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.
Ben and his parents return 3 months later.
They have been working with a private therapist on behavior management techniques. She helped them to set up a behavior reward system at home which has been somewhat helpful, but…Ben is still having behavioral challenges at home and school and parents are ready to talk about medication.
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.
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.
Based on your review of the initial parent and teacher Vanderbilt behavioral rating scales, Ben’s medical history, your clinical observations, physical examination, and parent report, you conclude that Ben meets diagnostic criteria for ADHD, combined type.
**The Vanderbilt assessment helped you determine there were significant symptoms of inattention (at least 6 symptoms) and hyperactivity/impulsivity (at least 6 symptoms) present in at least two environments – home (parents report) and school (teacher report). Additionally the symptoms interfere with functioning (as noted by the presence of any performance problems on the Vanderbilt scale).
You begin to discuss with Ben’s mother that based on his age and diagnosis, there are different treatment options to consider. Two important options are (1) parent behavioral management training and (2) medication management.
Ben’s mother looks hesitant, and with some encouragement, eventually asks you whether treatment with medication is even necessary to consider, as she has heard that most children “outgrow” ADHD?
Ben’s mother acknowledges that his behavior is pretty difficult to control. She is ready to consider all the different treatment options, if they are safe.
Below are some aspects of Ben’s history and physical examination you may want to consider before initiation of medication. Click on the “+” signs below for clinical pearls associated with the various aspects of the history and physical exam.
Ben’s mother is open to looking into behavioral techniques, and she is starting to ask a question about medication, when Ben’s father arrives at the visit. He explains that he got caught up trying to finish something for a deadline at work and almost forgot about Ben’s appointment altogether.
You catch Ben’s father up on the visit, explaining that Ben meets diagnostic criteria for ADHD, combined type and you were just about to discuss possible medication treatments with Ben’s mother.
At this, Ben’s father says, “Whoa, wait a minute. I don’t think Ben needs medication. He is just like me when I was a kid, and I turned out just fine!”
Ben’s mother shoots his father a dirty look, and then they both look back to you.
Ben’s parents do not agree about the treatment course for their child’s medical condition. From your view point, there are multiple treatment options that could be suitable for Ben. This can be a common, but difficult, clinical scenario.
Together, you and Ben’s parents eventually decide to try behavior management/parent training first. Ben’s father just can’t get behind the idea of medications. You make a plan to see Ben in 3 months to discuss how things are going.
On Parent Vanderbilt forms Jill’s parents endorse:
On Teacher Vanderbilt forms Jill’s teacher endorses:
*** Don’t forget to compare your answer to the sample solution provided after you check your answer.
