Physical Exam:
Growth parameters who weight, height, and head circumference measurements between the 5th and 10th percentiles.
Vision and hearing screens, and complete physical exam are normal.
Observations:
Jill presented as a petite girl, who was initially shy, but could be engaged in conversation. Her speech was clear and intelligible, although she answered questions with short phrases. She sometimes needed to have questions repeated. She was not hyperactive.
Ben’s family returns the Vanderbilt forms you had requested. You review the forms and don’t see much change at all. ADHD symptoms are still elevated on the Vanderbilt scale. Ben is not experiencing side effects.
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.
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.
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:
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.
After discussion, Ben’s parents decide to start a trial of Concerta 18mg daily. They wanted something long-acting that would last through the school day and Ben can swallow pills whole without chewing.
The plan is to follow-up in 1 month. In addition, you asked the parents to fill out a parent vanderbilt assessment scale and have his teacher complete the teacher version. You explained to the parents that the Vanderbilt assessment scales help clinicians monitor medication effectiveness.
To read through the AAP’s guidance on ADHD management, click through the slides below:
You get a phone call from Ben’s mother. Ben has been complaining of stomach aches and wonders if it could be from the medication.
You describe that stomach aches can be a minor, but relatively common transient side effect of stimulant medications – they should go away after a couple weeks of taking the medication.
Ben’s mother asks you to review other potential side effects.
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.
