Pediatric Primary Care Case Studies (48 page)

There appears to be some effect early in the morning, which fades away in a few hours. This is typical of a subtherapeutic medication dose. At this point increase the dose of Focalin XR to 10 mg given in the morning. Additionally, have the parents begin behavior modification by slowly integrating various chores and tasks into Jason’s daily routine. Keeping his school supplies neat and ready for school the next day is a good starting point. Encourage the parents to visit the Web sites previously mentioned to further their understanding of ADHD.

Second Management Evaluation Visit

Jason presents for the 1-month follow-up appointment with both parents. The father is concerned because Jason has lost 4 pounds of body weight and does not have much appetite. Also, he expresses concern that Jason will “become a zombie because this medicine sedates him so much.” Despite these concerns, both parents agree that Jason is behaving better at home and school. The teacher reported that Jason turned in all his homework last week and correctly spelled 19 of 20 words on his spelling test. However, by 2:00 p.m. he becomes restless and continues to be unable to concentrate on homework.

What is the appropriate next step in treating Jason?

The following should now be done to treat Jason:

   Increase the dose to 15 mg given as a single morning dose. Tell the parents 15–20 mg appears to be the necessary dose to provide efficacy over time. Observe him on the 15 mg dose for approximately 1–2 weeks, then decide if additional medication is necessary.

   Discuss a strategy for encouraging him to eat more. Some children will eat well at breakfast before taking medication, but then have no appetite the remainder of the day. Drinking or eating a small amount of food with complex carbohydrates and protein is sometimes the best plan at lunchtime. Often it is helpful to have the evening meal as late as possible.

   If he has difficulty following through with tasks at home or he remains oppositional, then referral to a psychologist is necessary.

   Plan to see him for follow-up in 1 month. At that point, if he is stable on medication, visits may be every 3 months.

It is important to provide education at each visit. Behavioral modification through instructions from the clinician prescribing medication or, in more difficult cases, from a psychologist, is necessary for the best clinical results according to the major MTA study (MTA Cooperative Group, 1999). However, stimulant or nonstimulant medications alone are far superior to behavioral modification alone.

What is the long-term prognosis for ADHD?

Parents must understand that ADHD is often a lifelong condition. Parents are often concerned about medicating a child for a prolonged or indefinite period of time. At some point, a controlled wean of the medication can be attempted. This is often requested by middle school–and high school–age patients. However, parents and providers must understand that the symptoms or expression of ADHD change with age. The typical adolescent is not as hyperkinetic as an 8-year-old child. The symptoms may be more subtle in appearance to those involved with these patients, but they nonetheless interfere with life. A prospective study in Wisconsin followed cohorts of teenagers with ADHD who were either treated or not treated with medication to control symptoms of ADHD for more than 13 years as they became young adults. The study found that those with untreated ADHD were more likely to not graduate from high school, be fired from a job, have an STD, have an unwanted pregnancy, be divorced, and be a substance abuser (Barkley, Fische, Smallish, & Fletcher, 2006). This is compelling evidence that ADHD should never be considered cured. Symptoms that have been controlled without medication can return throughout the affected individual’s lifetime, especially during times of stress. Keep these points in mind and make patients and parents aware of the potential lifelong nature of this disease.

Key Points from the Case

1. It may take time before the symptoms of ADHD interfere with the child’s functioning in a manner that warrants intervention.

2. Symptoms are often more obvious in structured environments.

3. Impairment can be different in different settings, such as home, school, and social situations.

4. Diagnosing ADHD is based on criteria outlined in the DSM-IV-TR.

5. Patient and parent education is mandatory for optimal outcomes. Education should begin with the first visit and be continued at subsequent follow-up visits.

6. ADHD is a lifelong condition and should be considered as influencing any behaviors that interfere with life functioning from the time of diagnosis as a child and continuing throughout adulthood.

7. Refer children with an underlying cardiac problem to a cardiologist prior to treatment with stimulant medications.

8. Use a psychologist to assess for comorbidities and to help with behavior management.

REFERENCES

American Academy of Pediatrics, Subcommittee on Attention Deficit/Hyperactivity Disorder. (2000). Clinical practice guideline: Diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder.
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American Heart Association. (2008).
Cardiovascular monitoring of children and adolescents with heart disease receiving medications for attention deficit/ hyperactivity disorder
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American Psychiatric Association. (2000).
Diagnostic and statistical manual of mental disorders
(4th ed., text rev.). Washington, DC: APA.

Barkley, R. A., Fische, R. M., Smallish, L., & Fletcher, K. (2006). Young adult outcome of hyperactivity in children: Adaptive functioning in major life activities.
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Biederman, J. (2004). Impact of comorbidity in adults with attention-deficit/ hyperactivity disorder.
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Efron, D., Friedrich, J., & Barker, M. (1997). Side effects of methylphenidate and dexamphetamine in children with attention deficit hyperactivity disorder: A double-blind, crossover trial.
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Elia, J., Borcherding, B., Rappoport, J., & Keysor, C. (1991). Methylphenidate and dextroamphetamine treatment of hyperactivity: Are there true nonresponders?
Psychiatric Research, 36
, 141–155.

Epstein, J. N., Rabinar, D., & Johnson, D. E. (2007). Presenting implication of evidence based practices for ADHD children among primary care pediatricians.
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Froelich, T. E., Lamphear, B. P., & Epstein, J. N. (2007). Prevalence, recognition and treatment of attention-deficit/hyperactivity disorder in a national sample of U.S. children.
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Green, M., Wong, M., & Atkins, D. (1999).
Diagnosis of attention deficit/hyperactivity disorder: Technical review
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Gutgesell, H., Atkins, D., Barst, R., Buck, M., Franklin, W., Hanes, R., Ringel, R., et al. (1999). Cardiovascular monitoring of children and adolescents receiving psychotropic drugs.
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