A 12-year-old girl is brought to the office by her mother, who is upset over her daughter's poor grades. The mother says, "Although she has always been scatterbrained, she is a really smart kid. Her grades have been poor throughout middle school, but I feel she could do so much better." On her most recent report card, the girl received Cs and Ds in most academic subjects. Typical teacher comments have included, "Mind seems elsewhere," "Frequently misses important details," and "Work is handed in late and is messy, incomplete, and disorganized." At home, the girl is occasionally moody and easily frustrated. Her mother says, "She gets upset when reminded of her chores, when the problem is usually that she simply forgot or wasn't listening in the first place." Apart from the issue of her grades, the girl enjoys school and is sleeping and eating well. The mother adds that the girl recently felt sad and rejected when she was not invited to a friend's party, but the girl says it was "no big deal." The patient has no medical conditions. On mental status examination, she makes good eye contact. She is responsive to the physician's questions but is occasionally distracted, requiring redirection. In addition to psychosocial interventions, which of the following medications would be most effective for this patient?

Question

A 12-year-old girl is brought to the office by her mother, who is upset over her daughter's poor grades.  The mother says, "Although she has always been scatterbrained, she is a really smart kid.  Her grades have been poor throughout middle school, but I feel she could do so much better."  On her most recent report card, the girl received Cs and Ds in most academic subjects.  Typical teacher comments have included, "Mind seems elsewhere," "Frequently misses important details," and "Work is handed in late and is messy, incomplete, and disorganized."  At home, the girl is occasionally moody and easily frustrated.  Her mother says, "She gets upset when reminded of her chores, when the problem is usually that she simply forgot or wasn't listening in the first place."  Apart from the issue of her grades, the girl enjoys school and is sleeping and eating well.  The mother adds that the girl recently felt sad and rejected when she was not invited to a friend's party, but the girl says it was "no big deal."  The patient has no medical conditions.  On mental status examination, she makes good eye contact.  She is responsive to the physician's questions but is occasionally distracted, requiring redirection.  In addition to psychosocial interventions, which of the following medications would be most effective for this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d799_2e9d_bc81_5367e099c18d_MD0003_00 This girl's inattention, distractibility, careless mistakes at school, disorganization, and forgetfulness are characteristic of the inattentive subtype of attention-deficit hyperactivity disorder (ADHD). Although ADHD is more common in boys, girls are more likely to present with predominantly inattentive features. Diagnosis requires onset of several symptoms before age 12 (eg, "has always been scatterbrained") and impairment in more than one setting (eg, school and home). Children with ADHD often have increased conflict with peers, teachers, and/or parents because their inattention is often considered volitional. In addition to psychosocial interventions (eg, behavioral therapy), stimulant medications (eg, methylphenidate, amphetamines) are first-line agents in school-aged children with ADHD and are more effective than nonstimulant medications. They have a long record of efficacy, safety, and rapid onset of action and are generally well-tolerated. Nonstimulant options include the norepinephrine reuptake inhibitor atomoxetine and alpha-2 adrenergic agonists. Atomoxetine is appropriate for patients with a history of illicit substance use or when there is a strong family preference against stimulant medication (Choice B). Alpha-2 adrenergic agonists (eg, guanfacine, clonidine) are typically used when there is a poor response to or intolerable adverse effects from stimulants or coexisting conditions (eg, tic disorders) (Choice D). Treatment goals include improving relationships and academic performance. (Choice C) This patient lacks persistent depressive symptoms, and her impaired concentration and academic dysfunction are more likely due to ADHD. Fluoxetine is a selective serotonin reuptake inhibitor used to primarily treat mood and anxiety disorders; it is not effective in ADHD. (Choice E) First-line treatment for ADHD in school-aged children includes a combination of behavioral therapy and stimulant medications, which has been shown to be highly effective in managing ADHD symptoms. Educational objective: Stimulant medications (eg, methylphenidate, amphetamines) are a first-line treatment for attention-deficit hyperactivity disorder in school-aged children. They are effective in inattentive, hyperactive, and combined subtypes. References: Stimulant drug response in the predominantly inattentive and combined subtypes of attention-deficit hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/20035584) Background, clinical features, and treatment of attention-deficit hyperactivity disorder in children. (http://www.ncbi.nlm.nih.gov/pubmed/23865438) Efficacy and tolerability of different interventions in children and adolescents with attention-deficit hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29180967)

A 12-Year-Old Girl Is Brought to the Office by Her