Attention-Deficit/Hyperactivity Disorder (Case 1)

Chapter 27 Attention-Deficit/Hyperactivity Disorder (Case 1)



Amanda E. Bennett, MD, MPH , Nathan J. Blum, MD




Case


The parent of a 7-year-old boy is concerned about his performance in first grade. He makes careless mistakes and often does not complete his work. He is loud, calls out inappropriately, and makes noise in class and typically does not follow instructions at home or school.




Differential Diagnosis











Attention-deficit/hyperactivity disorder Learning problems
Other developmental or behavioral problems Sleep disorder


Speaking Intelligently


When I consider a diagnosis of attention-deficit/hyperactivity disorder (ADHD) in a child with school performance or behavioral problems, I take a history seeking information about the core symptoms of ADHD (inattention, impulsivity, and hyperactivity) as well as other possible medical, emotional, and environmental contributing factors. Specific information about behaviors, including frequency, will help in assessment about whether they are developmentally inappropriate and functionally impairing. Standardized behavior rating scales completed by parents and teachers help in assessing symptom severity. Information on the child’s medical history, developmental milestones, sleep schedule, and family and peer relationships helps in assessing for other possible diagnoses.



Patient Care



Clinical Thinking



• Does the child have difficulty in multiple settings, both academic and nonacademic?

• Inattention, hyperactivity, and impulsivity are nonspecific symptoms. Exclude alternative diagnoses such as seizure disorders, sleep problems, thyroid disorders, hearing and visual deficits, or mental health problems.


History



• Are parental and teacher reports on symptoms consistent? If not, evaluation for learning and other behavioral problems will be critical before diagnosing ADHD.

• Evaluate for specific learning disability if child has difficulty learning academic skills or has a history of language delays.

• Significant developmental delay or persistent academic problems may warrant subspecialty evaluation.

• Review sleep history: Snoring with daytime fatigue suggests obstructive sleep apnea.


Physical Examination



• Vital signs: Plot height, weight, and head circumference for clues to other medical conditions. Document baseline heart rate and blood pressure in case medications are considered.

• General neurologic examination should be normal. Children with ADHD may have difficulty with coordinating rapid alternating movements or have mirror movements (i.e., moving the right hand when asked to perform sequential finger thumb opposition with the left hand or vice versa).


Tests for Consideration



• Parent- and teacher-completed behavior rating scale Free download

• Vision screening $120

• Hearing screening $250

• Thyroid function (TSH, free T4 and T3) studies in select cases $190



Clinical Entities: Medical Knowledge



















Attention-Deficit/Hyperactivity Disorder
Pϕ ADHD is a condition affecting approximately 5% to 10% of school-age children in the United States. There is a strong genetic component, because most children have someone else in the family who has ADHD. Based largely on the medications that are effective in treatment, it is believed that the dopamine and norepinephrine neurotransmitter systems are involved. Neuronal circuits involving the striatum, thalamus, and frontal lobes have also been implicated, yet specific pathophysiology is not well understood.
TP The typical child presents between 6 and 12 years of age with parental and/or teacher concerns about academic and/or specific behavioral difficulties. Symptoms of inattention, hyperactivity, and impulsivity are often first detected between 3 and 7 years of age. Some specific symptoms include difficulty sitting still; poor concentration or daydreaming; acting without thinking; difficulty completing tasks like chores, schoolwork, or homework; and interrupting others or calling out in school.
Dx Diagnosis is usually made by pediatricians, family physicians, psychiatrists, psychologists, neurologists, or clinical social workers, using criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR). Diagnostic criteria include:
• Six or more symptoms of inattention and/or six or more symptoms of hyperactivity-impulsivity from a diagnostic list of nine inattention and nine hyperactivity-impulsivity symptoms.

• Symptoms are present for at least 6 months.

• DSM-IV-TR states that symptoms must be present before age 7 years and cause impairment in social, academic, or occupational functioning. However, some children with mostly inattentive symptoms are not detected until late elementary or early middle school.

• Impairment from symptoms occurs in two or more settings (e.g., school, home, social settings with peers).

• Symptoms are not better accounted for by another mental disorder.
Diagnosis of ADHD can be divided into three subtypes:
• Attention-deficit/hyperactivity disorder, combined type if both hyperactive-impulsive and inattentive symptoms are present
 
• Attention-deficit/hyperactivity disorder, predominantly inattentive type if mostly inattentive symptoms are present

• Attention-deficit/hyperactivity disorder, predominantly hyperactive-impulsive type if mostly hyperactive-impulsive symptoms are present—this is seen mostly in children under 6 years of age
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Attention-Deficit/Hyperactivity Disorder (Case 1)

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