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Case Study 46: Attention Deficit/Hyperactivity Disorder By Ryan Raroque What is ADHD? Psychological disorder that involves significant, age inappropriate issues with any or all of the following: Attention Hyperactivity Impulsivity Mother’s Chief Complaints -“I’m at the end of my rope and don’t know what to do anymore” Mother’s Chief Complaints -“I’m at the end of my rope and don’t know what to do anymore” -He won’t behave in school or listen at home Mother’s Chief Complaints -“I’m at the end of my rope and don’t know what to do anymore” -He won’t behave in school or listen at home -He’s always in motion and can’t sit still for five minutes Mother’s Chief Complaints -“I’m at the end of my rope and don’t know what to do anymore” -He won’t behave in school or listen at home -He’s always in motion and can’t sit still for five minutes -He likes watching cartoons but gets bored in a matter of minutes Mother’s Chief Complaints -“I’m at the end of my rope and don’t know what to do anymore” -He won’t behave in school or listen at home -He’s always in motion and can’t sit still for five minutes -He likes watching cartoons but gets bored in a matter of minutes Mother’s Chief Complaints -His first grade teacher says he can’t sit still at school and constantly squirms in his seat Mother’s Chief Complaints -His first grade teacher says he can’t sit still at school and constantly squirms in his seat -Sometimes gets up in the middle of class and roams around the room to look at different things Mother’s Chief Complaints -His first grade teacher says he can’t sit still at school and constantly squirms in his seat -Sometimes gets up in the middle of class and roams around the room to look at different things -Becomes problematic when he has to wait for things that he wants Mother’s Chief Complaints -His first grade teacher says he can’t sit still at school and constantly squirms in his seat -Sometimes gets up in the middle of class and roams around the room to look at different things -Becomes problematic when he has to wait for things that he wants -Always grabs things away from other children Mother’s Chief Complaints -His first grade teacher says he can’t sit still at school and constantly squirms in his seat -Sometimes gets up in the middle of class and roams around the room to look at different things -Becomes problematic when he has to wait for things that he wants -Always grabs things away from other children -Interrupts when others are speaking Mother’s Chief Complaints -His first grade teacher says he can’t sit still at school and constantly squirms in his seat -Sometimes gets up in the middle of class and roams around the room to look at different things -Becomes problematic when he has to wait for things that he wants -Always grabs things away from other children -Interrupts when others are speaking -Doesn’t wait for teacher to finish asking a question before beginning to answer History of Present Illness -6-year-old boy -Has difficulty waiting his turn -Mom says he’s shown hyperactive/inattentive behaviors for almost one year -Can’t engage in playground games for any significant length of time -“Everything seems to be getting worse” -Behavior has been so disruptive that no daycare centers will accept him -Teachers complain that he doesn’t listen or follow instructions like other kids, gets easily bored during activities -Mom is a single parent and must work to support son and herself Past Medical History Son was taken to pediatrician 4 months ago for similar symptoms; Mother’s complaints were dismissed Pregnancy and delivery were normal Vaccinations up to date No prior surgeries, serious medical problems, or established psychiatric illnesses Family History Father left the family before the boy was born Both maternal grandfather and maternal uncle have history of hyperactivity as children Mother denies drug, tobacco, and alcohol abuse during pregnancy Family History Father left the family before the boy was born Both maternal grandfather and maternal uncle have history of hyperactivity as children Mother denies drug, tobacco, and alcohol abuse during pregnancy Miscellaneous Information Review of Systems Occasional GI upset and colds Miscellaneous Information Review of Systems Occasional GI upset and colds Medications None Miscellaneous Information Review of Systems Occasional GI upset and colds Medications None Allergies No Known Drug Allergies Limited Physical Examination and Lab Tests Hearing Vision Skin Within Normal Limits Within Normal Limits Warm and dry with no discoloration Limited Physical Examination and Lab Tests Hearing Vision Skin Within Normal Limits Within Normal Limits Warm and dry with no discoloration Head, Ears, Eyes, Nose, Throat Neck/Lymph Nodes Heart PERRLA Neck supple without obvious nodal enlargement or thyromegaly Regular Rate and Rhythm with no murmurs, rubs, or gallops Tympanic Membranes intact Nose clear Throat without erythema Mucous Membranes normal Limited Physical Examination and Lab Tests Hearing Vision Skin Within Normal Limits Within Normal Limits Warm and dry with no discoloration Head, Ears, Eyes, Nose, Throat Neck/Lymph Nodes Heart PERRLA Neck supple without obvious nodal enlargement or thyromegaly Regular Rate and Rhythm with no murmurs, rubs, or gallops Tympanic Membranes intact Nose clear Throat without erythema Mucous Membranes normal Limited Physical Examination and Lab Tests Lungs Genitalia Abdomen Clear, normal breath sounds Normal external male genitalia with circumcised penis Soft and non-tender with normal bowel sounds and no palpable viscera or masses Limited Physical Examination and Lab Tests Lungs Genitalia Abdomen Clear, normal breath sounds Normal external male genitalia with circumcised penis Soft and non-tender with normal bowel sounds and no palpable viscera or masses Musculoskeletal/Extremities Neurological No Cyanosis, Clubbing, or Edema Alert and Oriented Range of motion intact Cranial Nerves II-XII intact Good peripheral pulses bilaterally Deep Tendon Reflexes 3+ throughout Sensory and motor function intact and gait normal Limited Physical Examination and Lab Tests Lungs Genitalia Abdomen Clear, normal breath sounds Normal external male genitalia with circumcised penis Soft and non-tender with normal bowel sounds and no palpable viscera or masses Musculoskeletal/Extremities Neurological No Cyanosis, Clubbing, or Edema Alert and Oriented Range of motion intact Cranial Nerves II-XII intact Good peripheral pulses bilaterally Deep Tendon Reflexes 3+ throughout Sensory and motor function intact and gait normal General Appearance Patient is healthy-appearing and well-nourished General Appearance Patient is healthy-appearing and well-nourished He moves constantly, fidgeting with both his hands and feet General Appearance Patient is healthy-appearing and well-nourished He moves constantly, fidgeting with both his hands and feet Gets easily distracted by minor noises General Appearance Patient is healthy-appearing and well-nourished He moves constantly, fidgeting with both his hands and feet Gets easily distracted by minor noises Repeatedly interrupts his mother and the pediatrician Case Question 1 Are any of the boy’s vital signs a major cause for concern? Case Question 1 Are any of the boy’s vital signs a major cause for concern? BP 112/70 RR P 65 15 HT 3’9 T 98.2 F WT 50 lbs Case Question 1 Are any of the boy’s vital signs a major cause for concern? BP 112/70 RR P Age Heart Rate (beats/min) 65 15 HT 3’9 T 98.2 F WT 50 lbs Blood Pressure (mm Hg) Respiratory Rate (breaths/min) 3-6 yr 65-110 95-110/60-75 20-25 6-12 yr 60-95 100-120/60/75 14/22 12 > yr 55-85 110-135/65/85 12-18 Case Question 1 Are any of the boy’s vital signs a major cause for concern? Age BP 112/70 RR P T 98.2 F WT 50 lbs Heart Rate (beats/min) 65 15 HT Blood Pressure (mm Hg) 3’9 Respiratory Rate (breaths/min) 3-6 yr 65-110 95-110/60-75 20-25 6-12 yr 60-95 100-120/60/75 14-22 12 > yr 55-85 110-135/65/85 12-18 Case Question 1 Are any of the boy’s vital signs a major cause for concern? Age BP 112/70 RR P T 98.2 F WT 50 lbs Heart Rate (beats/min) 65 15 HT Blood Pressure (mm Hg) 3’9 Respiratory Rate (breaths/min) 3-6 yr 65-110 95-110/60-75 20-25 6-12 yr 60-95 100-120/60/75 14-22 12 > yr 55-85 110-135/65/85 12-18 Case Question 1 Are any of the boy’s vital signs a major cause for concern? Age BP 112/70 RR P T 98.2 F WT 50 lbs Heart Rate (beats/min) 65 15 HT Blood Pressure (mm Hg) 3’9 Respiratory Rate (breaths/min) 3-6 yr 65-110 95-110/60-75 20-25 6-12 yr 60-95 100-120/60/75 14-22 12 > yr 55-85 110-135/65/85 12-18 Case Question 2 What is the patient’s single most critical risk factor that is consistent with ADHD? Case Question 2 What is the patient’s single most critical risk factor that is consistent with ADHD? Case Question 2 What is the patient’s single most critical risk factor that is consistent with ADHD? Additional Risk Factors Exposure to: -Polychlorinated Biphenyls (PCBs) -Lead Case Question 3 Can hyperthyroid disease be ruled out as a cause of hyperactivity in this child? Case Question 3 Can hyperthyroid disease be ruled out as a cause of hyperactivity in this child? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Plt 290,000/mm3 TSH 3.8 µU/mL BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL Case Question 3 Can hyperthyroid disease be ruled out as a cause of hyperactivity in this child? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Plt 290,000/mm3 TSH 3.8 µU/mL BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL Case Question 3 Can hyperthyroid disease be ruled out as a cause of hyperactivity in this child? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 34 – 40% WBC 5 – 14.5/mm3 Plt 290,000/mm3 TSH 3.8 µU/mL BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 3 Can hyperthyroid disease be ruled out as a cause of hyperactivity in this child? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 34 – 40% WBC 5 – 14.5/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 3 Can hyperthyroid disease be ruled out as a cause of hyperactivity in this child? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 34 – 40% WBC 5 – 14.5/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 3 Can hyperthyroid disease be ruled out as a cause of hyperactivity in this child? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Note that the physical examination showed no obvious nodal enlargement or thyromegaly. Case Question 4 Is this patient’s CBC normal or abnormal? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 35 – 46% WBC 5k – 14.5k/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 4 Is this patient’s CBC normal or abnormal? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 35 – 46% WBC 5k – 14.5k/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 4 Is this patient’s CBC normal or abnormal? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 35 – 46% WBC 5k – 14.5k/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 4 Is this patient’s CBC normal or abnormal? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 35 – 46% WBC 5k – 14.5k/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 4 Is this patient’s CBC normal or abnormal? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 35 – 46% WBC 5k – 14.5k/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 4 Is this patient’s CBC normal or abnormal? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 35 – 46% WBC 5k – 14.5k/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 5 What is the significance of this patient’s BUN and Cr concentrations? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 35 – 46% WBC 5k – 14.5k/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 5 What is the significance of this patient’s BUN and Cr concentrations? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Hb 11.5 -15.5 g/dL Ht 35 – 46% WBC 5k – 14.5k/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL Plt 150,000 – 450,000/mm3 TSH 0.32 – 5.0 µU/mL BUN T4’ total 6.4 – 13.3 µg/dL Cr 5-20 mg/dL 0.3-0.7 mg/dL Glu, fasting 70 – 110 mg/dL Case Question 5 What is the significance of this patient’s BUN and Cr concentrations? Hb 15.1 g/dL Ht 43% WBC 7,253/mm3 Plt 290,000/mm3 TSH BUN 11 mg/dL T4’ total 6.8 µg/dL Cr 0.7 mg/dL Glu, fasting 75 mg/dL 3.8 µU/mL -Within normal ranges - Rules out the presence of kidney disease or malnutrition Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? 1. 2. 3. 4. 5. Either criteria for inattention or criteria for hyperactivity/impulsivity must be met Onset occurs no later than 7 years of age Symptoms must be present in two or more settings Behavior causes clinically significant distress or impairment in social, academic, or occupational settings Symptoms do not occur during the course of schizophrenia or another psychotic disorder Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Inattention Fails to be closely attentive to details, makes careless mistakes in schoolwork or other activities Has difficulty sustaining attention during tasks or while at play Does not seem to listen when spoken to directly Does not follow through with instructions and fails to finish schoolwork, chores, or duties Has difficulty organizing tasks and activities Avoids/strongly dislikes tasks that require sustained mental effort Loses items necessary to complete tasks or activities Is easily distracted by extraneous stimuli Is forgetful in daily activities Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Criteria for Hyperactivity/Impulsivity Fidgets with hands or feet or squirms in seat Leaves seat in classroom or in other situations in which remaining seated is expected Runs around or climbs excessively in situations in which this behavior is inappropriate Has difficulty playing quietly or engaging in leisure activities Often “on the go” or acts as if “driven by a motor” Talks excessively Blurts out answers to questions before questions have been completed Has difficulty waiting turns Interrupts or intrudes on others Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? 1. 2. 3. 4. 5. Either criteria for inattention or criteria for hyperactivity/impulsivity must be met Onset occurs no later than 7 years of age Symptoms must be present in two or more settings Behavior causes clinically significant distress or impairment in social, academic, or occupational settings Symptoms do not occur during the course of schizophrenia or another psychotic disorder Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? 1. 2. 3. 4. 5. Either criteria for inattention or criteria for hyperactivity/impulsivity must be met √ Onset occurs no later than 7 years of age Symptoms must be present in two or more settings Behavior causes clinically significant distress or impairment in social, academic, or occupational settings Symptoms do not occur during the course of schizophrenia or another psychotic disorder Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? 1. 2. 3. 4. 5. Either criteria for inattention or criteria for hyperactivity/impulsivity must be met √ Onset occurs no later than 7 years of age √ Symptoms must be present in two or more settings Behavior causes clinically significant distress or impairment in social, academic, or occupational settings Symptoms do not occur during the course of schizophrenia or another psychotic disorder Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? 1. 2. 3. 4. 5. Either criteria for inattention or criteria for hyperactivity/impulsivity must be met √ Onset occurs no later than 7 years of age √ Symptoms must be present in two or more settings √ Behavior causes clinically significant distress or impairment in social, academic, or occupational settings Symptoms do not occur during the course of schizophrenia or another psychotic disorder Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? 1. 2. 3. 4. 5. Either criteria for inattention or criteria for hyperactivity/impulsivity must be met √ Onset occurs no later than 7 years of age √ Symptoms must be present in two or more settings √ Behavior causes clinically significant distress or impairment in social, academic, or occupational settings √ Symptoms do not occur during the course of schizophrenia or another psychotic disorder Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? 1. 2. 3. 4. 5. Either criteria for inattention or criteria for hyperactivity/impulsivity must be met √ Onset occurs no later than 7 years of age √ Symptoms must be present in two or more settings √ Behavior causes clinically significant distress or impairment in social, academic, or occupational settings √ Symptoms do not occur during the course of schizophrenia or another psychotic disorder √ Case Question 6 Does this patient satisfy all of the criteria that are required for a diagnosis of ADHD? 1. 2. 3. 4. 5. Either criteria for inattention or criteria for hyperactivity/impulsivity must be met √ Onset occurs no later than 7 years of age √ Symptoms must be present in two or more settings √ Behavior causes clinically significant distress or impairment in social, academic, or occupational settings √ Symptoms do not occur during the course of schizophrenia or another psychotic disorder √ Case Question 7 Is this patient predominantly hyperactive, predominantly inattentive, does he show signs of combined inattention and hyperactivity, or are the minimal diagnostic criteria for ADHD lacking? Case Question 7 Is this patient predominantly hyperactive, predominantly inattentive, does he show signs of combined inattention and hyperactivity, or are the minimal diagnostic criteria for ADHD lacking? Predominantly Hyperactive Case Question 8 Which of the following is the most appropriate therapy for this patient? Ritalin hydrochloride, 5 mg before breakfast and lunch Ritalin hydrochloride, 20 mg before each meal Cylert 37.5 mg as a single dose every morning Adderall, 5 mg once daily + psychotherapy Tofranil, 25 mg twice daily + psychotherapy Case Question 8 Which of the following is the most appropriate therapy for this patient? Ritalin hydrochloride Prescribed for a stabilizing effect in children with ADHD Should be initiated in small doses, starting with 5mg twice a day Case Question 8 Which of the following is the most appropriate therapy for this patient? Cylert 37.5 mg as a single dose every morning Case Question 8 Which of the following is the most appropriate therapy for this patient? Cylert Specifically indicated for treatment of ADHD Case Question 8 Which of the following is the most appropriate therapy for this patient? Cylert Specifically indicated for treatment of ADHD CAUTION: Associated with life-threatening hepatic failure Case Question 8 Which of the following is the most appropriate therapy for this patient? Adderall, 5 mg once daily + psychotherapy Case Question 8 Which of the following is the most appropriate therapy for this patient? Adderall Specifically indicated for treatment of ADHD and Narcolepsy Case Question 8 Which of the following is the most appropriate therapy for this patient? Tofranil, 25 mg twice daily + psychotherapy Case Question 8 Which of the following is the most appropriate therapy for this patient? Tofranil Used to treat depression Case Question 8 Which of the following is the most appropriate therapy for this patient? Ritalin hydrochloride, 5 mg before breakfast and lunch Ritalin hydrochloride, 20 mg before each meal Cylert 37.5 mg as a single dose every morning Adderall, 5 mg once daily + psychotherapy Tofranil, 25 mg twice daily + psychotherapy Case Question 8 Ritalin Adderall Effects Increases amount of dopamine and norepinephrine between synapses in the brain. Increases amount of dopamine and norepinephrine between synapses in the brain. Potential Side Effects Nervousness, drowsiness, insomnia. Can cause psychosis with long-term use Weight loss, insomnia, headaches, irritability, increased muscle tension, anxiety, increased heart rate, increased blood pressure, dry mouth, reduced efficacy over time. Dependence Liability Lower compared to Adderall High Case Question 8 Which of the following is the most appropriate therapy for this patient? Ritalin hydrochloride, 5 mg before breakfast and lunch Ritalin hydrochloride, 20 mg before each meal Cylert 37.5 mg as a single dose every morning Adderall, 5 mg once daily + psychotherapy Tofranil, 25 mg twice daily + psychotherapy Case Question 8 Which of the following is the most appropriate therapy for this patient? Ritalin hydrochloride, 5 mg before breakfast and lunch Ritalin hydrochloride, 20 mg before each meal Cylert 37.5 mg as a single dose every morning Adderall, 5 mg once daily + psychotherapy Tofranil, 25 mg twice daily + psychotherapy