Chapter 27 Attention-Deficit/Hyperactivity Disorder (Case 1)
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
History
Physical Examination
Tests for Consideration
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.
• 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).
Diagnosis of ADHD can be divided into three subtypes:
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• 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 | |
