A 4-year-old boy is brought to the office by his parents due to behavioral problems. The parents recently decided to take him out of preschool after receiving numerous complaints from the staff about his hyperactive behavior (running and climbing in the classroom, interrupting the teacher) and inability to listen and follow directions. This is the second school he has attended this year. He was asked to leave the first school for similar behavior. The patient's mother says that at home, he "runs wild" and fights with his older siblings all the time. She says, "He is always bothering or interrupting his older sister and brother. Another difficulty is that we are always running late for school because I can't get him to follow through with getting dressed and eating breakfast." The father had a history of attention-deficit hyperactivity disorder as an adolescent and was treated with amphetamines. He says, "I think I never would have graduated from high school without them." The boy has no medical problems and developmental milestones are within normal range. The parents are reluctant to have their son take medication and are particularly concerned about the risk of weight loss because he is already very thin. The parents participate in a program on attention-deficit hyperactivity disorder (ADHD) and see some improvement in their son's response to their directions and ability to follow household rules. However, he remains hyperactive, easily distractible, and impulsive. They return 2 years later after receiving multiple phone calls from their son's first grade teacher. The patient has difficulty sitting still for more than a few minutes and frequently disrupts the class by blurting out answers or talking to classmates instead of listening to the teacher. If his behavior does not improve, he may have to repeat first grade. The patient undergoes a comprehensive evaluation for ADHD and no comorbid psychiatric or learning disorder is identified. The parents are now receptive to starting medication. Which of the following is most important to obtain prior to starting stimulant medication?

Question

A 4-year-old boy is brought to the office by his parents due to behavioral problems.  The parents recently decided to take him out of preschool after receiving numerous complaints from the staff about his hyperactive behavior (running and climbing in the classroom, interrupting the teacher) and inability to listen and follow directions.  This is the second school he has attended this year.  He was asked to leave the first school for similar behavior.  The patient's mother says that at home, he "runs wild" and fights with his older siblings all the time.  She says, "He is always bothering or interrupting his older sister and brother.  Another difficulty is that we are always running late for school because I can't get him to follow through with getting dressed and eating breakfast."  The father had a history of attention-deficit hyperactivity disorder as an adolescent and was treated with amphetamines.  He says, "I think I never would have graduated from high school without them."  The boy has no medical problems and developmental milestones are within normal range.  The parents are reluctant to have their son take medication and are particularly concerned about the risk of weight loss because he is already very thin. The parents participate in a program on attention-deficit hyperactivity disorder (ADHD) and see some improvement in their son's response to their directions and ability to follow household rules.  However, he remains hyperactive, easily distractible, and impulsive.  They return 2 years later after receiving multiple phone calls from their son's first grade teacher.  The patient has difficulty sitting still for more than a few minutes and frequently disrupts the class by blurting out answers or talking to classmates instead of listening to the teacher.  If his behavior does not improve, he may have to repeat first grade.  The patient undergoes a comprehensive evaluation for ADHD and no comorbid psychiatric or learning disorder is identified.  The parents are now receptive to starting medication.  Which of the following is most important to obtain prior to starting stimulant medication?

Quizplus · Accepted Answer

Explanation: The patient has had minimal improvement in core attention-deficit hyperactivity disorder (ADHD) symptoms with behavioral intervention, and the increased demands of first grade are causing significant functional impairment. Medication is appropriate, and stimulants (methylphenidate or amphetamines) are first-line options. Atomoxetine and alpha adrenergic agonists may be used as alternate therapy. Prior to initiating stimulant therapy, a comprehensive cardiac history and examination, baseline weight, and vital signs should be obtained. The history should include any signs of cardiac disease in the patient or family, including history of sudden cardiac death. Despite the FDA warning of sudden cardiac death with stimulants, there is no evidence that stimulant-treated ADHD patients are at increased risk. If history and physical examination show no cardiac disease, routine ECG screening is not indicated (Choice B). Stimulants may cause mild elevations in heart rate and blood pressure, and vital signs should be monitored in patients treated with stimulants. (Choice C) Development of tics or increased tic frequency may occur with stimulants but cannot be predicted based on family history. Most children with tics can be treated with stimulants without worsening of tics. (Choice D) Although a history of substance abuse in a household member may be one consideration in medication selection (eg, choosing longer-acting preparations or a methylphenidate patch with less risk of abuse), obtaining the patient's cardiac history is most important. (Choice E) Baseline liver function tests are not indicated. The stimulant pemoline is associated with increased risk of liver toxicity and hepatic failure and is no longer recommended. Educational objective: Stimulant pharmacotherapy for children with attention-deficit hyperactivity disorder can be initiated if history and physical examination do not suggest cardiac disease. In the absence of positive cardiac history, further evaluation, including ECG, is unnecessary. References: Risk of serious cardiovascular problems with medications for attention-deficit hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/23160939)

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