An 8-year-old boy is brought to the office by his parents due to difficulty at school. The boy's teacher reported that he is disruptive to other students and his behavior has worsened over the course of the year. He has difficulty making friends due to his annoying behavior and has trouble sitting still and focusing. At home, the boy is active and affectionate but can easily become irritable, and he has trouble sharing toys with his younger siblings. His mother says, "Everything seems okay, and then suddenly he will start shouting and throwing his toys or occasionally hit his brothers. He routinely forgets to do his homework and chores despite my reminding him over and over, and he gets angry and argumentative when he is reprimanded." Medical history is insignificant. The patient sleeps and eats well. On examination, he is noted to be fidgety and interrupts the conversation with various questions and comments. In addition to psychosocial interventions, which of the following medications would be most effective for this patient?

Question

An 8-year-old boy is brought to the office by his parents due to difficulty at school.  The boy's teacher reported that he is disruptive to other students and his behavior has worsened over the course of the year.  He has difficulty making friends due to his annoying behavior and has trouble sitting still and focusing.  At home, the boy is active and affectionate but can easily become irritable, and he has trouble sharing toys with his younger siblings.  His mother says, "Everything seems okay, and then suddenly he will start shouting and throwing his toys or occasionally hit his brothers.  He routinely forgets to do his homework and chores despite my reminding him over and over, and he gets angry and argumentative when he is reprimanded."  Medical history is insignificant.  The patient sleeps and eats well.  On examination, he is noted to be fidgety and interrupts the conversation with various questions and comments.  In addition to psychosocial interventions, which of the following medications would be most effective for this patient?

Quizplus · Accepted Answer

11ec25c8_d238_61e1_bc81_e1d31bae48d9_MD0003_00 This boy's difficulty sitting still and focusing, forgetfulness despite reminders, fidgetiness, disruptiveness in class, and interruption of others is characteristic of attention-deficit hyperactivity disorder (ADHD). Diagnosis requires onset of symptoms prior to age 12 with impairment in more than one setting (eg, school and home, as in this case). Children with ADHD often demonstrate poor frustration tolerance and impulsive behavior (eg, throwing toys, shouting, hitting) that result in conflict with peers, siblings, and authority figures. In school-age children and adolescents, stimulant medications (eg, methylphenidate, amphetamines) are first-line treatment. They are more effective than nonstimulant medications, with good tolerability, a positive safety record, and rapid onset of action. Common stimulant side effects, including decreased appetite and insomnia, can generally be managed with dosage or timing adjustments. Stimulants are often combined with behavioral therapy (eg, positive reinforcement for good behavior, maintaining a schedule). (Choices A and C) Nonstimulant options for treating ADHD include the norepinephrine reuptake inhibitor atomoxetine and the alpha-2 adrenergic agonists clonidine and guanfacine. Atomoxetine can be considered if there is a family preference for nonstimulant medications or in patients with substance use disorders. Alpha-2 adrenergic agonists are typically used following adverse effects or lack of response from stimulants or atomoxetine. (Choice B) Bupropion is a dopamine/norepinephrine reuptake inhibitor most commonly used in the treatment of major depression and as an aid in smoking cessation. It is not first-line treatment for ADHD. (Choice D) Fluoxetine is a selective serotonin reuptake inhibitor used in the treatment of pediatric depression. Although pediatric depression can present with irritability as well as difficulty focusing, this patient lacks other symptoms characteristic of depression, such as lack of enjoyment, social withdrawal, and problems with sleep or appetite. (Choices E and G) Haloperidol and risperidone are antipsychotic agents used in the treatment of psychotic disorders and tic disorders. Risperidone can also be considered in the treatment of aggression associated with autism spectrum disorders. Neither medication is used to treat ADHD. Educational objective: First-line treatment for attention-deficit hyperactivity disorder in school-age children is with stimulant medications (eg, methylphenidate, amphetamines) due to their efficacy, safety, and tolerability. References: Efficacy and tolerability of different interventions in children and adolescents with attention deficit hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29180967) Diagnosis and management of ADHD in children. (http://www.ncbi.nlm.nih.gov/pubmed/25369623)

An 8-Year-Old Boy Is Brought to the Office by His