Presentations of ADHD

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Discussion: Presentations of ADHD

Although ADHD is often associated with children, this disorder is diagnosed in clients across the lifespan. While many individuals are properly diagnosed and treated during childhood, some individuals who have ADHD only present with subsyndromal evidence of the disorder. These individuals are often undiagnosed until they reach adulthood and struggle to cope with competing demands of running a household, caring for children, and maintaining employment. For this Discussion, you consider how you might assess and treat individuals presenting with ADHD.

To prepare for this Discussion:

Case 1: Volume 1, Case #13: The 8-year-old girl who was naughty

The Case: 8-year-old girl who was naughty The Question: Do girls get ADHD? The Psych pharm Dilemma: How do you treat ADHD with oppositional symptoms? Pretest Self-Assessment Question (answer at the end of the case) what is true about oppositional symptoms in patients with ADHD A. They can be part of the diagnostic criteria for ADHD in children B. They can be confused with impulsive symptoms of ADHD C. They can be part of oppositional defiant disorder (ODD) which can be comorbid with ADHD D. They can be part of conduct disorder (CD) which can be comorbid with ADHD Patient Intake • 8-year-old girl brought to her pediatrician by her 26-year-old mother • Chief complaint: fever and sore throat Psychiatric History • While evaluating the patient for an upper respiratory infection, the pediatrician asks if school is going well • The patient responds “yes” but in the background the mother shakes her head “no” • The mother states that her daughter is negative and defiant at home and she has similar reports, mostly of disobedience, from her teacher at school • The patient has had temper tantrums since age 5 but these have decreased over the past 3 years, especially the past year • Still angry and resentful since her little sister was born 6 years ago • Academic problems • Fights with other children, mostly arguments and harsh words with other girls at school Social and Personal History • Goes to public school • Has a younger sister age 6 • Does not see her father much, lives in a nearby city • Not many friends • Spends most of her time with her sister and either her mother or her maternal grandmother who helps with after school supervision and baby sitting

Medical History • None Family History • None known for medical or psychiatric disorders other than the father who drinks a bit too much and his father (paternal grandfather) who some think might be an alcoholic • Mother was adopted and no family history known Pediatrician’s Notes: Initial Evaluation • Not enough time to do any more evaluation • Instead, the mother is given the parent and teacher version of the Conners ADHD rating scale and is instructed to bring the completed forms to the follow-up visit • A variety of rating scales are available, some without charge (see • The Connors scale charges a fee but other rating scales available at this link, or listed in the Two-Minute Tute below are free. Pediatrician’s Notes: Follow-up Visit Week 3 • At the follow-up visit, the mother admits to having been too busy to fill out the parent form • Also admits to having forgotten to send the rating form to the teacher • Mother acknowledges being more disorganized since her second child started school this year • Since then it has also been extremely difficult to keep the patient organized and focused on school • The mother is on the verge of tears • “Two children are too much for a single mother” • The pediatrician offers to send the teacher form to the school and gives the mother tips on how to remember to fill out her own form • When the teacher form is sent back to the pediatrician’s office the mother will be contacted for a follow-up visit Pediatrician’s Notes: Follow-up Visit Week 6 • At the follow-up visit, the mother comes alone • Teacher’s ADHD rating scale responses state that the patient has significant problems with – Talking excessively – Sustaining attention – Being organized – Being distracted – Being forgetful

– Following instructions – Making careless errors (except when it comes to her homework) • The teacher also complains of the patient being more argumentative and disobedient than the other children in her class • The mother’s responses on the ADHD rating scales are similar to the teacher’s but she endorses only five symptoms as significantly impairing • Checked “severe” for ability to listen (rated only mild by the teacher) • Upon further questioning by the pediatrician, it becomes clear that the mother is compensating for her daughter by – Double checking her homework – Making sure homework is in her backpack – Helping the patient be organized • Eventually, symptoms that were originally determined to be “mild” by the mother are changed to “significantly impairing” • Mother confirm that the patient argues a lot with her, especially when the mother is trying to oversee her work, and that the patient still occasionally has temper tantrums similar to when she was five years old, but milder Based on just what you have been told so far about this patient’s history what do you think is her diagnosis? • ADHD • ODD (oppositional defiant disorder) • CD (conduct disorder) • ADHD comorbid with ODD • ADHD comorbid with CD • A child acting out again her mother’s divorce and against having to share her mother with her sister • Other Pediatrician’s Mental Notes: Follow-up Visit, Week 6, Continued • The patient is diagnosed with ADHD, mostly inattentive type, comorbid with symptoms of oppositional defiant disorder – ADHD symptoms include inattention but not hyperactivity – Some of her impulsive symptoms such as being argumentative and disobedient overlap with her ODD symptoms but the ODD symptoms seem to be willful and on purpose rather than truly thoughtlessly impulsive • To be diagnosed with conduct disorder, the patient would need to exhibit symptoms similar to ODD plus have aggression towards animals, destruction of property, deceitfulness or theft, and serious violations of rules, symptoms of a type and severity that neither the teacher nor the mother brought up

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