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 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?
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.
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.
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.
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.
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.
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.
