Patient Encounter Part 1

A single mother and her rambunctious 6-year-old boy, AD, come to your clinic. The mother is concerned because her neighbor, who watches AD after school for no charge, has complained about the problems he is causing among her own children (4/- and 6-year-old boys). AD refuses to wait for his turn in games and frequently hits the younger boy. The neighbor has said that unless AD becomes more manageable, she will not watch him after school. This is very distressing to AD's mother, who barely provides for her son and herself by working at the local convenience store for minimum wage. She cannot afford a professional babysitter for AD. She does not qualify for medical assistance. Further, she explains that his performance at school is getting worse, and he is becoming unmanageable in the classroom.

Which of the patient's symptoms are suggestive of ADHD?

What other information do you need to assess for ADHD?

What help/suggestions could you offer to AD's mother?

Table 42-1 DSM-IV-TR Diagnostic Criteria for ADHD

A. Inattention. Must have at least six or more of the following symptoms of inattention for at least 6 months:

1. Does not pay close attention to details in schoolwork, work, or other activities.

2. Has trouble maintaining attention to tasks or activities.

3. Has trouble actively listening when directly spoken to.

4. Has difficulty following instructions and fails to finish important daily tasks (i.e., homework, chores, and responsibilities at work).

5. Demonstrates difficulty in organizing tasks/activities.

6. Tends to avoid or put off activities that require concentration.

7. Tends to misplace items needed to complete tasks or activities.

8. Is easily distracted from current tasks or activities.

9. Forgetful.

B. Hyperactivity/impulsivity. Must have at least six or more of the following symptoms of hyperactivity/impulsivity for at least 6 months: Hyperactivity

1. Fidgets and is restless in a sitting position.

2. Cannot sit still for extended periods.

3. Runs around when it is not appropriate.

4. Cannot play quietly.

6. Talks excessively.

Impulsivity

1. Answers questions prematurely.

2. Difficulty waiting one's turn.

3. Interruptive or intrudes on others.

II. Above symptoms were present before 7 years of age.

III. Above symptoms are present in two or more settings.

IV. Impairment is clearly evident in social, school, or work functioning.

V. Symptoms cannot be attributed to another mental disorder (e.g., anxiety, depression, autism, or a personality disorder).

Based on the above criteria, ADHD can be divided into three types:

1. ADHD combined type: Both 1A and 1B.

2. ADHD inattentive type: 1A criteria are met.

3. ADHD hyperactive-impulsive type: 1B criteria are met.

Adult ADHD is difficult to assess, and diagnosis is always suspect in patients failing to display clear symptoms prior to 7 years of age.4 Adults with ADHD have higher rates of psychopathology, substance abuse, social dysfunction, and occupational un-derachievement.

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