A 4-year-old boy is brought to the office by his mother for a well-child visit. As they walk down the hallway to the examination room, the mother yells at the patient to stop banging his toy car against the wall and pulls on his sleeve to hurry him up. The mother says, "He is a real handful. He never sits still, doesn't listen, and jumps on the furniture. I give him candy to get him to behave, but even that doesn't work. What am I supposed to do?" The mother receives frequent phone calls from the patient's preschool about the boy's disruptive behavior. She often has to leave work early to pick him up, which has started to affect her job performance. The patient's height and weight are tracking at the 50th percentile, and all developmental milestones are within normal range. Physical examination is normal apart from abrasions on both knees and a bruise on his right shin, which the mother explains he sustained while riding his bicycle and playing soccer. Which of the following is the most appropriate intervention?

Question

A 4-year-old boy is brought to the office by his mother for a well-child visit.  As they walk down the hallway to the examination room, the mother yells at the patient to stop banging his toy car against the wall and pulls on his sleeve to hurry him up.  The mother says, "He is a real handful.  He never sits still, doesn't listen, and jumps on the furniture.  I give him candy to get him to behave, but even that doesn't work.  What am I supposed to do?"  The mother receives frequent phone calls from the patient's preschool about the boy's disruptive behavior.  She often has to leave work early to pick him up, which has started to affect her job performance.  The patient's height and weight are tracking at the 50th percentile, and all developmental milestones are within normal range.  Physical examination is normal apart from abrasions on both knees and a bruise on his right shin, which the mother explains he sustained while riding his bicycle and playing soccer.  Which of the following is the most appropriate intervention?

Quizplus · Accepted Answer

The physician is confronted here with a frustrated parent who is having difficulty handling a hyperactive child. Although medication is a first-line treatment for school-aged children (age ≥6) with attention deficit hyperactivity disorder (ADHD), preschool-aged children (age 4-5) with ADHD or with problematic behavior that does not meet full criteria for ADHD should be managed with behavioral therapy, such as parent-child behavioral therapy (also known as parent management training). Parent-child behavioral therapy improves problem behaviors and parent-child relationships by focusing on positive parenting techniques. Parents are taught to consistently implement effective behavioral strategies (eg, using rewards and nonpunitive consequences to shape behavior rather than punishment, setting limits calmly rather than engaging in arguments, using time-outs rather than physical punishment, setting structured daily schedules). (Choice A) Although simple carbohydrates should not replace balanced, nutritious meals, there is no evidence that elimination diets (eg, no food additives, no sugars) have a clinically significant impact on ADHD behaviors. (Choice B) Behavioral interventions should precede pharmacotherapy in the preschool-aged group. The stimulant methylphenidate could be considered at a later date if behavioral interventions fail. (Choice C) Although it is sometimes difficult to differentiate active children from those with ADHD at this patient's age, the child's behavior is causing difficulties both at school and at home and should not be dismissed as normal. (Choice E) This child's knee abrasions and shin bruising are consistent with playing soccer or riding a bicycle. If this child had unexplained injuries or other evidence of neglect or abuse, it would be appropriate to report the case to child protective services. Educational objective: Behavioral therapy is the preferred initial treatment for preschool-aged children with attention deficit hyperactivity disorder or problematic hyperactive behavior. References: Attention deficit hyperactivity disorder in preschool-age children. (http://www.ncbi.nlm.nih.gov/pubmed/28577607)

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