Home Psychiatry Attention Deficit Hyperactivity Disorder
Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References

A 6-year-old boy, resident of an urban area, studying in 1st standard, from a nuclear family, with an elder sister, belonging to lower socioeconomic status presented to the psychiatry OPD with his 

mother, with difficulty to sit at one place, difficulty to focus, and increased irritability since 1 year. The mother reported that the teachers complained of the boy who could not wait for his turn in school and was constantly switching between tasks. Teachers also complained about his distractibility, as he would do different tasks before completing the one at hand. He has often forgotten his belongings at school. He grabs anything in his vicinity and tends to destroy those items not realizing the consequences. He has been increasingly demanding and throws tantrums if his demands are not met immediately. He has also had physical altercations with other children of his age group and even a few who are older than him.

The child was born by a full-term cesarean section. He was admitted to neonatal care a few days post-birth due to respiratory difficulties, and difficulty in feeding. But, there was a delay in milestones reported – the mother reports that the child started walking at the age of 2 years. Pediatrician evaluation found no abnormality except obesity.

Negative History:

No history of any nail biting, thumb sucking, bed wetting, head banging or any self harm.

General physical examination: The boy was well built, adequately nourished, conscious, oriented to time, place, and person. Not easily cooperative.

Vitals: Within Normal Limits

Height: 127cm    

Weight: 35kg

BMI: 21.7kg/sq.m

Systemic examination:

CNS- normal motor and sensory system, reflexes elicited normally

CVS- Normal S1 S2 heart sounds heard. No murmurs heard.

RS- Bilateral normal vesicular breath sounds heard

GI- Soft, non tender abdomen. No organomegaly. Normal Bowel sounds heard.

Diagnostic Test of Attention Deficit Hyperactivity Disorder(DT-ADHD) was done and the scoring suggested a severe deficit in attention, severe hyperactivity, and severe impulsivity, and the overall scoring suggested Attention Deficit Hyperactivity Disorder.

Attention Deficit Hyperactivity Disorder (ADHD)

WHO ICD10 Criteria:

F90.2, Attention-deficit hyperactivity disorder, combined type

For a clinical diagnosis of ADHD, an individual must exhibit six or more symptoms of one of the types of ADHD and also meet each of the following three criteria:

The symptoms caused problems before the age of 7.

The behavior is abnormal for a non-ADHD child of the same age.

The symptoms have lasted longer than six months, and they impair school, work, home life, or relationships in more than one setting.

Differential diagnosis:

Hyperkinesia

Hyperkinetic syndrome

Conduct disorders

Simple disturbances of activity and attention

Tab Methylphenidate 10mg 1-0-0 for a month and further evaluation for dose adjustments.

Attention-enhancing tasks such as Bead Sorting or Colouring were planned and the mother was involved in the education of the process.

Education of family members about the condition and continued therapy for ADHD.

Refer to the dietician for necessary modifications because of the management of obesity.

Attention Deficit Hyperactivity Disorder is a disorder of childhood that mainly affects the attention, concentration, impulsivity, and activity of the affected children. It affects less than 5% of children but some studies range 8-20% of children in India, mainly in the primary school-going age group(1). If untreated, ADHD affects various domains of an individual’s life such as academic difficulties, quality of life,  difficulties in the social domains like negative peer status, family functioning (relationship with parents/spouse), unintentional injury, and even substance use disorders (2). The most common treatment modalities include pharmacological agents, mainly stimulants methylphenidate and modafinil. Non-pharmacological interventions like intensive behavioral modification treatments are found to benefit ADHD in childhood. Other psychotherapies which are beneficial in all age groups of ADHD affected are attention enhancing tasks, cognitive-behavioral treatment (3).

1. Manjunath R, Kishor M, Kulkarni P, Shrinivasa BM, Sathyamurthy S. Magnitude of attention deficit hyper kinetic disorder among school children of Mysore city. International Neuropsychiatric Disease Journal. 2016:1-7. DOI:10.9734/INDJ/2016/21954

2. Barkley RA. Global issues related to the impact of untreated attention-deficit/hyperactivity disorder from childhood to young adulthood. Postgraduate Medicine. 2008 Jan 1;120(3):48-59. DOI:10.3810/pgm.2008.09.1907


3. Caye A, Swanson JM, Coghill D, Rohde LA. Treatment strategies for ADHD: an evidence-based guide to select optimal treatment. Molecular Psychiatry, 390–408(2019)

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