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ADHD (continued)
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Sample Cases
Case 1: ADHD, Inattentive Type
Jennifer had no problems in preschool. In kindergarten, she seemed to
learn her letters and numbers, and could read a dozen words on sight.
Her teacher said that she was doing well, but her parents noticed that
she seemed more disorganized and inattentive than her older sister was at the same age. They often had to repeat instructions, and she
left half-finished drawings all over her room. In first grade, Jennifer
had mild difficulty with arithmetic, but now the teacher was concerned that she seemed to not be listening much of the time.
Jennifer's school work was inconsistent and often she failed to finish
assignments. The teacher suggested that Jennifer's parents have her tested for ADD.
Case 1 Discussion
This presentation is consistent with inattentive type ADHD, however,
more information is needed. Children with inattentive ADHD have difficulty concentrating and completing tasks, but usually do not have
significant "externalizing" symptoms such as impulsive, fidgety, or disruptive behavior. The primary care physician should exclude other
causes of inattention from consideration, elicit more details about how the child functions in other settings, and document the severity
of the problem. Since many other disorders can look like inattentive ADHD, a more complete evaluation may be needed, including
cognitive testing and educational assessment.
It is important to determine the time course of the problem (the
chronicity) and how the parents and school had been dealing with the
problem, including tutoring, behavior management, and special education approaches.
Parent and teacher rating scales would help establish a baseline for a
medication trial and give the teacher an opportunity to comment more about Jennifer's academic performance. A routine medical
history and physical exam would be a sufficient medical assessment.
Non-routine laboratory studies would not be indicated unless the
history or physical examination was strongly suggestive of seizures,
neurodevelopmental regression, or localizing neurologic findings, or if
an acute or chronic medical disorder was suspected.[20]
Case 2: Tics Complicating the Course of ADHD
Dixon was a friendly and charming 9-year-old who had ADHD. He had a good response for 3 years on a moderate dose of methylphenidate. He
recently had a sinus computed tomography (CT) scan after having been
treated with nasal steroids for 6 months for chronic sniffing and an
occasional cough. Presence of middle ear fluid was also suspected due to head tossing
and parental reports that Dixon acted "like he had water in his ears." Ear exams were normal.
Dixon's doctor was on vacation, so he was seen by a new associate in
the office for a refill of his sinus medication. The associate noticed
that Dixon frequently blinked his eyes and cleared his throat. When questioned, his mother said that Dixon also often made sucking noises
with his teeth and his humming had started to bother the teacher. The sinus CT scan was normal.
Case 2 Discussion
Dixon's ADHD diagnosis was well established. He had a history of a
good response to medication. Several drug-free trials had established
that he did much better on medication. It is not unusual for a tic disorder to present as allergy, or as another problem, like seizures or habit disorder. ADHD and Tourette's syndrome are frequently comorbid
in clinic-referred populations, but this may not be the case in the nonreferred population.[21,22]
Suspected allergy, with negative laboratory findings and lack of response to treatment, is a well-known presentation of tics. Since this
has been documented for less than a year, the diagnosis would be chronic motor and phonic tics. Tics may improve with a change of medication to
dextroamphetamine or a tricyclic antidepressant. Referral is warranted in this case.
Case 3: Obsessive-Compulsive Disorder in Disguise
Lila, age 9, had been previously treated with dextroamphetamine salts
for ADHD. When she came in for follow-up, her doctor talked to her about her daily life. When she was asked about how she got to school,
she said it depended on whether it was an odd-numbered day or an even-numbered day. It seemed like a strange answer, so the doctor
asked her to explain. She said that she walked 90 steps on odd days to
get to the bus and 150 steps on even days, so she walked around the back of the apartment complex on even days.
If she walked too many steps, she had to walk backwards to "erase"
the steps and then take longer steps so she'd walk the right number of
steps. She also said that she had trouble getting her work done in school because she had to do things in fours, and sometimes there were an uneven number of math problems, so she couldn't finish. The
astonished doctor asked how long she had been doing these counting rituals, she said at least since kindergarten. "I always have to count
things. Sometimes I can't pay attention to the teacher because I am counting the tiles in the ceiling."
Case 3 Discussion
Behaviors in obsessive-compulsive disorder (OCD) are not always
obvious. Sometimes, the anxiety associated with obsessive thinking can lead to serious performance problems which can look like ADHD,
but it can be seen with ADHD and tic disorders.[23]
Psychiatric referral is usually indicated, and cognitive-behavioral
psychotherapy might also be beneficial. This child will also need academic support because it is likely that she has developed academic
deficits that will require remediation even if her OCD symptoms are well controlled.
Case 4: Difficult Child or ADHD?
Robbie came for his 4-year-old well-child visit with his mother,
14-month-old sister, and a cloud of dust. He created a great deal of
commotion in the waiting room, and managed to "escape" and start running around the office, getting into drawers, and screaming when his mother tried to redirect him. A well-meaning staffer, trying to
demonstrate "effective parenting" was treated to cries of "No! No! No!
You're hurting me" as Robbie threw himself on the floor. A few minutes later, in the exam room, he was "fine," playing with some toys
while his mother waited for the doctor to come in. He then cooperated with the exam.
His mother reported that it is always difficult to go places with him because he has tantrums coming and going, and gets upset or out of
control very easily. He has a good attention span when he is engaged
in play, and he is making excellent progress in preschool. Growth and physical examination were normal.
Case 4 Discussion
ADHD is often treated as a categorical disorder, but can also be seen as
a "spectrum" disorder, blending in to the range of normal variation.[24] Temperamentally difficult children may have problems with initial
negativity, problems with transition, and difficulty with self-regulation
(including sleep and appetite) and thus may appear to have ADHD. However, they may not be impulsive, overactive, or distractible most
of the time. Their problems may be largely related to changes. Although ADHD hyperactive-impulsive type could also be present, the
key issue will be the degree of impairment and its impact in multiple
settings.
Robbie may have a difficult temperament, but he may also have
oppositional defiant disorder. The Diagnostic and Statistical Manual
for Primary Care (DSM-PC) Child and Adolescent Version provides good description of the "problem" level of diagnosis.[19]
Case 5: Dyslexia, Auditory Processing Disorder, and...?
Kari's teacher told her mother to have Kari tested for ADHD. She
wasn't keeping up with the rest of the second grade class, "didn't want
to listen," and didn't follow through with instructions. In third grade,
Kari was reading at the late first grade level.
Kari had "taken forever" learning her letter sounds. Her mother knew what the teacher meant: Kari seemed "spacey." When she was given
some instructions at home, she would often come back with a puzzled looked and ask to have them repeated. Still, she got along well with
other children, had an excellent vocabulary, and drew beautifully.
Both of Kari's parents and her older sister were honor students. Kari
had her hearing tested (for the third time) and the results were normal. The audiologist suggested a test for central auditory processing
disorder. The test results were reported as showing problems with "tolerance fading memory, phonemic synthesis" and indicated that speech discrimination in noise was at the 5th percentile for age. She
had a 25 dB hearing loss above 2000 Hz in the left ear. Kari's mother
asked whether Kari should be put on Ritalin (methylphenidate).
Case 5 Discussion
Children with learning and behavior problems often follow a winding
road to diagnosis. Parents may take the phrase "tested for ADHD" literally and expect neurodiagnostic testing or at least some ritual, and
are disappointed when the assessment consists of a history and standardized questionnaires. Hearing and auditory processing deficits
can contribute to learning problems, although there are many questions about at the specificity and validity of a diagnosis of central
auditory processing disorder.[25] At minimum, this diagnosis does not
exclude the possibility of ADHD and it indicates that a more comprehensive assessment will be required.
Absence seizures are often considered but usually can be excluded based on history. Absence seizures more typically interrupt activities
rather than just appearing when the child has nothing to do. They are
not limited to specific settings like school. They also usually represent
a significant change in behavior, compared with ADHD, which is a developmental disorder. Absence status epilepticus and temporal or
frontal seizures can be difficult to diagnose, and could also be comborbid with ADHD.
Kari's history strongly suggests a specific reading disorder. ADHD can
be associated with auditory processing problems and ADHD itself can cause false-positives on an auditory processing evaluation, which
mainly consists of behavioral tests. This is a difficult case to sort out.
Diagnosis will depend on symptoms that are separate from listening and reading performance problems.
The history should focus on questions about organization, planning,
vigilance, and performance consistency in areas outside the language/auditory domain. A multidisciplinary team evaluation is very
helpful in these cases. Specific therapy for auditory processing and phonological awareness can be very beneficial for both reading and
auditory processing problems.[26]
Without compelling evidence for ADHD, it may be more prudent to pursue therapy for the language-based learning disorder first and then
reconsider the ADHD diagnosis after 3 to 6 months of treatment.
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