- The clinical history is the most important step in making or excluding a diagnosis of AD/HD. The clinician must know how the symptoms of inattention, hyperactivity and impulsivity manifest themselves in the behavior of children. Listed below are some of the behaviors children may exhibit for each symptom. (Please also review the DSM IV Criteria for other examples.)
- (A) Inattention
- careless mistakes in school work
- unable to complete chores/homework without frequent redirection
- frequent changing of toys
- unable entertain him/herself for an age appropriate period
- difficulty following instructions
- procrastinates homework
- forgetful
- frequently miss places items
- daydreams, wanders off
- Hyperactitivy
- fidgets
- can not remain in seat when expected
- runs/climbs in inappropriate situations
- can not play quietly
- can not relax/ "driven by a motor"
- talks excessively
- Impulsivity
- blurts out answers
- can not wait turn
- interrupts others
- fails to respond to consistent discipline
- acts without thinking (e.g. runs into street after ball)
- The correct answer is (c)3-5%.
- The correct answer is (d) in at least more than one environment. (Please review DSM IV Criteria.) Note that children with AD/HD may show their symptoms to a different extent in different environments. Specifically, they may be less symptomatic in a very structured environment (e.g. one-on-one child care) or an environment which can tolerate extremes of behavior (e.g. playing at Jungle Max). Since AD/HD is a biologically based disorder, diagnosis requires evidence that symptoms are present to some in extent in at least two environments. If symptoms are only present in one environment (e.g. home, school) an alternative diagnosis should be sought (e.g. chaotic environment, inappropriate classroom for cognitive abilities).
- The correct answer is (c) make a referral to the child study team. Children with AD/HD have a higher incidence of learning disabilities (LD) than children without AD/HD. The clinician must have a low threshold to evaluate for LD and not attribute all classroom failure to the child's AD/HD. Ideally, all children with AD/HD should be screened for learning disabilities. There are several ways that a practicing clinician could approach this issue. One solution is to utilize an in-office screening tool . Other options include referral to the school's Child Study Team (see Interacting with the School System and The Individualized Education Plan for information about the Child Study Team), a private psychologist or child developmental clinic for evaluation. Waiting for the child to flunk grades or "monitoring" for significant improvements in performance only prolongs the child's period of failure.
-
- (A) Epidemiological Data
- The correct answer is (c) "statistical analysis estimates that genetic effects account for 50% of the explainable variance in hyperactivity and inattentiveness among twin pairs." The incidence of AD/HD among parents of children with AD/HD is 25%. The link between AD/HD and adverse family and perinatal factors is weak.
- (B) Biochemical Data
- The correct answer is (c). There is a correlation between behavior and biochemical data with consistent changes in urinary noradrenergic metabolites in clinical responders to medication.
- (C) Neuroanatomical Studies
- The correct answer is (d) "prefrontal damage causes disturbances in drive and executive control resulting in impulsive actions." Patients with AD/HD appear to equally sized left and right frontal lobes compared to the normal right greater than left pattern. Glucose metabolism is globally decreased on PET scans of patients with AD/HD. Clinically, lesions of the left hemisphere are associated with no effect on attention. Lesions of the right hemisphere induce severe inattention thus the right hemisphere is suspected to be dominant in mediating attention.
- The correct answer is (d). Improvements have been documented in attention span, conduct, social interaction, impulsive behavior, self control, aggression and academic performance.
- The correct answer is (c) at school and at home. The importance of employing multimodal therapies across all environments should be underscored. This requires effective communication between the physician, family and education or daycare provider. Stimulant therapy alone has never been shown to improve the long-term outcome for children with AD/HD.
- The correct answer is (d)all of the above.
- To effectively manage children with AD/HD in the primary care setting, the clinician must be prepared to provide guidance to the family and school regarding behavioral therapy and environmental adjustments. (Please review the patient handouts Survival Tips for Parents of Children with AD/HD and The Child with AD/HD - Modifying the Classroom for more information.)
- Examples of environmental adjustments in the home include:
- providing a safe place for free play
- choosing a child-care that has a low child/adult ratio
- avoiding formal gatherings, shopping trips or eating out if these are more than the child can handle
- routine and structure (meals, toileting, chores and bedtime should be as regular as possible).
- Examples of environmental adjustments in the classroom include:
- seating the child close to the teacher
- providing a structured classroom with clear expectations
- limiting open spaces which may encourage hyperactive behaviors
- reducing distracting stimuli
- The correct answer is (a). Although a child with AD/HD and aggressive/hyperaroused behaviors may have a therapeutic response on stimulants, clonidine is often chosen to treat this group of children since it has more of an impact on aggressive/hyperaroused behaviors. A tic disorder is a relative contraindication to methylphenidate and dextroamphetamine. Clonidine is often the first choice in children with known tics since it may suppress tics. However, if clonidine is contraindicated then the stimulants can be tried with very close monitoring for exacerbation of the tics. Their have been recent reports of liver failure due to pemoline and the manufacturer no longer considers it to be a first line agent for treatment of AD/HD. Clonidine requires several weeks to titrate to therapeutic levels and should be weaned off over at least one week to avoid rebound symptoms. Therefore, it should not be held for weekends and holidays.
- The correct answer is (d) give medication with meals. Please see the handout Feeding Your Child with AD/HD for more information.
- The correct answer is (c). Placebo controlled trials in clinical practice are quite easy to do and can be very useful in clarifying placebo effect, side effects and benefits of therapy.
- The correct answer is (c)allow objective measurement of effectiveness of therapy. A diagnosis of AD/HD should never be made based solely upon a score on a standardized rating scale (e.g. Connor's questionnaires). These scales measure symptoms of inattention, impulsivity and increased activity but do not identify their origin. These symptoms may reflect other conditions including cognitive impairments, psychosocial stresses, medical and psychiatric disorders.
- The correct answer is (d) parents should be allowed to decide if children need stimulant medication seven days a week/ year round. Behavioral therapy, environmental adjustments and pharmacotherapy should be utilized across all environments in which the child is having functional difficulties.
Return to Questions
Return to Education Module Introduction
|
