A 9-year-old boy is brought to the office by his parents for evaluation of behavior problems. His mother says that he never listens, gets distracted easily, and is hyperactive all the time. He is unable to sit still at the dinner table, constantly interrupts her when she is speaking on the phone, and makes excuses for forgetting his homework and chores. The father says his wife is overreacting as the boy has always been very active. He adds, "I was the same way as a kid; I am sure he'll grow out of it." There have been no changes in the patient's appetite or sleep. He has friends at school and likes to play sports and video games. Physical examination is remarkable for a scar on his right leg and multiple scabs on his right knee, which he reports are due to falling off his bike and skateboard. The remainder of the physical examination is normal. The child's mother asks if there is any medication that can help him "calm down." Which of the following is the most appropriate next step in management of this patient?

Question

A 9-year-old boy is brought to the office by his parents for evaluation of behavior problems.  His mother says that he never listens, gets distracted easily, and is hyperactive all the time.  He is unable to sit still at the dinner table, constantly interrupts her when she is speaking on the phone, and makes excuses for forgetting his homework and chores.  The father says his wife is overreacting as the boy has always been very active.  He adds, "I was the same way as a kid; I am sure he'll grow out of it."  There have been no changes in the patient's appetite or sleep.  He has friends at school and likes to play sports and video games.  Physical examination is remarkable for a scar on his right leg and multiple scabs on his right knee, which he reports are due to falling off his bike and skateboard.  The remainder of the physical examination is normal.  The child's mother asks if there is any medication that can help him "calm down."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d606_0bc4_bc81_219a8e1e0014_MD0003_00 Although this boy's parents have different viewpoints, the overall picture of a high activity level, inability to sit still, distractibility, and impulsivity is concerning for possible attention-deficit hyperactivity disorder (ADHD). The diagnosis of ADHD is made clinically with evidence of symptoms being present in 2 or more settings (eg, home, school). Teacher evaluations are helpful in assessing if the symptoms extend beyond the home environment. Teachers' observations of classroom behavior (eg, inattentiveness; fidgeting; difficulty staying seated; talkativeness; difficulty listening, following instructions, completing assignments) in relation to same-age peers will help to establish the diagnosis. Ideally, teacher evaluations should involve observations over a 6-month period and be supplemented with validated ADHD-specific rating scales. (Choice A) Initiating treatment with the stimulant methylphenidate would be appropriate only after the diagnosis of ADHD is made. (Choice B) Separate parental interviews may be helpful if one parent is noted to be quiet or not contributing during the interview. However, in this case, both parents express their opinions about the patient's behavior. (Choices C and F) This patient's behavioral problems are concerning to his mother and are likely impacting his academic performance. It would be inappropriate to offer reassurance or take a wait-and-see approach. (Choices D and G) A hearing test and educational testing are not routinely performed in the initial evaluation of ADHD. These may be appropriate, however, if coexisting hearing impairment or learning disabilities are suspected. Educational objective: The diagnosis of attention-deficit hyperactivity disorder is based on clinical evaluation of symptoms and associated impairment in 2 different settings. Teacher evaluations are an important tool for assessing behavior in the school environment. References: ADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/22003063) Comparison of mother, father, and teacher reports of ADHD core symptoms in a sample of child psychiatric outpatients. (http://www.ncbi.nlm.nih.gov/pubmed/22441890)

A 9-Year-Old Boy Is Brought to the Office by His