Case Files Pediatrics, (LANGE Case Files) 4th Ed.

CASE 52

The mother of a healthy 8-year-old boy is concerned about his school performance. At the last parent–teacher conference, his teacher noted that he is easily distracted and routinely fails to complete both homework assignments and classroom papers. His mother states that at home he also has difficulty in completing tasks and he fidgets constantly. Although the child is very talkative, he does not answer questions clearly. His physical examination is significant only for fidgeting.

Image What is the most likely diagnosis?

Image What is the next step in management?

ANSWERS TO CASE 52: Attention-Deficit/Hyperactivity Disorder

Summary: An 8-year-old easily distractible, hyperkinetic boy who cannot complete school work or stay on task at home.

• Most likely diagnosis: Attention-deficit/hyperactivity disorder (ADHD).

• Next step in management: An ADHD evaluation, which includes information regarding his behavior obtained from both the caregiver and the classroom teacher.

ANALYSIS

Objectives

1. Understand the basic evaluation of the child with symptoms of ADHD.

2. Know the various treatment options available for this condition.

Considerations

This boy exhibits ADHD behaviors, including easy distractibility, inability to focus and complete tasks, and excessive fidgeting. The next step is a complete ADHD evaluation as described. If data suggest ADHD, he should undergo developmental and psychological evaluations for coexisting psychiatric conditions or learning disability. Target outcomes then can be identified and a behavioral therapy, classroom modification, and possibly medication treatment plan designed.

APPROACH TO:

Attention-Deficit/Hyperactivity Disorder

DEFINITION

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD): A condition consisting of developmentally inappropriate inattentiveness, hyperactivity, and impulsivity.

CLINICAL APPROACH

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes criteria of inattentiveness and hyperactivity/impulsivity necessary to make an ADHD diagnosis. Attention-deficit/hyperactivity disorder is estimated to affect 3% to 10% of school-aged children with a significant male predominance; 25% of ADHD patients have an affected primary relative. The pathophysiology of ADHD remains to be elucidated, but decreased activity of certain brain regions in the frontal lobes may be responsible.

Inattention criteria of ADHD include careless mistakes, having difficulty paying attention, not listening, not completing assigned tasks, avoiding sustained mental effort, frequently losing things, easy distractibility, and forgetfulness.

Hyperactivity criteria of ADHD includefrequent fidgeting, being out of his or her seat frequently, running or climbing excessively, having difficulty playing quietly, and often talking excessively.

Impulsivity criteria of ADHD includeblurting out answers, having difficulty waiting for his or her turn, and interrupting or intruding frequently.

Attention-deficit/hyperactivity disorder is subdivided into three types: ADHD/I (at least 6 of 9 inattention behaviors), ADHD/HI (at least 6 of 9 hyperactive/impulsive behaviors), and ADHD/C (at least 6 of 9 of both the inattention and hyperactive/impulsive behaviors). Symptoms must be present for at least 6 months in two or more settings, some symptoms must have been present before the age of 7, and symptoms must result in impaired function. Caregivers and classroom teacher(s) provide the critical information by filling out checklists, such as the Conners rating, the AHDH index, the Swanson, Nolan, and Pelham checklist (SNAP), or the ADD-H comprehensive teacher rating scale (ACTeRS). Alternatively, information can be surmised through narratives or descriptive interviews.

Psychological and developmental testing is part of the evaluation of an ADHD child; coexisting psychological and learning disorders occur frequently. Common coexisting conditions include oppositional-defiant disorder (35.2%), conduct disorder (25.7%), anxiety disorder (25.8%), and depressive disorder (18.2%). Approximately 12% to 60% of ADHD children have concurrent learning disorders and may benefit from special education services.

Management includes the implementation of a long-term treatment program in collaboration with caregivers and teachers. The care plan includes setting specific goals such as increasing independence, decreasing disruptive behavior, improving academic performance, organization, and task completion, and improving relationships with family members, teachers, and peers. Behavioral modification can be used alone or in conjunction with pharmacologic therapy. Positive reinforcement (providing rewards or privileges) and negative consequences (time-out or withdrawal of privileges) emphasize appropriate behavior. Small class size, structured work, stimulating schoolwork, and appropriate seating arrangements can help decrease disruptive classroom behaviors. Medications are often used to assist in treatment. Stimulant medications are considered first-line pharmacologic therapy to decrease ADHD behaviors. Commonly used stimulant medications include methylphenidate and dextroamphetamine. Atomoxetine (Strattera) is a nonstimulant, selective norepinephrine reuptake inhibitor approved for use in adults and children. Tricyclic antidepressants, clonidine and bupropion, often prescribed under the direction of a psychiatrist or neurologist, are also used.

Long-term sequelae of ADHD include poor peer relationships, poor fine motor control, and increased risk of accidents. Adolescents may develop substance abuse problems as a comorbid condition, but this comorbidity does not seem to be related to treatment of ADHD with stimulants. Approximately 50% of children function well in adulthood; others demonstrate continued inattention and impulsivity symptoms.

COMPREHENSION QUESTIONS

52.1 An 8-year-old boy presents because his mother is concerned that he has ADHD. At home he is always restless, never seems to pay attention, and is always losing things. In the clinic, the child is cooperative and has a normal examination. Which of the following is the best next step in management?

A. Give the child a 2-week trial of stimulant medication.

B. Obtain further information from the parents and teachers.

C. Reassure the child’s mother that this behavior is age appropriate.

D. Send the child for psychological assessment.

E. Send the child for psychiatric evaluation.

52.2 A 7-year-old boy appears distracted. His mother notes that he daydreams “all of the time,” and when he is daydreaming he does not respond to her. She describes the episodes as short (lasting several seconds) and occurring many times per day. When he is not daydreaming, he is attentive and can complete tasks. His behavior in class is not disruptive. Which of the following is the best next step in management?

A. Obtain further information from his parents and teachers with the Conners rating scale.

B. Begin a program of behavioral modification.

C. Reassure the child’s mother that this behavior is age appropriate.

D. Send the child for an electroencephalogram.

E. Send the child for psychological assessment.

52.3 A 14-year-old adolescent male was recently diagnosed with ADHD. His evaluation for coexisting psychiatric disorders is most likely to identify which of the following?

A. Bipolar disorder

B. Oppositional-defiant disorder

C. Pervasive developmental disorder

D. Posttraumatic stress disorder

E. Schizophrenia

52.4 An 8-year-old boy has completed the initial ADHD evaluation, which demonstrates that he meets 7 of the 9 criteria for inattention and that he also has many impulsive behaviors. Which of the following is the most appropriate next step in management?

A. Give the child a 2-week trial of stimulant medication.

B. Arrange for special education placement.

C. Send the child for a complete psychoeducational assessment.

D. Send the child for an electroencephalogram.

E. Reassure the child’s mother that this behavior is age appropriate.

ANSWERS

52.1 B. A physical examination (with emphasis on the neurologic component) is completed to identify any soft signs of neurologic conditions. If none are found, he should undergo an ADHD evaluation with ADHD-specific behavior information obtained from caregivers and teachers. A diagnosis is considered if he has ADHD-specific behaviors in two or more settings. His ability to maintain focus during a brief visit to your clinic does not preclude the diagnosis of ADHD.

52.2 D. This child does not fit the classic ADHD pattern. Episodes of “daydreaming,” which last several seconds, may be petit mal or absence seizures; an electroencephalogram is needed.

52.3 B. Common coexisting psychiatric conditions include oppositional-defiant disorder (35.2%), conduct disorder (25.7%), anxiety disorder (25.8%), and depressive disorder (18.2%).

52.4 C. Prior to developing a management plan, the child is assessed for coexisting psychiatric and learning disorders (psychoeducational testing). Management can include stimulant medication, behavioral modification, and therapy appropriate for coexisting conditions.


CLINICAL PEARLS

Image Attention-deficit/hyperactivity disorder (ADHD) is considered in children who have specific behaviors in two or more settings, such as at home and school or work.

Image Children with ADHD frequently have coexisting psychiatric or learning disorders, including oppositional-defiant disorder, conduct disorder, anxiety disorder, and depression.

Image Commonly used pharmacologic agents for treatment of ADHD are methylphenidate and dextroamphetamine.


REFERENCES

American Academy of Pediatrics. Clinical practice guideline: diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder. Pediatrics. 2000; 105:1158-1170.

American Academy of Pediatrics. Clinical practice guideline: treatment of the school-aged child with attention-deficit/hyperactivity disorder. Pediatrics. 2001; 108:1033-1044.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (Text Revision). Washington: American Psychiatric Association; 2000:92.

Cunningham NR, Jensen P. Attention deficit hyperactivity disorder. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: WB Saunders; 2011:108-112.

Cutting LE, Mostofsky SH, Denckla MB. School difficulties. In: McMillan JA, Feigin RD, DeAngelis CD, Jones MD, eds.Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:674-680.

Stein MT, Reiff MI. Hyperactivity and inattention. In: Rudolph CD, Rudolph AM, Lister GE, First LR, Gershon AA eds. Rudolph’s Pediatrics. 22nd ed. New York, NY: McGraw-Hill; 2011:321-327.