An 8-year-old boy is brought to the office by his mother, who says that the boy has become "unmanageable" over the past 2 years. He does not do anything that he is told, including chores and homework. He either makes excuses, saying that he "forgot," or does tasks "half-heartedly," often making careless mistakes while rushing through his work. The boy does not listen to his mother and argues with her about getting ready for school. He recently was taken to the principal's office for getting out of his seat and talking out of turn. The patient's teachers like him but describe him as "difficult to teach." His grades are poor, and he is at risk of not being promoted. The patient has also lost friends due to his intrusive behavior. His mood is usually upbeat, and he enjoys playing soccer and video games. The boy's weight is in the 40th percentile, his overall development has been normal, and he has met all developmental milestones. The family moved to a new neighborhood, and the patient started attending a different school last year. There is a family history of bipolar disorder in the patient's uncle. During the course of the evaluation, the boy repeatedly interrupts the discussion with rapid, loud speech. He jumps up and grabs the physician's stethoscope even after his mother tells him not to touch anything. Which of the following is the most likely diagnosis in this patient?

Question

An 8-year-old boy is brought to the office by his mother, who says that the boy has become "unmanageable" over the past 2 years.  He does not do anything that he is told, including chores and homework.  He either makes excuses, saying that he "forgot," or does tasks "half-heartedly," often making careless mistakes while rushing through his work.  The boy does not listen to his mother and argues with her about getting ready for school.  He recently was taken to the principal's office for getting out of his seat and talking out of turn.  The patient's teachers like him but describe him as "difficult to teach."  His grades are poor, and he is at risk of not being promoted.  The patient has also lost friends due to his intrusive behavior.  His mood is usually upbeat, and he enjoys playing soccer and video games.  The boy's weight is in the 40th percentile, his overall development has been normal, and he has met all developmental milestones.  The family moved to a new neighborhood, and the patient started attending a different school last year.  There is a family history of bipolar disorder in the patient's uncle.  During the course of the evaluation, the boy repeatedly interrupts the discussion with rapid, loud speech.  He jumps up and grabs the physician's stethoscope even after his mother tells him not to touch anything.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d70c_a64a_bc81_690ca98d9ee0_MD0003_00 This child's behavioral problems are characteristic of attention-deficit hyperactivity disorder (ADHD), combined type. His inattentive symptoms include making careless mistakes, forgetfulness, not listening, and avoidance/lack of follow-through with tasks. His hyperactive/impulsive symptoms include difficulty staying seated, hyperactivity, talkativeness, impulsivity, difficulty waiting his turn, and interrupting others. His symptoms cause impairment in more than one setting (school and home). Diagnosis of ADHD requires that several symptoms be present before age 12, although symptoms may often appear as early as kindergarten. ADHD is twice as common in boys, with girls more likely to have predominantly inattentive symptoms. ADHD symptoms commonly cause family discord (eg, difficulty following routines due to disorganization and not listening) and problems with peer relationships (eg, rejection, teasing). (Choice A) Adjustment disorder with disturbance of conduct is diagnosed when symptoms occur in response to an identifiable psychosocial stressor and do not meet criteria for another disorder. This patient's behavioral problems began 2 years ago, prior to his move and change to a new school. (Choice C) Hyperactivity, talkativeness, loud speech, and poor impulse control can be seen in both ADHD and hypomanic episodes of bipolar II disorder. However this patient lacks discrete mood episodes and other key hypomanic features (eg, grandiosity, decreased need for sleep). (Choice D) Conduct disorder involves behaviors that violate major societal norms or the rights of others (eg, aggression, property destruction, theft, deceitfulness, rule violations), which this patient does not exhibit. (Choice E) Disruptive mood dysregulation disorder involves severe, pervasive irritability and poor frustration tolerance, resulting in frequent temper outbursts. Inattention, hyperactivity, and disorganization are not prominent, but ADHD can be diagnosed as a comorbid condition if criteria are met. (Choice F) Although this patient's ADHD symptoms have led to conflict with his mother and peers, there is insufficient evidence to substantiate a comorbid diagnosis of oppositional defiant disorder. This disorder is characterized by a pattern of angry/irritable mood and argumentative/defiant behavior toward authority figures. These patients are temperamental, hostile, and defiantly break rules. This patient's mood is upbeat, and his arguments with his mother and classroom behavior are more likely related to his impulsivity rather than deliberate or vindictive defiance. Educational objective: A diagnosis of attention-deficit hyperactivity disorder (ADHD) should be considered in children with symptoms of inattention, impulsivity, and hyperactivity in 2 or more settings. In addition to academic difficulty, ADHD often results in impaired family and peer relationships. References: Functional consequences of attention-deficit hyperactivity disorder on children and their families. (http://www.ncbi.nlm.nih.gov/pubmed/27061213) Attention deficit hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26386541)

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