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:

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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.

Discussion:

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?

Discussion:

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.

Discussion continued…

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.

Discussion:

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.

One month later:

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.