The small girl who was not completing her class works

Case Description

A 7-year-old girl Rita is brought to her pediatrician on the suggestion of her second-grade teacher. The patient has been back in school following a summer break. According to the teacher, the patient has found it very difficult to complete her classroom tasks since returning to school. The child does not disturb other students but cannot finish her assignments in the allotted time although her classmates do so without difficulty.

She is also known to make careless mistakes in her work. Although she is still passing her classes, her grades dropped, and she seems to daydream a great deal in class as well. The teacher reports that it takes several repetitions of the instructions for the patient to complete a task (eg, in an art class).

The patient enjoys physical education and does well in that class. The child indicates that when it appears to others that she is not paying attention she is thinking about other things. Teachers report that her attention wanders constantly and they have to call her name or wave to get her immediate attention. There have been no episodes where she stares blankly and the teacher cannot get her attention for a few seconds.

Although her parents have noticed some of the same behaviors at home, they have not been particularly concerned because they have found ways to work around them. If they monitor the child and her work directly, she can complete her homework, but they must continually check her work for careless mistakes.  She does seem to know the right answer when it is pointed out.

The parents also report that the patient does not get ready for school in the mornings without moment-by-moment monitoring.  Her bedroom is in shambles, and she loses things all the time. The parents describe their daughter as a happy child who enjoys playing with her siblings and friends. They note that she does not like school, except for the physical education classes.

Analysis

Most likely diagnosis: Attention-deficit/hyperactivity disorder (ADHD)

Signs and symptoms of  ADHD

Attention deficit :

• Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
• Often has trouble keeping attention on tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow instructions and fails to finish schoolwork, chores, or duties in the workplace
• Often has trouble organizing activities.
• Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
• Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
• Is often easily distracted.
• Often forgetful in daily activities.
• Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level

Hyperactivity:

• Often fidgets with hands or feet or squirms in seat.
• Often gets up from seat when remaining in seat is expected.
• Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
• Often has trouble playing or enjoying leisure activities quietly.
• Is often "on the go" or often acts as if "driven by a motor".
• Often talks excessively.

Impulsiveness:

• Often blurts out answers before questions have been finished.
• Often has trouble waiting one's turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games).

Other general characteristics to remember

• Some symptoms that cause impairment were present before age 7 year
• There must be clear evidence of significant impairment in social, school, or work functioning
• The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

Differential Diagnosis

• The presence of oppositional defiant disorder (ODD) or conduct disorder in a child or youth with ADHD is relatively common.
• Patients with ADHD often have learning disabilities, and a thorough evaluation of this problem should be conducted for every child suspected of having this disorder.
• Lead intoxication can lead to hyperactivity, and the presence of this disorder should be ruled out by determining the lead level in the blood at the initial evaluation.
• Patients with petite mal seizures may report poor attention. However, with careful questioning, clinicians can usually get a history of brief periods where the patient is unaware of what is happening around them, often describing brief periods when they have lost time(absences).
• Parents and teacher should be asked about staring spells when the child is unresponsive even when directly spoken to face-to-face, suggesting petit mal seizures.
• ADHD, especially if occurring with oppositional defiant disorder, may be mistaken for childhood bipolar disorder.

Treatment Approach

• Approximately 70% to 80% of all children with ADHD will respond to stimulant medications, either methylphenidate or amphetamine preparations.
• Occasionally, the stimulants are associated with the development of tics or worsening of tics in those with tic disorders. Stimulants have, as a group, a very rapid onset of action, and typically, their therapeutic effects wear off by the end of the day.
• Adverse effects typically include decreased appetite (sometimes with subsequent slowed growth rate), initial insomnia, irritability, dysphoria, and headache.

Summary

There are three primary subtypes of ADHD (inattentive type, hyperactive-impulsive type, and combined type), all of which have different presentations.

Use of a stimulant medication or atomoxetine is probably the best medication for these children. Pemoline is effective in ADHD, but its association with a rare hepatotoxic reaction has resulted in recommendations that a baseline ALT be obtained and that it be remonitored every 2 weeks while the patient is on the medication.

References

DSM IV Handbook for differential Diagnosis for PDA
Case Files Psychiatry
A Quick reference to APA practice guidelines