Pediatrics · Year 3 · from Pediatrics
Case 2: Attention-Deficit/Hyperactivity Disorder
Patient Demographics
- Age: 8-year-old male
- Sex: Male
Chief Complaint
"His teacher says he can't sit still and isn't finishing his work."
History of Present Illness
An 8-year-old boy is brought by his parents after receiving concerning reports from his third-grade teacher. The teacher notes that he is constantly fidgeting, leaves his seat frequently, talks excessively, and often blurts out answers without raising his hand. He rarely completes assignments in class and seems to "zone out" during lessons. At home, parents describe him as always "on the go" and note he has difficulty following through on chores and loses things constantly (homework, shoes, sports equipment). He is described as bright but "not living up to his potential." These behaviors have been present since kindergarten but are now more problematic with increasing academic demands. He sleeps well (9 hours/night) and has no history of trauma.
Developmental History
- Milestones: All achieved on time
- Academic history: Bright child, reading and math skills appropriate when he focuses
- Social: Has friends but sometimes struggles due to interrupting and not waiting his turn
ADHD Evaluation
Parent Rating Scale (Vanderbilt):
- Inattentive symptoms: 7/9 items rated "often" or "very often"
- Hyperactive-impulsive symptoms: 8/9 items rated "often" or "very often"
- Symptoms present for >6 months, causing impairment
Teacher Rating Scale (Vanderbilt):
- Inattentive symptoms: 8/9 items rated "often" or "very often"
- Hyperactive-impulsive symptoms: 7/9 items rated "often" or "very often"
- Performance significantly affected
Physical Examination
- Vital Signs: HR 88 bpm, BP 100/62 mmHg, Height 75th percentile, Weight 50th percentile
- General: Active boy, difficulty sitting still during interview, frequently interrupts
- Cardiovascular: Regular rhythm, no murmurs
- Neurologic: Normal
Diagnosis
Attention-deficit/hyperactivity disorder, combined presentation
Clinical Reasoning
This child meets DSM-5 criteria for ADHD, combined presentation:
- Inattention (6+ symptoms): Fails to give close attention, difficulty sustaining attention, does not follow through on tasks, difficulty organizing, avoids sustained mental effort, loses things, easily distracted, forgetful
- Hyperactivity-Impulsivity (6+ symptoms): Fidgets, leaves seat, runs/climbs inappropriately, difficulty playing quietly, "on the go," talks excessively, blurts out answers, difficulty waiting turn, interrupts
Additional criteria met:
- Symptoms present before age 12 (since kindergarten)
- Symptoms present in 2+ settings (home AND school)
- Clear functional impairment (academic underperformance, social difficulties)
- Not better explained by another disorder
Normal sleep history and absence of trauma make other explanations less likely. Academic abilities are intact, ruling out learning disability as primary cause.
Management
- Medication: Methylphenidate extended-release starting dose 18-27 mg every morning (first-line for children 6+ years)
- Behavioral therapy: Parent training in behavior management; classroom behavioral interventions
- Educational support: 504 plan or IEP evaluation for classroom accommodations (preferential seating, extended time, chunked assignments)
- Monitoring: Follow-up in 2-4 weeks for medication titration; check height, weight, BP, HR at each visit
- Side effect counseling: Discuss appetite suppression, sleep difficulties; give medication with breakfast, consider drug holidays if growth concerns
- School collaboration: Regular communication with teacher; repeat rating scales to monitor response
Clinical Image
Image Description: Illustration of a child with ADHD in a classroom setting, showing characteristic behaviors including difficulty remaining seated, fidgeting, and appearing distracted while classmates are focused.
Source: Wikimedia Commons URL: https://commons.wikimedia.org/wiki/File:ADHD-3.svg License: CC BY-SA 4.0