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Ask the father about the child’s behavior at home
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Inquire about the child’s behavior at school
No further intervention, as the child is exhibiting normal childhood behavior
Start atomoxetine
Start methylphenidate
Select Answer to see Preferred Response
This boy presents with signs of hyperactivity (fidgeting, always hyperactive, interrupting others) and inattention (not listening to his mother, fails to follow through on chores). Although these can be symptoms of attention deficit hyperactivity disorder (ADHD), symptoms must occur in at least 2 settings for the diagnosis to be made; thus, the physician should inquire about the child’s behavior in another setting (e.g., at school). ADHD is characterized by 2 core sets of symptoms: hyperactivity/impulsivity and inattention. Hyperactivity/impulsivity symptoms include excessive fidgetiness, difficulty remaining seated, difficulty taking turns, and blurting out answers too quickly. Inattention symptoms include failure to pay attention to detail, difficulty maintaining attention, distractibility, and forgetfulness. Critically, these symptoms must cause impairment in academic, social, or occupational function and must be present in at least 2 settings. If present in only 1 setting and not causing significant impairment, this could be normal behavior. Restructuring that setting could eliminate the behavior. Thus, physicians should review the child’s functioning in day care or school, obtaining collateral information from other sources as needed. Treatment of ADHD in school-aged children (≥6 years old) includes a combination of stimulants such as methylphenidate and behavioral therapy. Sibley et al. review the pharmacological and psychosocial treatment options for ADHD in adolescents. Behavioral therapy provides beneficial effects on impairment, and medication provides effective symptomatic relief. They recommend revising the current guidelines to reflect a broader scope of treatment rather than only using stimulant medications. Incorrect Answers: Answer 1: Asking the father about the child’s behavior at home may be useful if the other parent is unable to provide complete information on the child’s home behavior (e.g., joint custody). However, the mother of this patient provides an excellent description of the patient’s hyperactive and inattention symptoms at home. Asking his father about his home behavior would not provide additional information for diagnosis. Answer 3: No further intervention may be appropriate if the child is displaying normal childhood behavior. His behavior is not normal, as it is causing impairment in his function at home. Additional information about the child’s behavior in other settings is needed. Answer 4: Starting atomoxetine may be appropriate once a diagnosis of ADHD is made and the family expresses a preference for non-stimulant medications. However, additional information about the child’s behavior in other settings is needed before a diagnosis can be made. Answer 5: Starting methylphenidate may be appropriate once a diagnosis of ADHD is made, as this is generally a well-tolerated medication considered to be a first-line agent. However, additional information about the child’s behavior in other settings is needed before a diagnosis can be made. Bullet Summary: The diagnosis of attention deficit hyperactivity disorder (ADHD) requires the presence of hyperattentive/impulsive and/or inattention symptoms that cause impairment and are present across ≥2 settings.
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