Pediatric Primary Care Case Studies (45 page)

It is important to base your questions on the diagnostic criteria for ADHD listed in the
Diagnostic and Statistical Manual of Mental Disorders
, 4th edition, text revision (DSM-IV-TR; APA, 2000). Refer to
Table 12-1
and become familiar with these criteria. The child must exhibit six of nine symptoms associated with inattention or six of nine symptoms associated with hyperactivity-impulsivity to consider the diagnosis of ADHD and avoid overidentification and underidentification of the disease. The DSM-IV-TR criteria define three different subtypes of ADHD: 1) ADHD that is predominately inattentive (meets six of nine inattentive behaviors); 2) ADHD that is predominately hyperactive-impulsive (meets six of nine hyperactive-impulsive behaviors); 3) combined type ADHD (has six of nine behaviors in both the inattention and hyperactive-impulsivity behavioral realms).

Are there guidelines to help clinicians deal with ADHD problems?

A combination of open- and closed-ended questions based on DSM-IV-TR criteria (APA, 2000) will provide insight into the patient’s behavioral history and current problems. The clinician needs to develop questions that are a part of a conversation with parents and children to uncover these issues. The American Academy of Pediatrics (AAP) developed clinical practice guidelines for ADHD in 2000 that highlight the importance of obtaining input from parents, teachers, other caregivers, and professional consultants when evaluating a child for possible ADHD (American Academy of Pediatrics, 2000). Working with these individuals as members of a team will provide information to assist in making the diagnosis of ADHD to help guide you in effective patient management.

Table 12–1 DSM-IV Criteria for ADHD

I. Either A or B:

A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is disruptive and inappropriate for developmental level:

Inattention

1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.

2. Often has trouble keeping attention on tasks or play activities.

3. Often does not seem to listen when spoken to directly.

4. Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).

5. Often has trouble organizing activities.

6. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).

7. Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools).

8. Is often easily distracted.

9. Is often forgetful in daily activities.

B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:

Hyperactivity

1. Often fidgets with hands or feet or squirms in seat.

2. Often gets up from seat when remaining in seat is expected.

3. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

4. Often has trouble playing or enjoying leisure activities quietly.

5. Is often “on the go” or often acts as if “driven by a motor.”

6. Often talks excessively.

Impulsivity

1. Often blurts out answers before questions have been finished.

2. Often has trouble waiting one’s turn.

3. Often interrupts or intrudes on others (e.g., butts into conversations or games).

 II. Some symptoms that cause impairment were present before age 7 years.

III. Some impairment from the symptoms is present in two or more settings (e.g., at school/work and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

 V. The symptoms do not happen only during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder. The symptoms are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or a personality disorder).

Based on these criteria, three types of ADHD are identified:

1. ADHD,
Combined Type
: if both criteria 1A and 1B are met for the past 6 months

2. ADHD,
Predominantly Inattentive Type
: if criterion 1A is met but criterion 1B is not met for the past 6 months

3. ADHD,
Predominantly Hyperactive-Impulsive Type
: if criterion 1B is met but criterion 1A is not met for the past 6 months.

Source:
American Psychiatric Association. (2000).
Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text rev.). Washington, DC: American Psychiatric Association.

Further questioning provides the following information about the history of these behaviors. Jason has always been a very active boy. The mother describes him as “on the go and all boy since he could walk.” He attended a preschool class 2 days each week for 3 hours per day at age 4 years and got along well except for trouble sharing and an occasional disagreement with peers. At that time he was described as “energetic” and “loud” on caregiver reports. There has been some concern about behavior since he began kindergarten. He has always been more loud and restless than his peers. Teachers have complained that Jason requires frequent redirection in the classroom. He has performed well academically until this year. Though he was always disorganized and messy, he made A’s and B’s on most papers in first and second grade. He had no problem learning to read, but does not enjoy sitting and reading because he would rather do something active. This has become a problem area because more reading has been required at school this year. Currently, there is less directed study and more independent study expected within the classroom. Jason cannot keep on task and often interrupts other students while they are working. When asked to complete assignments, he often gets up from his seat. He runs in the hall when the class moves between classrooms. He rarely completes an assignment unless there is one-on-one encouragement from the teacher. His work contains many careless mistakes despite his ability. He has academic potential, as suggested by his scoring above the 90th percentile on the state standards test last spring; however, he has fallen behind this school year in reading and mathematics. He is currently making all D’s on his report card. He usually makes B’s on tests, but only turns in half his homework assignments, which has a negative impact on his overall grades.

What additional information might be helpful in evaluating this patient?

It is important to rule out other medical and psychological causes of inattention and poor behavior when evaluating a child for ADHD. A thorough medical history and review of systems should be performed to exclude other conditions in the differential diagnosis.
Table 12-2
provides a differential diagnosis list to consider when evaluating a child for possible ADHD. The history should include questions about:

•   Pregnancy, delivery, and developmental milestones

•   Sleep and dietary habits

•   Family dynamics to rule out family stress or dysfunction as the cause of behavioral problems.

•   Possible environmental relationships such as lead poisoning or Lyme disease, if the history warrants consideration.

As you listen to parents and children discuss pertinent information about behavior, consider comorbid disorders being present that may obscure or make the diagnosis less clear. They include conduct disorder, oppositional defiant disorder, and bipolar disorder, which are more common in children with ADHD (Biederman, 2004). These comorbidities can result in incorrect diagnoses and/or inappropriate treatment. For example, treating a bipolar child with a stimulant medication can cause behavior to deteriorate. Comorbid conditions must be considered alone and as potentially existing in conjunction with ADHD for the child to receive appropriate treatment.

Jason perceives himself in a negative way, as his earlier comments suggest. Some children with ADHD become depressed to some degree because of the recurring negative interactions or consequences brought about by their behavior. This depression and low self-esteem often improve when the symptoms of ADHD are treated. Persistent depression warrants referral to a psychologist.

What findings are important on the physical examination?