Transcript Attention Deficit Hyperactivity Disorder (ADHD) Case Presentation

Attention Deficit Hyperactivity Disorder
(ADHD)
Case Presentation and Topic Discussion
William Johns MSIV
University of South Florida
College of Medicine
Goals and Objectives
 To Familiarize the viewer with a presentation of a child with ADHD.
 To illustrate the derivation and history of the diagnosis including
current prevalence and treatment data.
 To define ADHD with the appropriate DSM-IV diagnostic criteria.
 To make aware the many tests commonly used to screen and diagnose
ADHD.
 To summarize some of the many characteristics ADHD patients
present with, as well as some of the diagnosis that may mimic ADHD
or coexist with it.
 To discuss treatment issues with regard to behavioral therapy and in
initiating pharmacological treatment.
 Summary.
Case Summary
 Identifying Information:
This is an 8 year old white male, third grader who lives at home with his biological parents and older
brother. One year ago he was diagnosed with ADHD and has been treated with Ritalin 10mg 3X day.
 Chief Complaint:
The patient’s parents have noticed that he has become increasingly argumentative in the past two
weeks, and have found him to be preoccupied with his diagnosis of ADHD. The parents and patient
are also concerned with his lack of appetite and the possible growth effects thereof.
 History of Present Illness:
The patient presents today for an increase in outbursts and arguments at home per family report. It is
also reported that the patient is having intermittent difficulty with low frustration tolerance when
playing sports with his peers. On further questioning, it was noted that he was not always receiving
his medication secondary to his forgetting, teacher changes, and at times due to his resistance to take
the medication. The patient reports he is doing good in school, but does not want to be like his other
friend with ADHD. He reports his friend is “Rowdy, Real Rowdy.” Furthermore, the patient also
mentioned that the medicine results in his not wanting to eat. He reports that if he does not eat, that
he will not grow like the other kids in school.
Case Summary continued...
 Past Psychiatric History:
This is an 8 year old white male who was referred for an ADHD evaluation by his teachers one year
previous because he was observed at school to be unable to sit still and was quite distractible. He
was reported to always be running around and had been disruptive in class. His mother also
verbalized that he was distractible at home and at school. She also reports that he was socially
awkward around kids his age. He did not have many peer friends and had a short fuse and became
easily frustrated. Other examples of impulsive behavior included riding out with his bicycle in the
middle of the street without looking and slamming the door when he was angry at home.
In the preceding year his homework had been a struggle for the patient because of difficulty
in focusing and concentrating. His mother also reported he was having problems with the retention
of learned materials,,, and his confidence in himself had decreased since his difficulty focusing on his
homework had become more of a problem. She also reports it was an effort for the patient to wait for
anything. The patient’s mother denied that the patient had shown symptoms of behavior consistent
with depression, anxiety, or self-destructive behavior, or psychosis. The patient was reported to
sleep eight hours a day, but was light and interrupted. The patient was started on Ritalin by mouth
three times a day. This resulted in a marked improvement in his ability to concentrate and focus his
attention to a specific task, not only academic, but socially as well. The family reported decreased
hyperactive behavior and an increased frustration tolerance with less emotional outbursts and
tantrums. A marked improvement was noted on the Connors abbreviated parent and teacher
questionnaire.
Case Summary continued...
 Past Medical History:
Asthma which is triggered by dust and colds
 Operative Procedures:
None.
 Medications:
Proventil metered dose inhaler two puffs prn.
Ritalin 10mg po tid.
 Allergies:
No known drug allergies.
 Review of Systems:
non-contributory.
 Physical Examination:
The patient’s weight and height were in the 25% by age, down from a previous 50% one year ago.
The patient appeared thin and was noticeably restless and had a difficult time remaining seated
without being in constant motion. There was no other abnormalities on physical examination.
The family, developmental, and social histories, as well as the mental status examination,
psychometric testing, and biopsychosocial formulation will be given on request.
Case Summary continued...
 Diagnosis:
Axis I:
ADHD
Axis II:
None
Axis III:
Asthma
Axis IV:
Chronic distractibility and hyperactivity
Axis V:
Global Assessment of Functioning 75
 The patient appears to be in good control when receiving the medication as prescribed.
Much of his current symptoms appear to be related to “breakthrough” from not
receiving his daytime dose. A sustained release formula could likely ameliorate these
symptoms. It is also possible that he may becoming tolerant to the previous dosage. His
weight and growth will need to be carefully monitored to ensure that he develops
appropriately despite his appetite suppression from stimulant therapy
Case Summary continued...
 Plan:
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The dosage of Ritalin will be changed from 10mg 3Xday to 20mg sustained release in
the morning with 5mg at roughly 3pm or when he returns home from school.
The family and patient were encouraged to increase the amount and number of meals
with an increase in snacks. The family was also instructed to take height and weight
measurements every week so that medical management can be tailored to growth as well
as psychosocial development.
The patient’s mother was given abbreviated Connor’s scales to distribute to teachers and
to use at home to monitor the patient’s progress after the change in medication regimen.
The patient and family were counseled as to ensure the patient that anger is normal, and
that he will probably have a more difficult time with it. The patient was instructed to
recognize his emotion and try to be considerate to his loved one’s and peers when acting
on it. A good approach would be to talk through problems in his life rather than to
internalize them and react with “outbursts.”
Patient and family are to return in one month, or call as needed for problems or to
discuss medication changes.
Derivation and History of ADHD
For years pediatricians, psychologists, psychiatrists, other physicians, mental health
workers, parents, and teachers have believed that some children who can not sit still and
pay attention in school have a biologically based behavior disorder. This has been
called many names in the past but has at this time evolved to Attention Deficit
Hyperactivity Disorder.
Clinicians and researchers continue to argue as to define ADHD, estimate prevalence,
over/under diagnose, determine causes, and treatments. Evidence as high as 20-30%
has been cited for prevalence rates, but it is generally agreed that the true incidence is
between 3 and 5%.
The Etiology of ADHD is of wide dispute. Some look to genetics and suggest that there
is an underaroused nervous system. Others feel it could be from brain damage or
trauma, birth trauma, CNS infections, toxic insults such as lead, pre-natal exposure to
alcohol, drugs or toxins, undernutrition, visual deficiencies, thyroid dysfunction, chronic
illnesses, or medications such as phenobarb or theophylline. As you can see there is a
wide range of postulations as to the underlying cause.
Attention deficit disorders:
Then and now
DSM-III (1979)
DSM-IV (1994)
Attention Deficit Disorder with
Hyperactivity
Attention Deficit Disorder without
Hyperactivity
Attention Deficit Disorder, Residual Type
Attention Deficit/Hyperactivity Disorder,
Predominately Inattentive Type
Attention Deficit/Hyperactivity Disorder,
Predominately Impulsive Type
Attention Deficit/Hyperactivity Disorder,
Combined Type
Attention Deficit/Hyperactivity Disorder,
Not Otherwise Specified
(In partial Remission)
DSM-III-R (1987)
Attention Deficit Hyperactivity Disorder
Undifferentiated Attention Deficit Disorder
Diagnostic Criteria for ADHD
The DSM-IV Outline
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Either 1 or 2
1. Six or more of the following symptoms of inattention have persisted for at least six months to a
degree that is maladaptive and inconsistent with developmental level:
a. Often fails to give close attention to details or makes careless mistakes in schoolwork,
work, or other activities.
b. Often has difficulty sustaining attention in tasks or play activities.
c. Often does not seem to listen when spoken to directly.
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or
duties in the workplace (not due to oppositional behavior of failure to understand
instructions).
e. Often has difficulty organizing tasks and activities.
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental
effort (such as schoolwork or homework).
g. Often losses things necessary for tasks or activities (e.g., toys, school assignments,
pencils, books, or tools).
h. Is often easily distracted by extraneous stimuli.
i. Is often forgetful in daily activities.
Diagnostic Criteria continued
2. Six or more of the following symptoms of hyperactivity/impulsivity have persisted for at least six
months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
a. Often fidgets with hands or feet or squirms in seat.
b. Often leaves seat in classroom or in other situations in which remaining seated is expected
c. Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or
adults, may be limited to subjective feelings of restlessness).
d. Often has difficulty playing or engaging in leisure activities quietly.
e. Is often “on the go” or often acts as if “driven by a motor.”
f. Often talks excessively.
Impulsivity
g. Often blurts out answers before questions have been completed.
h. Often has difficulty awaiting turn.
i. Often interrupts or intrudes on others (e.g., butts into conversations or games).
Diagnostic Criteria continued
 Some hyperactive impulse or inattentive symptoms that caused
impairment were present before 7 years of age.
 Some impairment from the symptoms is present in two or more
settings (e.g., at school or work and at home).
 There must be clear evidence of clinically significant impairment in
social, academic,or occupational functioning.
 The symptoms do not occur exclusively during the course of a
pervasive developmental disorder, schizophrenia, or other psychotic
disorder, and are not better accounted for by another mental disorder
(e.g., mood disorder, anxiety disorder, dissociate disorder, or a
personality disorder).
Tests to Screen and Diagnose
ADHD
A number of neuropsychological tests have been associated with various aspects od
attention, but none are diagnostic for ADHD.
 Focus-execute attention: coding subset of WISC-III, Trail-making test of the ReitonIndiana neuropsychiatric battery for children, and the color card interference test.
 Sustained attention: reaction time test on the RTT.
 Encode attention: digit span and arithmetic subtests of WISC-III.
 Attention shift: Wisconsin card sort.
Behavior assessment tests:
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Minnesota Child Development Inventory
Achenbach Child Behavior checklist
Connor’s Behavior Rating Scale
ACTeRS: The Attention Deficit Hyperactivity Comprehensive Teacher Rating Scale
Mimics, Look-alikes, and
coexisting conditions
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Medical conditions
Hearing loss
Thyroid Dysfunction
Visual disturbances
Some genetic disorders
Chronic medical illness
Allergy and effects of allergy medication
Mental disorders
Tourette’s Disorder
Oppositional Defiant Disorder
Conduct Disorder
Anxiety and depressive disorders
Pervasive Developmental Disorder, Not
Otherwise Specified
Obsessive-Compulsive Disorder
Schizophrenic and thought disorders
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Learning and language disabilities
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Accompanying behavioral and neurological
conditions
Night terrors
Sleep Difficulties
Coordination problems
Enuresis
Encopresis
Articulation problems
Treatment Issues
 Educational
Classroom modifications
Special education
 Psychological
Counseling
Behavioral modification
Social skills training
Psychotherapy
Demystification
 Medical
CNS stimulants: Ritalin, Dexedrine, Desoxyn,and Cylert
other psychotropic meds
Summary and Discussion
The diagnosis of attention-deficit hyperactivity disorder serves the purpose of indicating
those individuals who have impairment in their lives such as in school, work, or at home
secondary to symptoms of hyperactivity/impulsivity, inattention, or both. The diagnosis has a welldefined array of symptoms as outlined in the DSM-IV. The diagnosis of ADHD is still behavioral.
No test as of yet can diagnose ADHD, although some may corroborate or help exclude the diagnosis.
When making a diagnosis of ADHD it is important to realize that exclusionary criteria are as
important as inclusionary. Information on intellectual and academic functioning and on the presence
of other psychiatric or behavioral disorders is essential for diagnosis and management.
Due to their hyperactive/impulsive and inattentive behavior, the nature and quality of many
of their interactions are problematic. Many have difficulty modulating their responses to adapt to
changing tasks or situations and adhering to plans for carrying out smooth social exchanges.
Behavior and attention vary widely from one situation to another and with different people.
Standard treatment for ADHD generally consists of a combination of educational, psychological, and
medical therapies. Educational considerations such as classroom modification and/or special
education should be implemented. Psychological therapy may include the following:
patient/parent/teacher behavior modification, social skills training, psychotherapy, demystification,
and the use of support groups if necessary. Medical management’s first line of treatment would
consist of psychostimulants such as Ritalin (methylphenidate), Dexedrine (d-amphetamine), or Cylert
(pemoline). The results are very promising with a 70-80% response rate. It should be noted that
pharmacologic treatment in and of itself without appropriate counseling would be below the standard
of care.
Summary and Discussion Cont’d.
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Psychostimulant medications generally have the same effect: stimulation of the central nervous
system in the areas of the brain that control impulses, self-regulation of behavior, and
attention. Although these medications often facilitate remarkable changes in behavior, they are not
without their downfalls. The most common side effects are insomnia and a decrease in appetite,
although somatic complaints, growth inhibition, an increase in heart rate and blood pressure are
reported as well. Rarely, they have been observed to precipitate symptoms of Gilles de la Tourette’s.
It was formerly believed that ADHD underwent spontaneous remission in adolescence, and that this
remission maintained through adulthood. In the past few years it has become an observation that
ADHD symptoms often continue through adolescence and into adulthood, although generally in a
more subtle form. It is estimated that between 30-70% of those children with ADHD will need
continued medical management throughout the remainder of their adult lives.