Birth History/Past Medical History
Unremarkable
Developmental History:
Oliver did not say his first words until 15 months. Now there are no speech concerns.
He achieved his other developmental milestones on time.
Review of Systems:
Negative
Family History
Paternal first cousin with ADHD
Social History
Parents separated 6 months ago and the social situation has been very stressful. However, mother describes that Oliver has always been “out of control”.
Birth History/Past Medical History
Unremarkable
Developmental History:
Unremarkable
Review of Systems:
Negative
Family History
Jill’s mother describes herself as a “worrier” but no formal diagnosis.
Jill’s father completed high school, but had trouble with reading and received extra reading help in elementary school. He recalls his teachers telling his parents that he was “hyperactive”.
Social History
Jill lives with her married parents and a younger sister, age 6, who is healthy. Her parents describe their home life as good, with a lot of family activities together on the weekends since they both work full-time. Her mother teaches English as a second language and her father works in construction.
At your last visit he was switched from Concerta to a low dose of Adderall. Ben’s parents hand you parent and teacher Vanderbilt rating scales that are sub-threshold for the core symptoms of ADHD. He is not experiencing any major side effects.
Parents are pleased they are not getting frantic phone calls from school, and Ben is happy because he was able to take home the class pet last week as a reward for his improved behavior in class.
Ben and his family leave with a plan for follow-up in 3 months.
Physical Exam:
Normal growth and vital signs.
Healthy appearing 4.5 year old.
No dysmorphic features.
Physical exam and neurologic exam are completely normal.
Observations:
Oliver is constantly moving around the exam room. Oliver is somewhat interested in coloring with provided crayons and paper but quickly loses interest. He climbs up on the exam table and begins to pull on the cord attached to the ophthalmoscope. The ophthalmoscope falls from the wall onto the exam table. Oliver then climbs off and begins tapping on various keys on the computer keyboard located in the room.
During the exam, his mother frequently apologizes for his Oliver’s behavior and reports she “doesn’t know what to do with him” at times.
Oliver’s mother hands you a parent and teacher Vanderbilt assessment scales**, both of which are elevated in the core area of hyperactivity and impulsivity.
Oliver appears to be experiencing impairments in functioning as his performance scores were problematic in relationships with siblings, peers, and participation in group activities.
** Note: This family completed Vanderbilt assessment scales rather than the preschool version of the rating scales. The NICHQ Vanderbilt Assessment Scales are used by health care professionals to help diagnose ADHD in children between the ages of 6- and 12-years. In practice, many pediatricians prefer to use one scale (even in younger children) for ease of evaluation.
Below is a link to the ADHD Preschool Rating Scale:
Impression:
Based on Oliver’s history, parent report, and behavioral scales from Oliver’s parents and preschool teacher, you diagnosis Oliver with ADHD hyperactive/impulsive type.
Oliver’s mother looks shocked when you share this news with her.
She immediately says, “No way! I don’t want my 4 year-old on medication! My sister’s son went on Ritalin and he turned into an absolute ‘zombie’! He was calm, but he wasn’t himself, just super out of it all the time. I don’t want that for Oliver.”
Recommendations:
*** Don’t forget to compare your answer to the sample solution provided after you check your answer.
Physical Exam:
Normal growth and vital signs.
Healthy appearing 8 year old.
No dysmorphic features.
Physical exam and neurologic exam are completely normal.
Observations:
Ben is fidgeting on the chair during the interview and plays with the blood pressure cuff and other instruments while being examined.
He interrupts, saying “Mom, look at me!” as he tries to jump off the exam table.
During the exam, his mother is firm and consistent with redirecting Ben; he obeys, but is quick to resume his activities.
Conclusion:
After you tell Oliver’s mother that the first-line treatment recommendation for ADHD in a child his age is parent behavior management training, she relaxes and says, “Oh, OK, I could definitely stand to learn more effective skills in how to handle Oliver’s behavior. Where can I find more information about that?”
You provide Oliver’s mother with the link to the online Positive Parenting Program (Triple P), as well as some private therapists in their area. You plan for a follow-up visit in 3 months.
Ben’s mother hands you the following rating scales. Take a look at the documents. Next you will learn how to interpret the scales.
Parent Informant – Vanderbilt Assessment Scales
Teacher Informant – Vanderbilt Assessment Scales
Now using the slides below, evaluate the Vanderbilt Assessment Scales that Ben’s mother handed you. If the writing is too small, utilize the expand window icon in the lower right corner of each window. When you are done with each Vanderbilt do not forget to check your answers.
