A 14-year-old boy is brought to the office by his mother, who is concerned about his academic performance. The patient has a history of attention-deficit hyperactivity disorder (ADHD) diagnosed at age 6. He responded well to methylphenidate and continued stimulant medication through age 11. Currently, he takes no medication. His mother says, "He is less hyperactive at home and I no longer get phone calls from the school about his behavior, but adjusting to high school has been a challenge. Even though he is very bright, he has difficulty keeping up with his schoolwork. He often hands assignments in late and his work is sloppy. Now that he is in high school and grades are important, I worry that his poor grades will limit his options for college." The boy feels fine but says that "the teachers are boring and treat me unfairly. I know the answer, but then get in trouble for not raising my hand." The patient struggles, particularly in math, and is getting mostly Cs and Ds in his other classes. He has several friends and was excited when he made the soccer team. However, he decided to quit after receiving several warnings for being late to practice and forgetting his equipment. His mother says that he is much less hyperactive at home and hopes that he has "outgrown" his ADHD by now. The physician meets with the boy alone to obtain additional history. The patient says, "I hate high school. The work really isn't that hard; I just always put off my homework until the last minute or hand in assignments late. I know I would have gotten better test grades if I had just caught some stupid mistakes. I'm always the one who gets in trouble for talking, when it's really the kid next to me who gets me started. I also got in trouble with the soccer team for forgetting my uniform and talking back and not listening to the coach. My friends think I'm funny, but when it comes to getting together outside of school, they always say they're busy and can't make it." The boy has tried alcohol and marijuana on 2 occasions, but does not use these regularly. There is a family history of alcohol abuse in the patient's father and grandfather. The boy is interested in restarting medication for attention-deficit hyperactivity disorder. Which of the following is the most appropriate statement regarding treatment for this patient?

Question

A 14-year-old boy is brought to the office by his mother, who is concerned about his academic performance.  The patient has a history of attention-deficit hyperactivity disorder (ADHD) diagnosed at age 6.  He responded well to methylphenidate and continued stimulant medication through age 11.  Currently, he takes no medication.  His mother says, "He is less hyperactive at home and I no longer get phone calls from the school about his behavior, but adjusting to high school has been a challenge.  Even though he is very bright, he has difficulty keeping up with his schoolwork.  He often hands assignments in late and his work is sloppy.  Now that he is in high school and grades are important, I worry that his poor grades will limit his options for college."  The boy feels fine but says that "the teachers are boring and treat me unfairly.  I know the answer, but then get in trouble for not raising my hand."  The patient struggles, particularly in math, and is getting mostly Cs and Ds in his other classes.  He has several friends and was excited when he made the soccer team.  However, he decided to quit after receiving several warnings for being late to practice and forgetting his equipment.  His mother says that he is much less hyperactive at home and hopes that he has "outgrown" his ADHD by now. The physician meets with the boy alone to obtain additional history.  The patient says, "I hate high school.  The work really isn't that hard; I just always put off my homework until the last minute or hand in assignments late.  I know I would have gotten better test grades if I had just caught some stupid mistakes.  I'm always the one who gets in trouble for talking, when it's really the kid next to me who gets me started.  I also got in trouble with the soccer team for forgetting my uniform and talking back and not listening to the coach.  My friends think I'm funny, but when it comes to getting together outside of school, they always say they're busy and can't make it."  The boy has tried alcohol and marijuana on 2 occasions, but does not use these regularly.  There is a family history of alcohol abuse in the patient's father and grandfather.  The boy is interested in restarting medication for attention-deficit hyperactivity disorder.  Which of the following is the most appropriate statement regarding treatment for this patient?

Quizplus · Accepted Answer

Explanation: This patient describes additional attention-deficit hyperactivity disorder (ADHD) symptoms, including excessive procrastination, forgetfulness, making careless mistakes, not listening, and hyper-talkativeness. In addition to academic difficulty, he alludes to difficulty in peer relationships that may be due to impulsive behaviors that annoy others. Given that his persistent ADHD symptoms cause significant functional impairment, pharmacological treatment should be considered. Stimulant medications are a first-line treatment for adolescents or school-aged children (age >6) and include methylphenidate and amphetamines. Although there has been concern that stimulant treatment can lead to substance abuse, current research demonstrates that stimulant therapy does not increase the risk for substance use or abuse. This patient's limited personal history of substance use and family history of alcohol abuse are not contraindications to stimulant therapy (Choices D and E). Non-stimulant medications would be preferred if this patient had a personal history of a substance use disorder (ie, more than just occasional substance use). (Choice A) Behavioral therapy alone is unlikely to be as effective as stimulants in reducing core ADHD symptoms but is useful in combination with pharmacotherapy. If this were a preschool child (age <6), then behavioral therapy would be a first-line option. (Choice B) A non-stimulant (eg, atomoxetine) is an alternate therapy, but a trial of this medication is not required prior to giving a stimulant. Educational objective: Stimulant therapy for attention-deficit hyperactivity disorder does not increase the risk of developing a substance use disorder. References: Stimulant medication and substance use outcomes: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23754458) Stimulant treatment for attention-deficit hyperactivity disorder and risk of developing substance use disorder. (http://www.ncbi.nlm.nih.gov/pubmed/23846996)

A 14-Year-Old Boy Is Brought to the Office by His