A 9-year-old boy is brought to the office by his parents for evaluation of behavioral concerns. His mother says that the patient never listens, gets distracted easily, and is hyperactive all the time. He is unable to sit still at the dinner table, constantly interrupts her when she is speaking on the phone, and makes excuses for forgetting his chores. The father says his wife is "overreacting" and that the patient has always been very active. He adds, "I was the same way as a kid; I am sure he'll grow out of it just like I did." There have been no changes in the patient's appetite or sleep. He has friends at school and likes to play sports and video games. Physical examination is remarkable for a scar on his right leg and multiple scabs on his right knee, which he reports are due to falling off his bike and skateboard. The remainder of the physical examination is normal. The mother asks if there is any medication that can help "calm him down." Which of the following is the most appropriate next step in management?
Attention deficit hyperactivity disorder | |
Clinical |
|
Treatment |
|
Attention deficit hyperactivity disorder (ADHD) should be considered when a child has academic or behavioral concerns and symptoms of inattention (eg, "never listens," "gets distracted easily," forgets chores), hyperactivity (eg, "unable to sit still," "constantly interrupts"), or impulsivity (eg, recurrent injuries). However, a diagnosis requires 6 months of ≥6 inattentive or ≥6 hyperactivity/impulsivity symptoms in 2 or more settings (eg, social, academic, occupational).
In this case, there are symptoms only in the home setting and there is a disagreement between the parents on the symptom severity. Therefore, the best next step is to reach out to collateral informants (eg, teachers, coaches) for information about similar behaviors in other settings. Behavioral rating scales are often provided to teachers because they can report on the presence or absence of symptoms (eg, losing assignments, difficulty staying seated, disrupting peers) in another setting. Rating scales also provide information for other possible causes of inattention or behavioral symptoms (eg, anxiety, oppositional defiant disorder, conduct disorder).
If the collateral information helps establish an ADHD diagnosis, the next step would be discussing medication options (eg, stimulants [methylphenidate], norepinephrine reuptake inhibitors [atomoxetine], alpha-2 adrenergic agonists) (Choices A and B). However, if an ADHD diagnosis is not supported, behavioral interventions (eg, to-do lists, daily schedules) combined with parental support (eg, Parent Management Training) would be indicated to manage this child's symptoms.
(Choice C) Separate parent interviews may be helpful if a parent is quiet or not contributing during the interview. However, in this case, both parents have already expressed their opinions about the patient's behavior.
(Choices E and F) This patient's behavioral symptoms are clearly impacting his home functioning and are distressing to his mother. It would be inappropriate to minimize these symptoms as age-appropriate when potentially effective interventions can be offered and should not be delayed for a "wait-and-see" approach. Collateral information should be pursued without unnecessary delay.
Educational objective:
The diagnosis of attention deficit hyperactivity disorder is based on clinical evaluation of symptoms plus associated impairment in 2 or more settings. Teacher-completed behavioral rating scales are an important tool for obtaining collateral information about school functioning and can assist with diagnosis.