Case Based Learning
Case # 1
with
Dr. Catharine Robertson
2016
Disclosures
• No financial associations with
industry in the last 5 years.
An 8-year-old boy, Robert, is
brought to your office by his
exasperated parents. He is
described by his parents as
being a very busy boy who is
“always on the go”. They report
that he doesn’t seem to listen
when they try to speak with
him, that he is easily distracted
and never seems to complete
any tasks.
Mother reports that when Robert
was very young she went
through numerous babysitters
for Robert. The babysitters
complained that Robert was
“too much of a handful” to
manage. They said Robert
would often be caught doing
dangerous things like hanging
off the stair railings, running out
into the street or jumping off
furniture. They said he never
sat still and did quiet activities
with the other children.
Father states his frustration with
Robert is mostly at mealtimes
when his son will not sit still.
Father estimates that Robert is
up and down “25 times” during
one meal. He has tried
punishing Robert for this
behaviour but it didn’t work.
Robert is also quite disobedient
and defiant at school and at
home. He has stolen money from
his parents and toys from the
other children at school. He
interrupts others constantly and
disrupts the class regularly. He
was recently suspended from
school after he was caught
swinging from a fluorescent lightfitting in his classroom.
• Specific Learning Objectives (CASE #1):
• (1) Describe the diagnostic criteria for Attention
Deficit/Hyperactivity Disorder.
• (2) Describe a differential diagnosis for a patient with
symptoms of ADHD.
• (3) Describe the common comorbidities with ADHD.
• (4) Describe how you would proceed to confirm a
diagnosis of ADHD.
• (5) Describe how you would manage this patient with a
diagnosis of ADHD.
• (6) Name two stimulants and outline how you would
prescribe one of these stimulants.
• (7) Describe the side effects of stimulants and how to
manage these side effects.
• (8) Outline a nonpharmacological approach to treatment
of ADHD.
ADHD –Diagnostic Criteria
DSM5
Neurodevelopmental
Disorders
-Intellectual disabilities
-Communication disorders
-Autism spectrum disorder
-Attention deficit/hyperactivity disorder
-Specific learning disorder
-Motor disorders
-Other neurodevelopmental disorders
A. Either (1) and/or (2) persistent pattern of I +/H/I, interferes with functioning
1. Inattention: ≥Six of the following symptoms
have persisted for at least 6 months to a degree
that is inconsistent with developmental level
and that impact directly on social and
academic/occupational activities. Note: for older
adolescents and adults (≥17 yrs), ≥5 symptoms
are required. The symptoms are not due to
oppositional behavior, defiance, hostility, or a
failure to understand tasks or instructions.
(a) Often fails to give close attention to details
or makes careless mistakes in schoolwork, at
work, or during other activities (e.g.,
overlooks or misses details, work is
inaccurate).
(b) Often has difficulty sustaining attention in
tasks or play activities (e.g., has difficulty
remaining focused during lectures,
conversations, or lengthy reading).
(c) Often does not seem to listen when spoken to
directly (e.g.,mind seems elsewhere, even in the
absence of any obvious distraction).
(d) Often does not follow through on instructions and
fails to finish schoolwork, chores, or duties in the
workplace (e.g.,starts tasks but quickly loses focus
and is easily sidetracked).
(e) Often has difficulty organizing tasks and
activities (e.g.,difficulty managing sequential
tasks and keeping materials and belongings in
order; messy,disorganized work; has poor time
management; fails to meet deadlines.)
(f) Often avoids, dislikes, or is reluctant to
engage in tasks that require sustained mental
effort (e.g., schoolwork or homework; for older
adolescents and adults, preparing reports,
completing forms, or reviewing lengthy
papers).
(g) Often loses objects necessary for tasks
or activities (e.g., school materials,
pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile
telephones).
(h) Is often easily distracted by extraneous
stimuli (for older adolescents and adults
may include unrelated thoughts.).
i) Is often forgetful in daily activities
(e.g.,doing chores, running errands; for
older adolescents and adults, returning
calls, paying bills, keeping appointments).
2. Hyperactivity and Impulsivity: ≥6
of the following symptoms have
persisted for at least 6 months to a
degree that is inconsistent with
developmental level and that
negatively impacts directly on social
and academic/occupational activities.
Note: The symptoms are not due to
oppositional behavior, defiance,
hostility, or a failure to understand
tasks or instructions. For older
adolescents and adults (≥17 yrs), ≥5
symptoms are required.
(a) Often fidgets or taps hands or feet or
squirms in seat.
(b) Often leaves seat in situations when
remaining seated is expected (e.g. leaves
his or her place in the classroom, in the
office or other workplace, or in other
situations that require remaining seated).
(c) Often runs about or climbs where it is
inappropriate. (Note: In adolescents or
adults, may be limited to feeling restless.)
(d) Often unable to play or engage
in leisure activities quietly.
(e) Is often “on the go,” acting as
if “driven by a motor” (e.g. is
unable to be or uncomfortable
being still for an extended time, as
in restaurants, meetings; may be
experienced by others as being
restless or difficult to keep up
with).
(f)
Often talks excessively.
(g) Often blurts out an answer before a
question has been completed (e.g.,
completes people’s sentences;
cannot wait for turn in conversation).
(h) Has difficulty waiting his or her
turn (e.g.while waiting in line.
(i) Often interrupts or intrudes on
others (e.g. butts into conversations,
games, or activities; may start using
other people’s things without asking
or receiving permission; for
adolescents and adults, may intrude
into or take over what others are
doing).
B. Several inattentive or hyperactiveimpulsive symptoms were present prior to
age 12 years.
C. Several inattentive or hyperactiveimpulsive symptoms are present in two or
more settings (e.g., at home, school or
work; with friends or relatives, or in other
activities).
D. There is clear evidence that the
symptoms interfere with or reduce
thequality of social, academic, or
occupational functioning.
B. Several inattentive or hyperactiveimpulsive symptoms were present prior to
age 12 years.
C. Several inattentive or hyperactiveimpulsive symptoms are present in two or
more settings (e.g., at home, school or
work; with friends or relatives, or in other
activities).
D. There is clear evidence that the
symptoms interfere with or reduce the
quality of social, academic, or occupational
functioning.
Specify Based on Current Presentation
-For past 6 months:
Combined Presentation:
Criterion A1 (Inattention) ✔ Criterion A2 (H-I)✔
Predominately Inattentive Presentation:
Criterion A1 (Inattention)✔
Criterion A2 (H-I) ✖
Predominately Hyperactive/Impulsive Presentation:
Criterion A1 (Inattention) ✖
Criterion A2 (H-I) ✔
Inattention
An 8-year-old boy, Robert, is
brought to your office by his
exasperated parents. He is
described by his parents as
being a very busy boy who is
“always on the go”. They report
that he doesn’t
doesn’t seem
seem to
to listen
listen
when they try to speak with
him, that he is easily
easily distracted
distracted
and never seems to complete
any tasks.
He is currently in Grade 3 and not
not
doing well at school.
school He cannot
sit still at school and often
blurts out answers without
remembering to raise his hand.
Hyperactivity
An 8-year-old boy, Robert, is
brought to your office by his
exasperated parents. He is
described by his parents as
being a very busy boy who is
“always on
on the
the go”.
go”. They report
“always
that he doesn’t seem to listen
when they try to speak with
him, that he is easily distracted
and never seems to complete
any tasks.
Mother reports that when Robert
was very young she went
through numerous babysitters
for Robert. The babysitters
complained that Robert was
“too much of a handful” to
manage. They said Robert
would often be caught doing
dangerous things like hanging
off the stair railings, running out
into the street or jumping off
furniture. They said he never
sat
sat still
still and did quiet activities
with the other children.
Father states his frustration with
Robert is mostly at mealtimes
when his son will not sit still.
Father estimates that Robert is
up and down “25 times” during
one meal. He has tried
punishing Robert for this
behaviour but it didn’t work.
Impulsivity
He is currently in Grade 3 and not
doing well at school. He cannot
sit still at school and often
blurts out answers without
remembering to raise his hand.
Robert is also quite disobedient
and defiant at school and at
home. He has stolen money from
his parents and toys from the
other children at school. He
interrupts
interrupts others constantly and
disrupts the class regularly - he
was recently suspended from
school after he was caught
swinging from a fluorescent lightfitting in his classroom.
Mother reports that when Robert
was very young she went
through numerous babysitters
for Robert. The babysitters
complained that Robert was
“too much of a handful” to
manage. They said Robert
would often be caught doing
dangerous things like hanging
off the stair railings, running out
into the street or jumping off
furniture. They said he never
sat still and did quiet activities
with the other children.
Differential Diagnosis
•
•
•
•
never seems to complete any tasks
doesn’t seem to listen
“too much of a handful” to manage
disobedient and defiant at school and
at home
• stolen money from his parents and toys
from the other children at school
? another disruptive behaviour dis.?
• doesn’t seem to listen
? physical problem e.g. hearing
problem?
• He is currently in Grade 3 and
not doing well at school.
? LD/cognitive problem?
• Normality
• Poor fit: academic ability vs
expectation
• Physical (and sleep) Problems
• Emotional/Psychiatric Problems
Common Comorbidities
Common Comorbidities
• Oppositional Defiant Disorder
• Conduct Disorder
• Substance Use Disorders
• Learning Disabilities
• Anxiety Disorder
• Mood Disorders
• Tic Disorders
Diagnosing ADHD
• The diagnosis is based on history.
• Need information about the
individual in more than one setting.
• ADHD is a diagnosis of exclusion.
• Standardized rating scales and
psychological tests can assist but
aren’t diagnostic.
Treatment
Non-Pharmacological
Psychoeducation
1. (Psycho) education: -impart
knowledge about the disorder, its
impacts and how to function
optimally ( organizational skills,
anger & sleep management, etc)
• Patients (esp ≥ 8yrs)
• families (+/or caregivers)
• teachers /employers
Behavioural interventions
• CPS, rewards & consequences,
etc
• Environmental management
• ADHD coaching
• Lifestyle changes (diet,
exercise, sleep)
Social Interventions
•
•
•
•
Social skills training
Anger management
Supervised recreation
Parent training
Psychotherapy
•
•
•
•
•
•
•
Supportive counselling
Play therapy
Expressive arts therapy
Family therapy
Interpersonal therapy
CBT
Self-talk
Educational/Vocational
Accommodations
• Academic remediation
• Specialized educational
placements
• Academic/ workplace
interventions
• Note: see www.caddac.ca
physical
support/coaching
managing
comorbidity e.g.
sensory
hypersensitivity
behavioural
Classroom Considerations
organizational &
social skills
training
parent-teacher
communication
teaching
style
remediation
Self- advocacy
Treatment
Pharmacological
*CAP-G Rec.s
(Children & Adults)
Front line:
mixed amphetamine salt= Adderrall XR
MPH controlled release capsules =Biphentin
OROS MPH = Concerta
lisdexamfetamine =Vyvanse
Second line:
atomoxetine = Strattera
Guanfacine XR = Intuniv XR
Dex.,Dex. spansule, MPH / Ritalin, Ritalin SR
Third Line (off label):
imipramine, bupropion
*Cdn ADHD Practice Guidelines
Side Effects of
Stimulants
-Insomnia
-Anorexia
-Headaches
-Stomach aches
-Growth
-+/- tics
-Rebound
-Mood: irritability/withdrawal/jittery
May 2006 :
Health Canada revised the prescribing and
patient information for ADHD meds and
advises Canadians (children + adults) not
to use them if they have:
•
•
•
•
high blood pressure,
heart disease or abnormalities,
hardening of the arteries
overactive thyroid gland
Sept. 2006
-Health Canada revised prescribing
and patient information for ADHD
meds to provide information about
the potential for psychiatric
adverse events, including rare
reports of agitation and
hallucinations in children.
Name two stimulants and outline
how you would prescribe one of
these stimulants
1st Line Stim Recs for Children
Brand
Name
Add XR
(5,10,15,
20,25,30mg)
Biphentin
(10,15,20,30,
40,50,60,80 mg)
Concerta
(18,27,36,54mg)
(CADDRA)
Starting Titration Max per day
Dose
Schedule (in up to 40
q 7 days kg child)
5-10 mg
qam
5 mg
30 mg
(5-10PM)
10- 20
mg qam
5-10 mg 60 mg
(10 PM)
18 mg
qam
9-18 mg 72 mg
(18 PM) 54 (PM)
1st Line Stim Recs for Children
(CADDRA Jan ‘11)
Brand
Name
Starting
Dose
Titration
Schedule
q 7 days
Vyvanse®
20-30 mg
10
(lisdexamfe once
mg/day
tamine) 20,
daily a.m. (by
30, 40, 50,
discretion
60 mg cap
PM)
Max per
day(in up
to 40 kg
child)
60 mg
That’s
it
folks!