Transcript Case 46

Case Study 46: Attention
Deficit/Hyperactivity Disorder
By Ryan Raroque
What is ADHD?
Psychological disorder that involves significant, age inappropriate issues with any
or all of the following:
Attention
Hyperactivity
Impulsivity
Mother’s Chief Complaints
-“I’m at the end of my rope and don’t know
what to do anymore”
Mother’s Chief Complaints
-“I’m at the end of my rope and don’t know
what to do anymore”
-He won’t behave in school or listen at home
Mother’s Chief Complaints
-“I’m at the end of my rope and don’t know
what to do anymore”
-He won’t behave in school or listen at home
-He’s always in motion and can’t sit still for
five minutes
Mother’s Chief Complaints
-“I’m at the end of my rope and don’t know
what to do anymore”
-He won’t behave in school or listen at home
-He’s always in motion and can’t sit still for
five minutes
-He likes watching cartoons but gets bored
in a matter of minutes
Mother’s Chief Complaints
-“I’m at the end of my rope and don’t know
what to do anymore”
-He won’t behave in school or listen at home
-He’s always in motion and can’t sit still for
five minutes
-He likes watching cartoons but gets bored
in a matter of minutes
Mother’s Chief Complaints
-His first grade teacher says he can’t sit still at school
and constantly squirms in his seat
Mother’s Chief Complaints
-His first grade teacher says he can’t sit still at school
and constantly squirms in his seat
-Sometimes gets up in the middle of class
and roams around the room to look at
different things
Mother’s Chief Complaints
-His first grade teacher says he can’t sit still at school
and constantly squirms in his seat
-Sometimes gets up in the middle of class
and roams around the room to look at
different things
-Becomes problematic when he has to wait
for things that he wants
Mother’s Chief Complaints
-His first grade teacher says he can’t sit still at school
and constantly squirms in his seat
-Sometimes gets up in the middle of class
and roams around the room to look at
different things
-Becomes problematic when he has to wait
for things that he wants
-Always grabs things away from other
children
Mother’s Chief Complaints
-His first grade teacher says he can’t sit still at school
and constantly squirms in his seat
-Sometimes gets up in the middle of class
and roams around the room to look at
different things
-Becomes problematic when he has to wait
for things that he wants
-Always grabs things away from other
children
-Interrupts when others are speaking
Mother’s Chief Complaints
-His first grade teacher says he can’t sit still at school
and constantly squirms in his seat
-Sometimes gets up in the middle of class
and roams around the room to look at
different things
-Becomes problematic when he has to wait
for things that he wants
-Always grabs things away from other
children
-Interrupts when others are speaking
-Doesn’t wait for teacher to finish asking
a question before beginning to answer
History of Present Illness
-6-year-old boy
-Has difficulty waiting his turn
-Mom says he’s shown
hyperactive/inattentive behaviors
for almost one year
-Can’t engage in playground games
for any significant length of time
-“Everything seems to be getting
worse”
-Behavior has been so disruptive
that no daycare centers will accept
him
-Teachers complain that he doesn’t
listen or follow instructions like
other kids, gets easily bored
during activities
-Mom is a single parent and must
work to support son and herself
Past Medical History
 Son was taken to pediatrician 4 months ago for similar
symptoms; Mother’s complaints were dismissed
 Pregnancy and delivery were normal
 Vaccinations up to date
 No prior surgeries, serious medical problems, or established
psychiatric illnesses
Family History
 Father left the family before the boy was born
 Both maternal grandfather and maternal uncle have history of
hyperactivity as children
 Mother denies drug, tobacco, and alcohol abuse during
pregnancy
Family History
 Father left the family before the boy was born
 Both maternal grandfather and maternal uncle have history of
hyperactivity as children
 Mother denies drug, tobacco, and alcohol abuse during
pregnancy
Miscellaneous Information
Review of Systems
Occasional GI upset and
colds
Miscellaneous Information
Review of Systems
Occasional GI upset and
colds
Medications
None
Miscellaneous Information
Review of Systems
Occasional GI upset and
colds
Medications
None
Allergies
No Known Drug Allergies
Limited Physical Examination and Lab
Tests
Hearing
Vision
Skin
Within Normal Limits
Within Normal Limits
Warm and dry with no discoloration
Limited Physical Examination and Lab
Tests
Hearing
Vision
Skin
Within Normal Limits
Within Normal Limits
Warm and dry with no discoloration
Head, Ears, Eyes,
Nose, Throat
Neck/Lymph Nodes
Heart
PERRLA
Neck supple without
obvious nodal
enlargement or
thyromegaly
Regular Rate and Rhythm with no
murmurs, rubs, or gallops
Tympanic Membranes
intact
Nose clear
Throat without
erythema
Mucous Membranes
normal
Limited Physical Examination and Lab
Tests
Hearing
Vision
Skin
Within Normal Limits
Within Normal Limits
Warm and dry with no discoloration
Head, Ears, Eyes,
Nose, Throat
Neck/Lymph Nodes
Heart
PERRLA
Neck supple without
obvious nodal
enlargement or
thyromegaly
Regular Rate and Rhythm with no
murmurs, rubs, or gallops
Tympanic Membranes
intact
Nose clear
Throat without
erythema
Mucous Membranes
normal
Limited Physical Examination and Lab
Tests
Lungs
Genitalia
Abdomen
Clear, normal breath sounds
Normal external male
genitalia with circumcised
penis
Soft and non-tender with
normal bowel sounds and no
palpable viscera or masses
Limited Physical Examination and Lab
Tests
Lungs
Genitalia
Abdomen
Clear, normal breath sounds
Normal external male
genitalia with circumcised
penis
Soft and non-tender with
normal bowel sounds and no
palpable viscera or masses
Musculoskeletal/Extremities
Neurological
No Cyanosis, Clubbing, or Edema
Alert and Oriented
Range of motion intact
Cranial Nerves II-XII intact
Good peripheral pulses bilaterally
Deep Tendon Reflexes 3+
throughout
Sensory and motor function intact
and gait normal
Limited Physical Examination and Lab
Tests
Lungs
Genitalia
Abdomen
Clear, normal breath sounds
Normal external male
genitalia with circumcised
penis
Soft and non-tender with
normal bowel sounds and no
palpable viscera or masses
Musculoskeletal/Extremities
Neurological
No Cyanosis, Clubbing, or Edema
Alert and Oriented
Range of motion intact
Cranial Nerves II-XII intact
Good peripheral pulses bilaterally
Deep Tendon Reflexes 3+
throughout
Sensory and motor function intact
and gait normal
General
Appearance
Patient is healthy-appearing
and well-nourished
General
Appearance
Patient is healthy-appearing
and well-nourished
He moves constantly,
fidgeting with both
his hands and feet
General
Appearance
Patient is healthy-appearing
and well-nourished
He moves constantly,
fidgeting with both
his hands and feet
Gets easily distracted by
minor noises
General
Appearance
Patient is healthy-appearing
and well-nourished
He moves constantly,
fidgeting with both
his hands and feet
Gets easily distracted by
minor noises
Repeatedly interrupts
his mother and the
pediatrician
Case Question 1
 Are any of the boy’s vital signs a major cause for concern?
Case Question 1
 Are any of the boy’s vital signs a major cause for concern?
BP 112/70 RR
P
65
15 HT
3’9
T 98.2 F WT 50 lbs
Case Question 1
 Are any of the boy’s vital signs a major cause for concern?
BP 112/70 RR
P
Age
Heart Rate (beats/min)
65
15 HT
3’9
T 98.2 F WT 50 lbs
Blood Pressure (mm Hg)
Respiratory Rate (breaths/min)
3-6 yr
65-110
95-110/60-75
20-25
6-12 yr
60-95
100-120/60/75
14/22
12 > yr
55-85
110-135/65/85
12-18
Case Question 1
 Are any of the boy’s vital signs a major cause for concern?
Age
BP 112/70
RR
P
T 98.2 F WT 50 lbs
Heart Rate (beats/min)
65
15 HT
Blood Pressure (mm Hg)
3’9
Respiratory Rate (breaths/min)
3-6 yr
65-110
95-110/60-75
20-25
6-12 yr
60-95
100-120/60/75
14-22
12 > yr
55-85
110-135/65/85
12-18
Case Question 1
 Are any of the boy’s vital signs a major cause for concern?
Age
BP 112/70
RR
P
T 98.2 F WT 50 lbs
Heart Rate (beats/min)
65
15 HT
Blood Pressure (mm Hg)
3’9
Respiratory Rate (breaths/min)
3-6 yr
65-110
95-110/60-75
20-25
6-12 yr
60-95
100-120/60/75
14-22
12 > yr
55-85
110-135/65/85
12-18
Case Question 1
 Are any of the boy’s vital signs a major cause for concern?
Age
BP 112/70
RR
P
T 98.2 F WT 50 lbs
Heart Rate (beats/min)
65
15 HT
Blood Pressure (mm Hg)
3’9
Respiratory Rate (breaths/min)
3-6 yr
65-110
95-110/60-75
20-25
6-12 yr
60-95
100-120/60/75
14-22
12 > yr
55-85
110-135/65/85
12-18
Case Question 2
 What is the patient’s single most critical risk factor that is
consistent with ADHD?
Case Question 2
 What is the patient’s single most critical risk factor that is
consistent with ADHD?
Case Question 2
 What is the patient’s single most critical risk factor that is
consistent with ADHD?
Additional Risk Factors
Exposure to:
-Polychlorinated Biphenyls (PCBs)
-Lead
Case Question 3
 Can hyperthyroid disease be ruled out as a cause of
hyperactivity in this child?
Case Question 3
 Can hyperthyroid disease be ruled out as a cause of
hyperactivity in this child?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Plt 290,000/mm3
TSH
3.8 µU/mL
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
Case Question 3
 Can hyperthyroid disease be ruled out as a cause of
hyperactivity in this child?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Plt 290,000/mm3
TSH
3.8 µU/mL
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
Case Question 3
 Can hyperthyroid disease be ruled out as a cause of
hyperactivity in this child?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
34 – 40%
WBC
5 – 14.5/mm3
Plt 290,000/mm3
TSH
3.8 µU/mL
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 3
 Can hyperthyroid disease be ruled out as a cause of
hyperactivity in this child?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
34 – 40%
WBC
5 – 14.5/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 3
 Can hyperthyroid disease be ruled out as a cause of
hyperactivity in this child?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
34 – 40%
WBC
5 – 14.5/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 3
 Can hyperthyroid disease be ruled out as a cause of
hyperactivity in this child?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Note that the physical examination showed no
obvious nodal enlargement or thyromegaly.
Case Question 4
 Is this patient’s CBC normal or abnormal?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
35 – 46%
WBC
5k – 14.5k/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 4
 Is this patient’s CBC normal or abnormal?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
35 – 46%
WBC
5k – 14.5k/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 4
 Is this patient’s CBC normal or abnormal?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
35 – 46%
WBC
5k – 14.5k/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 4
 Is this patient’s CBC normal or abnormal?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
35 – 46%
WBC
5k – 14.5k/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 4
 Is this patient’s CBC normal or abnormal?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
35 – 46%
WBC
5k – 14.5k/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 4
 Is this patient’s CBC normal or abnormal?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
35 – 46%
WBC
5k – 14.5k/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 5
 What is the significance of this patient’s BUN and Cr
concentrations?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
35 – 46%
WBC
5k – 14.5k/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 5
 What is the significance of this patient’s BUN and Cr
concentrations?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Hb
11.5 -15.5 g/dL
Ht
35 – 46%
WBC
5k – 14.5k/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
Plt 150,000 – 450,000/mm3
TSH
0.32 – 5.0 µU/mL
BUN
T4’ total
6.4 – 13.3 µg/dL
Cr
5-20 mg/dL
0.3-0.7 mg/dL
Glu, fasting 70 – 110 mg/dL
Case Question 5
 What is the significance of this patient’s BUN and Cr
concentrations?
Hb
15.1 g/dL
Ht
43%
WBC
7,253/mm3
Plt 290,000/mm3
TSH
BUN
11 mg/dL
T4’ total
6.8 µg/dL
Cr
0.7 mg/dL
Glu, fasting
75 mg/dL
3.8 µU/mL
-Within normal ranges
- Rules out the presence of kidney disease or malnutrition
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
1.
2.
3.
4.
5.
Either criteria for inattention or criteria for
hyperactivity/impulsivity must be met
Onset occurs no later than 7 years of age
Symptoms must be present in two or more settings
Behavior causes clinically significant distress or impairment in
social, academic, or occupational settings
Symptoms do not occur during the course of schizophrenia or
another psychotic disorder
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in








schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Inattention
 Fails to be closely attentive to details, makes careless mistakes in

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schoolwork or other activities
Has difficulty sustaining attention during tasks or while at play
Does not seem to listen when spoken to directly
Does not follow through with instructions and fails to finish
schoolwork, chores, or duties
Has difficulty organizing tasks and activities
Avoids/strongly dislikes tasks that require sustained mental effort
Loses items necessary to complete tasks or activities
Is easily distracted by extraneous stimuli
Is forgetful in daily activities
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining
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seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining
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
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
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seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining
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





seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining







seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining







seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining







seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining







seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining







seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining







seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Criteria for Hyperactivity/Impulsivity
 Fidgets with hands or feet or squirms in seat
 Leaves seat in classroom or in other situations in which remaining







seated is expected
Runs around or climbs excessively in situations in which this behavior
is inappropriate
Has difficulty playing quietly or engaging in leisure activities
Often “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers to questions before questions have been completed
Has difficulty waiting turns
Interrupts or intrudes on others
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
1.
2.
3.
4.
5.
Either criteria for inattention or criteria for
hyperactivity/impulsivity must be met
Onset occurs no later than 7 years of age
Symptoms must be present in two or more settings
Behavior causes clinically significant distress or impairment in
social, academic, or occupational settings
Symptoms do not occur during the course of schizophrenia or
another psychotic disorder
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
1.
2.
3.
4.
5.
Either criteria for inattention or criteria for
hyperactivity/impulsivity must be met √
Onset occurs no later than 7 years of age
Symptoms must be present in two or more settings
Behavior causes clinically significant distress or impairment in
social, academic, or occupational settings
Symptoms do not occur during the course of schizophrenia or
another psychotic disorder
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
1.
2.
3.
4.
5.
Either criteria for inattention or criteria for
hyperactivity/impulsivity must be met √
Onset occurs no later than 7 years of age √
Symptoms must be present in two or more settings
Behavior causes clinically significant distress or impairment in
social, academic, or occupational settings
Symptoms do not occur during the course of schizophrenia or
another psychotic disorder
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
1.
2.
3.
4.
5.
Either criteria for inattention or criteria for
hyperactivity/impulsivity must be met √
Onset occurs no later than 7 years of age √
Symptoms must be present in two or more settings √
Behavior causes clinically significant distress or impairment in
social, academic, or occupational settings
Symptoms do not occur during the course of schizophrenia or
another psychotic disorder
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
1.
2.
3.
4.
5.
Either criteria for inattention or criteria for
hyperactivity/impulsivity must be met √
Onset occurs no later than 7 years of age √
Symptoms must be present in two or more settings √
Behavior causes clinically significant distress or impairment in
social, academic, or occupational settings √
Symptoms do not occur during the course of schizophrenia or
another psychotic disorder
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
1.
2.
3.
4.
5.
Either criteria for inattention or criteria for
hyperactivity/impulsivity must be met √
Onset occurs no later than 7 years of age √
Symptoms must be present in two or more settings √
Behavior causes clinically significant distress or impairment in
social, academic, or occupational settings √
Symptoms do not occur during the course of schizophrenia or
another psychotic disorder √
Case Question 6
 Does this patient satisfy all of the criteria that are required
for a diagnosis of ADHD?
1.
2.
3.
4.
5.
Either criteria for inattention or criteria for
hyperactivity/impulsivity must be met √
Onset occurs no later than 7 years of age √
Symptoms must be present in two or more settings √
Behavior causes clinically significant distress or impairment in
social, academic, or occupational settings √
Symptoms do not occur during the course of schizophrenia or
another psychotic disorder √
Case Question 7
 Is this patient predominantly hyperactive, predominantly
inattentive, does he show signs of combined inattention and
hyperactivity, or are the minimal diagnostic criteria for
ADHD lacking?
Case Question 7
 Is this patient predominantly hyperactive, predominantly
inattentive, does he show signs of combined inattention and
hyperactivity, or are the minimal diagnostic criteria for
ADHD lacking?
Predominantly Hyperactive
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Ritalin hydrochloride, 5 mg before breakfast and lunch
 Ritalin hydrochloride, 20 mg before each meal
 Cylert 37.5 mg as a single dose every morning
 Adderall, 5 mg once daily + psychotherapy
 Tofranil, 25 mg twice daily + psychotherapy
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Ritalin hydrochloride
 Prescribed for a stabilizing effect in children with ADHD
 Should be initiated in small doses, starting with 5mg twice a day
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Cylert 37.5 mg as a single dose every morning
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Cylert
 Specifically indicated for treatment of ADHD
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Cylert
 Specifically indicated for treatment of ADHD
 CAUTION: Associated with life-threatening hepatic failure
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Adderall, 5 mg once daily + psychotherapy
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Adderall
 Specifically indicated for treatment of ADHD and Narcolepsy
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Tofranil, 25 mg twice daily + psychotherapy
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Tofranil
 Used to treat depression
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Ritalin hydrochloride, 5 mg before breakfast and lunch
 Ritalin hydrochloride, 20 mg before each meal
 Cylert 37.5 mg as a single dose every morning
 Adderall, 5 mg once daily + psychotherapy
 Tofranil, 25 mg twice daily + psychotherapy
Case Question 8
Ritalin
Adderall
Effects
Increases amount of dopamine and
norepinephrine between synapses
in the brain.
Increases amount of dopamine and
norepinephrine between synapses
in the brain.
Potential Side Effects
Nervousness, drowsiness,
insomnia. Can cause psychosis
with long-term use
Weight loss, insomnia, headaches,
irritability, increased muscle
tension, anxiety, increased heart
rate, increased blood pressure, dry
mouth, reduced efficacy over
time.
Dependence Liability
Lower compared to Adderall
High
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Ritalin hydrochloride, 5 mg before breakfast and lunch
 Ritalin hydrochloride, 20 mg before each meal
 Cylert 37.5 mg as a single dose every morning
 Adderall, 5 mg once daily + psychotherapy
 Tofranil, 25 mg twice daily + psychotherapy
Case Question 8
 Which of the following is the most appropriate therapy for
this patient?
 Ritalin hydrochloride, 5 mg before breakfast and lunch
 Ritalin hydrochloride, 20 mg before each meal
 Cylert 37.5 mg as a single dose every morning
 Adderall, 5 mg once daily + psychotherapy
 Tofranil, 25 mg twice daily + psychotherapy