Case 045: Attention-Deficit/Hyperactivity Disorder

PATIENT PRESENTATION

Chief Complaint

“I can’t finish my assignments”

History of Present Illness

JT, an 8-year-old male diagnosed with ADHD 1 year ago, presents to the pediatric clinic for a 3-month follow-up visit. He currently takes Ritalin LA 40 mg po every morning. School has become harder this year and he has more homework. He states it is difficult to focus on school assignments in class and he can’t finish his homework after school.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What are the three core symptoms of ADHD?

   Hint: See Clinical Presentation and Diagnosis in PPP

2. What neurotransmitters are involved in the pathophysiology of ADHD and how do they relate to symptoms and treatment?

   Hint: See Pathophysiology in PPP

3. What medication class should be used first line for therapy and why?

   Hint: See Treatment in PPP

4. Should JT’s therapy be adjusted? If so, what would be your recommendation?

   Hint: See Treatment in PPP

5. What are the goals of ADHD treatment?

   Hint: See Treatment in PPP

FOLLOW-UP

JT was changed to lisdexamfetamine chewable tablet 40 mg po daily. At his 1-month follow-up visit, he reports that he can concentrate more during school on activities and assignments and able to complete his homework after school. He states he is tolerating the medication and has no adverse effects. However, his mother notices that on some nights, he stays awake longer than before.

Was the change to lisdexamfetamine appropriate and why? Why could JT be staying up longer than before? What can be considered to manage this concern?

CASE SUMMARY

Global Perspective

ADHD is the most common neurobehavioral disorder in children in the United States. However, patients in other countries, such as Asia, Australia, Europe, and South America, also experience the disorder. The signs and symptoms of this disorder have been described in the medical literature since 1775. A majority of children with ADHD also have a co-morbid mental, emotional, or behavioral disorder. Treatment with stimulants is the main therapeutic approach as regulatory agencies in many countries have deemed this pharmacological therapy effective and safe for patients with ADHD. However, the economic burden of the disorder costs hundreds of billions of dollars worldwide, annually.

Key References