1. How does not seeing your dad make you feel?   It is well understood that familial structure and exposure to marital discord are key risk factors in children with disruptive behavioral disorders (DBDs).
  2. Do you believe your behavior is “ok” and acceptable?    Many children may have little insight into their behavior, the consequences, and how their behavior affects those around them.  Evaluating their perspective is valuable in that the feedback can be included in their treatment plan and goals.
  3. What in your daily life upsets you the most?    Workups of children with ADHD incorporates assessment for comorbid anxiety, depression, and developmental and learning disorders (Hamed, Kauer, & Stevens, 2015).  Evaluating daily anxiety causing factors such as school work, home environments, trauma, etc. can give the practitioner insight into clear diagnosis, treatment, and services appropriate for the client.

Feedback

The most important people in the client’s life that could provide valuable feedback are her mother, grandmother, and teacher because they have the most contact with the client.  The grandmother is important to interview as she may have different experiences with the client while in her care.  The grandmother can also be asked about the mother’s behaviors and temperament during her childhood and adolescent years, especially considering the mother is exhibiting obvious symptoms of ADHD in her adult life.  Studies have shown a mean heritability rate of 75% in family studies of behavioral disorders (Wilens & Spencer, 2010).  The client’s teacher can provide a overview on any specific triggers preceding her tantrums and outbursts in class, and relationships with peers.  The mother should be asked about the severity of the client’s behavior and tantrums at home, relationship with sister, and level of disobedience as these assessments may indicate progression into more severe behavioral disorders suggesting prompt attention (Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders, 2015).

Physical Exams and Diagnostic Tests

When diagnosing ADHD and other DBDs, a thorough physical evaluations is needed to rule out medical causes.  A structural MRI could document diffuse abnormalities in children with ADHD.  A study found, individuals with ADHD may have smaller total cerebrum, cerebellum, and four cerebral lobes that do not change over time; in adults, imaging studies have shown smaller anterior cingulate cortex, thought to be the region that regulates ability to focus on tasks and choose between options, and smaller dorsolateral prefrontal cortex, which controls memory and ability to process new information (Wilens & Spencer, 2010).  EEG should also be considered as one study found EEG’s show more Beta activity than Theta/Alpha activity in children medication responders compared to non-medication responders, strongly suggesting a biological correlation to the behaviors in ADHD (Hamed et al., 2015).  Blood chemistry, thyroid levels, and ferritin levels have also been linked to the diagnosis of ADHD.

Differential Diagnoses

  • ADHD (most likely):  Based on criteria outlined in the DSM-5, symptoms of inattention, hyperactivity, and impulsivity should be observed in at least different setting  and present for 6 months or longer; symptoms must result in impairment of social, academic, or other functioning; and symptoms must not be better explained or attributed to other physical or mental health condition, or social situation (Brown, Samuel, & Patel, 2018).
  • Oppositional Defiance Disorder (ODD):  Defined as a longstanding pattern of hostile, defiant, or disobedient behavior.  Children with ODD experience more school failures, suspensions, and expulsions; home relationships are often disrupted; and they are less successful at per relationships (Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders, 2015).  Characterized by temper tantrums, arguing with parents and other adults, defiance, refusal to comply with directives, deliberately annoying others, and being spiteful and vindictive.
  • Conduct Disorder:  A disruptive behavioral disorder with higher incidence in adolescence years, that includes some antisocial behaviors such as lying or stealing.  Severity of symptoms often rise with age and can co-occur with substance abuse disorders.  Adolescents with the disorder demonstrate  more school failure, drug abuse, and arrests than adolescents without the disorder.  It has been suggested that children with ADHD can progress to conduct disorder without proper treatment and intervention (Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders, 2015).

Pharmacological Agents

Dexedrine Spansule 5mg daily is sustained-release amphetamine used to treat adults and children age 6 years and older with ADHD.  The drug has up to an 8-hour duration of clinical action, making its use preferable over IR formulations (Stahl, 2014b).  Most stimulants are highly and equally efficacious hence the label as first-line treatment for ADHD.  The side effect profile consists of cardiovascular, CNS, and hormonal effects requiring pre-assessment and monitoring throughout therapy.  Also, the once a day dosing is beneficial to children because it eliminates the interruption of the school day to take noon dose, maintains confidentiality, and increases likelihood of compliance (Shier, Reichenbacher, Ghuman, H., & Ghuman, J., 2013).  Compared to Atomoxetine, a selective norepinephrine reuptake inhibitor used to treat ADHD in adults and children over the age of 6, amphetamines have a more robust response (Shier et al., 2013).  Atomoxetine carries the FDA warning for the potential to increase suicidal ideation children and adolescents and is metabolized through the CYP2D6 pathway in which a small percentage of the Caucasian population are poor metabolizers, therefore dose adjustments may be required (Brown et al., 2018).

Lessons Learned

Recommendations for treatment usually accompany the diagnosis of ADHD and have since been a source of controversy.  Although stimulant use to treat ADHD shows effectiveness in 65-75% of children after their first trial of use, the potentially dangerous side effects contribute to the indecisiveness of parents and children which affects treatment and compliance (Hamed et al., 2015). Approaching the diagnosis and suggested treatment should be done tactfully, as many parents have negative information and perceptions of the ADHD diagnosis.  As the practitioner, it is imperative that the challenges associated with assessing and treated ADHD are known.  The concerted effort to successfully treat children with ADHD involves family, caregivers, educators, and healthcare professionals alike.

REFERENCES

Brown, K., Samuel, S., & Patel, D. (2018).  Pharmacological management of attention deficit hyperactivity disorder in children and adolescents: A review for practitioners.  Translational Pediatrics, 7(1): 36-47.  doi: 10.21037/tp.2017.08.02.

Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders (2015).  Mental disorders and disabilities among low-income children.  Washington, DC: National Academies Press (US).

Hamed, A., Kauer, A., & Stevens, H. (2015).   Why the diagnosis of attention deficit hyperactivity disorder matters.  Frontiers in Psychiatry, 6: 168.  doi: 10.3389/fpsyt.2015.00168.

Shier, A., Reichenbacher, T., Ghuman, H., & Ghuman, J. (2013).  Pharmacological treatment of attention deficit hyperactivity disorder in children and adolescents: Clinical strategies.  Journal of Central Nervous System Disease, 5: 1-17.  doi: 10.4137/JCNSD.S6691.

Stahl, S. (2014b).  The prescriber’s guide (5th ed.).  St. Louis, MO: Cambridge University Press.

Wilens, T. & Spencer, T. (2010).  Understanding attention deficit/hyperactivity disorder from childhood to adulthood.  Postgraduate Medicine, 122(5): 97-109.  doi: 10.3810/pgm.2010.09.2206.

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