelter

syndrome) (see "Fragile X syndrome: Clinical features and diagnosis in children and
adolescents" and "Fetal alcohol spectrum disorder: Clinical features and diagnosis")

•Seizure disorder (see "Seizures and epilepsy in children: Classification, etiology, and clinical
features")

•Sequelae of central nervous system infection or trauma (see "Bacterial meningitis in children:

Neurologic complications", section on 'Neuropsychologic impairment')

•Metabolic disorders (eg, adrenoleukodystrophy, mucopolysaccharidosis type III)

(see "Adrenoleukodystrophy" and "Mucopolysaccharidoses: Clinical features and diagnosis", section
on 'MPS type III (Sanfilippo syndrome)')

•Motor coordination disorders (see "Developmental coordination disorder: Clinical features and

diagnosis")
 These disorders usually can be distinguished from ADHD through history and examination.
Specialized testing may be necessary in some circumstances (eg, psychometric testing for learning
disabilities; genetic testing for fragile X syndrome; electroencephalography for seizure disorder;
occupational therapy evaluation for motor coordination disorder, etc).

●Emotional and behavioral disorders – Emotional and behavioral disorders that can mimic or co-occur
with ADHD include anxiety disorder, mood disorders, oppositional defiant disorder, conduct disorder,
obsessive-compulsive disorder, posttraumatic stress disorder, and adjustment disorder. The use of a
broadband behavior scale may be helpful in the assessment of these disorders. However, evaluation by a
mental health professional generally is necessary for diagnosis. (See 'Coexisting disorders' above
and 'Behavior rating scales' above and 'Indications for referral' below.)

●Psychosocial and environmental factors – Environmental factors that can contribute to inattention,
impulsivity, or hyperactivity include a stressful home environment or an inappropriate educational setting.
In contrast to ADHD, psychosocial and environmental factors generally affect behavior only in one setting
(eg, at home but not at school, or at school but not at home). Parent-child temperament or "personality"
mismatch and parental mental health conditions (particularly maternal depression) can contribute to
parent report of ADHD-type symptoms in the home setting. However, mothers of ADHD children with
limited resources or support may also develop stress-related mental health conditions; in such
circumstances, multiple respondent (eg, teacher, coach) reports help to confirm the diagnosis of ADHD.

●Medical conditions – Medical conditions that may have clinical features that mimic ADHD include
hearing or visual impairment, lead poisoning, thyroid abnormalities, sleep disorders (eg, obstructive sleep
apnea, restless leg/periodic limb movement disorder), medication effects (eg, albuterol), and substance
abuse disorders [15,18,106]. These conditions usually can be differentiated from ADHD because their
symptoms fluctuate with the disease course or exposure to medication. In contrast, the symptoms in
ADHD are persistent and pervasive.

Differential Diagnosis
There are diagnostic rule-outs for the clinician to consider. In the DSM -5, disorders such as

ODD (Oppositional Defiant Disorder) ADD/ADHD, (Attention Deficit Disorder/Attention Deficit Hyperactivity
Disorder) bipolar disorder, adjustment disorder, IED (Intermittent Explosive Disorder), and substance use
disorders are recommended rule-outs (American Psychiatric Association, 2013). ODD will is typically
diagnosed in younger children, and involves a pattern of acting out and rebelliousness toward adults,
refusal to follow directives from elders, and deliberate efforts to annoy adults. ADD/ADHD will involve
inability to maintain attention and focus, or if the hyper-kinetic component is present, inability to sit in one
place, or contain behavior. The person with ADD/ADHD may desire to conform their behavior to parental
directives, or societal norms, but be unable to, but do not have malicious intent toward others. The manic
phase of Bi-polar disorder may involve reckless and impulsive behavior, but the etiology and course are
very different than Conduct Disorder. Adjustment disorders tend to be traceable to a specific stressor or
series of stressors, and tend to resolve over time, IED involves discrete period of explosive anger and
acting out, but may be accompanied by remorse and regret after the outburst. Behavior while under the
influence of drugs or alcohol will be altered, and drug seeking behavior will typically progress to
abandoning moral standards. There is a high comorbidity with Conduct Disorder and substance abuse
disorders, but they are discrete diagnoses (American Psychiatric Association, 2013).