A 4-year-old boy is brought to the office by his parents due to behavioral problems. The parents recently decided to take him out of preschool after receiving numerous complaints from the staff about his hyperactive behavior (running and climbing in the classroom, interrupting the teacher) and inability to listen and follow directions. This is the second school he has attended this year. He was asked to leave the first school for similar behavior. The patient's mother says that at home, he "runs wild" and fights with his older siblings all the time. She says, "He is always bothering or interrupting his older sister and brother. Another difficulty is that we are always running late for school because I can't get him to follow through with getting dressed and eating breakfast." The father had a history of attention-deficit hyperactivity disorder as an adolescent and was treated with amphetamines. He says, "I think I never would have graduated from high school without them." The boy has no medical problems and developmental milestones are within normal range. The parents are reluctant to have their son take medication and are particularly concerned about the risk of weight loss because he is already very thin. Treatment with methylphenidate is initiated at a low dose and gradually titrated to a maximum dose over 4 weeks. The patient is seen for a follow-up visit an additional 2 months later. The mother reports mild improvement in the boy's behavior at home (less talking back and fighting with siblings) but continued difficulty following the morning routine. She is concerned that the patient's recent headaches and moodiness may be due to the medication. Teacher feedback indicates some improvement with sitting in his chair but continued talking out of turn and distractibility. There has been no improvement in his academic performance, and he is in danger of having to repeat first grade. Which of the following is the most appropriate next step in management of this patient?

Question

A 4-year-old boy is brought to the office by his parents due to behavioral problems.  The parents recently decided to take him out of preschool after receiving numerous complaints from the staff about his hyperactive behavior (running and climbing in the classroom, interrupting the teacher) and inability to listen and follow directions.  This is the second school he has attended this year.  He was asked to leave the first school for similar behavior.  The patient's mother says that at home, he "runs wild" and fights with his older siblings all the time.  She says, "He is always bothering or interrupting his older sister and brother.  Another difficulty is that we are always running late for school because I can't get him to follow through with getting dressed and eating breakfast."  The father had a history of attention-deficit hyperactivity disorder as an adolescent and was treated with amphetamines.  He says, "I think I never would have graduated from high school without them."  The boy has no medical problems and developmental milestones are within normal range.  The parents are reluctant to have their son take medication and are particularly concerned about the risk of weight loss because he is already very thin. Treatment with methylphenidate is initiated at a low dose and gradually titrated to a maximum dose over 4 weeks.  The patient is seen for a follow-up visit an additional 2 months later.  The mother reports mild improvement in the boy's behavior at home (less talking back and fighting with siblings) but continued difficulty following the morning routine.  She is concerned that the patient's recent headaches and moodiness may be due to the medication.  Teacher feedback indicates some improvement with sitting in his chair but continued talking out of turn and distractibility.  There has been no improvement in his academic performance, and he is in danger of having to repeat first grade.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Assessing response to stimulant treatment involves parent and teacher feedback and/or attention-deficit hyperactivity disorder (ADHD) rating scales. This patient has had only modest improvement in core ADHD symptoms with a maximum dose of methylphenidate, and his mother is concerned about side effects. Children with persistent symptoms despite adequate treatment with the initial medication and/or intolerable side effects can be treated with an alternate ADHD medication, including other stimulants (eg, mixed amphetamine salts). No tapering or washout is needed, and the patient can be switched immediately from one stimulant to another. More than half of children who are inadequate responders or have side effects with one type of stimulant will have improved efficacy and tolerability with another. The norepinephrine reuptake inhibitor atomoxetine and an alpha-2 adrenergic agonist are nonstimulant options. (Choice A) This patient has had an inadequate response to methylphenidate and is experiencing side effects. Although behavioral therapy can be helpful as an adjunct to medication, it would be inappropriate to continue methylphenidate. (Choice B) Stimulant doses are typically titrated up on a weekly basis until there is no room for improvement, maximum dose limits are reached, or the patient experiences intolerable side effects. This patient has been titrated to a maximum dose of methylphenidate and has been treated for an additional 2 months. Response to a stimulant can usually be determined within weeks, and continued treatment is unlikely to result in further improvement. (Choices C and D) The patient is at a maximum dosage and further increase would risk worsening side effects. Because there is no evidence that the patient had better efficacy at a lower dose during the titration period, reducing the dose is not indicated. Educational objective: Patients with attention-deficit hyperactivity disorder who have an inadequate response or fail to tolerate a stimulant can be tried on another. Other options include switching to a nonstimulant medication such as atomoxetine or an alpha-2 adrenergic agonist. References: Current pharmacotherapy of attention deficit hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24191257) A review of pharmacological management of attention-deficit/hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27453697)

A 4-Year-Old Boy Is Brought to the Office by His