Diagnosis

Using the DSM-IV criteria for attention-deficit/hyperactivity disorder (ADHD), this patient presents the following set of symptoms for such a diagnosis (symptoms from AAP, 2000; Burns, 2008):

• Symptoms occur both at home and at school (per the consultation with the kindergarten teacher).
• Symptoms appear to have been present for an extended time (as documented by the parents’ attempts to use dietary restrictions to change behavioral patterns).
• Symptoms presented before age 7 years (child is currently 6 years old).

These match the essential features of an ADHD diagnosis.  In terms of other features:

• Inattention: The child has trouble keeping his attention on what he’s doing, exhibits signs of making careless mistakes, doesn’t seem to listen to instructions.
• Hyperactivity: The child squirms and fidgets, moves restlessly, acts without thinking, has trouble waiting his turn.
• Distractibility: The child is easily distracted at home and school as per parents and teacher reports.
• Impulsivity: The child is impulsive and doing occasionally dangerous behaviors (i.e., running into the street).

The parents have apparently struggled with this behavior for a considerable time and have tried dietary solutions (removing sugars, caffeine, and additives from the diet), as well as “all other known solutions” except drug therapy. The child’s health is difficult to determine due to fidgeting, but appears healthy.  The family is clearly exhausted from dealing with the child’s behavior.  The physical examination rules out obvious neurological, mental health, and other health problems. While additional information about the child’s background would be helpful (information on history, family situation, functional health patterns, etc.), a diagnosis of ADHD seems in order.

Disease Process

If untreated, ADHD creates stress in all environments, including family and school (Burns, 2008). Early interventions are important to avoid family and school conflict and negative effects on other family members, schoolmates, and others. (Ibid.)  This can also interfere with the child’s educational progress, and ultimately lead to aggressive behaviors (Ibid.). It is now understood that ADHD is not a disease that children “grow out of,” and difficulties of untreated ADHD progress into adolescence (Ibid.).

Orders

Begin with Ritalin 5 mg., twice a day, just before breakfast and just before lunch. Do not take it after 6 PM because that can cause difficulty sleeping. If you miss a dose, take it as soon as possible; if it is after 6 PM, skip the dose and return to the regular schedule before breakfast the next day.  Return in 30 days for follow-up assessment. If there are any concerns or questions about the medication or condition, call immediately.

Parent Counseling

Watch for side effects which can include nervousness, insomnia, loss of appetite, nausea, dizziness, headache, drowsiness, or stomach aches.  Report any of these immediately.  It’s possible that growth may be a slightly slower for a short period, but children generally recover and catch up to normal growth patterns over time. If there are any questions about drug tolerance, call immediately.

A referral to a local ADHD support group (if available) and a list of useful websites would be helpful for these parents to help them educate themselves on ADHD and treatment protocols (AAP, 2004). A referral to a family counselor who has experience with ADHD cases and family response would also be helpful.

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