Case Study 2: 1

Running head: CASE STUDY 2: BOY WITH ATTENTION DEFICIT

Case Study 2: Boy with Attention Deficit

Kim Bookout

Texas Woman's University

Case Study 2: 2

Case Study 2: Boy with Attention Deficit

Subjective Data

Patient Profile

Identifying Factors

The patient is an 8-year old white male who presents to 18 & Under MD with his mother

for evaluation of attention difficulties at school.

Background Information

Chief Complaint

Mom reports that the child is having difficulties at school with paying attention in class.

He has recently brought home several failing grades (20’s and 30’s) on work that he has

previously done very well.

History of Present Illness

The patient has had some failing grades during this school year unlike all other school

years. He has previously been a straight-A student. The patient was tested for LEAP (gifted-

talented program) because of his academic excellence. However, now, in second grade, he is

having more difficulties. The patient’s mother further reports that he has difficulty following

mulit-step instructions at home. Mom noticed some of the same tendencies in first grade but

because he did so well in class, no measures were taken. Despite the failing grades, the patient’s

teacher reports that he typically knows the answer to the questions missed but there is a

disconnect on getting it on paper. The patient’s teacher reports that his symptoms seem to have

worsened since the Christmas break. (Mom reports that the child’s older brother was home for 2

weeks during the break.)

Past Medical History

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Illnesses

1. Strabismus (both eyes) 2. Amblyopia

Allergies

1. Latex 2. NKDA

Surgeries

1. Circumcision and Meatoplasty, March 2007 2. Strasbismus repair x 1

Medications

1. None

Birth History

The patient was born to a G1 P1→2, 31-year old female via spontaneous vaginal

delivery. He was term weighing 8 lb 13 oz. Mom’s pregnancy was uncomplicated and he had no

problems at delivery. He was breastfed initially and was discharged home with his mother from

the hospital.

Health Maintenance

1. Immunizations are up to date according to mom

2. Sick visits only in our office (4/16/07; 1/30/09; 6/8/09; 7/9/09; 7/13/09; 1/18/10)

3. Optometry exam 7/09, glasses

Social History

The patient is an 8-year old white male who lives at home with his mom, dad and 10-year

old brother. He attends public elementary school. He has no history of chronic disease. The

family lives in a single story home in a safe, suburban neighborhood. His father is a local realtor

and mom went back to work this year teaching 2nd grade. (Mom and dad elected to send the boys

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to the elementary school in their neighborhood instead of the school where mom teaches.) The

family is privately insured but has experienced some financial challenges in the past year

according to the mother. The patient likes school and his teacher. He has several friends. He also

enjoys playing soccer in a local recreation league.

Family History

The patient’s father is 50 years old. He has a history of nasal allergies but no other

chronic disease. His mother is 39 years old and also has no chronic illness. The extended family

history is negative for diabetes, heart disease, kidney disease and lipid disorders. His paternal

grandfather has a history of alcohol abuse. The patient’s brother has a history of reactive airway

disease. He has one maternal uncle with ADHD. His father had nocturnal enuresis until an

advanced age. His mother suffers from sleepwalking including binge eating overnight. She now

has placed locks on the pantry and refrigerator to prevent this nightly overeating.

Review of Systems

General health: Good energy level. Reports difficulty in waking each morning. Does not wake feeling “refreshed”. No weight loss.

Skin/Hair/Nails: No excess sweating, rashes, or changes in skin color.

HEENT: No headaches. Wears glasses and is scheduled for a second surgery for strabismus in February, 2010. Positive history of amblyopia and strabismus. No drainage from eyes. Denies congestion or allergy symptoms. Does report snoring during sleep. No oral lesions. No untreated cavities. No hearing deficit. Neck/ Lymph: Anterior lymph nodes enlarged but non-tender.

Breast: Not discussed.

Chest/Lungs: No history of cough or reactive airway disease.

CV: No history of murmur, cyanosis. No dizziness or syncope. No edema to extremities.

Peripheral Vascular: No lower extremity pain, edema, or color changes.

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GI: Good appetite. Denies constipation, diarrhea, reflux.

GU: Nocturnal enuresis with episodes every night. No dysuria or daytime frequency/urgency.

Endocrine: No temperature intolerance. No weight loss with adequate weight gain.

M/S: Steady gait. No hypotonia. No back pain. Full ROM to all extremities.

Neurological: No dizziness, syncope, or seizure history. Has difficulty following multi-step instructions. Psychiatric: No obvious feelings of depression or sadness. No anxiety. No social isolation.

Objective Data

Physical Exam

Vital signs:

Ht: 52” Wt: 62.8 lbs BP: 97/59 Temp: 97.8 Pulse: 122 R: 20

General: 8 year old Caucasian, well-developed, well nourished, male in no acute distress. Well-groomed and dressed appropriately. Interactive with provider and parent. Skin/Hair/Nails: Skin warm, pink, and dry. No rashes or lesions.

Head: Atraumatic, normocephalic.

EENT: Pupils equal, round, and reactive to light. Extraocular movements intact in all 6 fields of gaze. No nystagmus. Mild strabismus. Vision 20/40 R eye; 20/25 L eye; 20/25 Both eyes while wearing correction. Hearing exam passed on R and L at 25 and 40 decibels. Tympanic membranes clear bilaterally. Nares patent. No erythema noted. Tonsils are 4+ with no exudates. Uvula midline. Soft and hard palate intact. No dental caries. Mild plaque buildup to lower teeth. Neck/Lymph: Supple. No lymphadenopathy.

Chest/Lungs: Lungs clear to auscultation bilaterally. No increased work of breathing.

Cardiovascular: Regular rate and rhythm. S1S2 noted with no murmur.

Abdomen: Soft, nontender. No distention. Bowel sounds normoactive. No hepatosplenomegaly. No masses. No CVA tenderness. Breasts: Not examined.

Musculoskeletal: Full range of motion all extremities. Muscle tone adequate.

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Extremities: Warm and well perfused. Peripheral pulses 2+ bilaterally. No swelling.

Genetalia: Not examined.

Rectal: Not examined.

Neurological: Strength 5/5 all extremities. Normal tone. Steady gait. No mental status changes. DTRs intact. Psychiatric: Awake, alert and oriented to person, place, and time. The patient is interactive with provider and parent. He is able to describe the reason for his visit on this date. Previous Labs: None

Discussion of Findings:

This patient presents with persistent difficulties in school/academic activity with a recent

exacerbation of symptoms. Despite having a previous record of straight-A’s and meeting the

initial requirements for testing for the gifted-talented program, he is struggling with work that is

seemingly easy for him. Additionally, he presents with tonsillar hypertrophy, a history of snoring

and bedwetting. There is some evidence to suggest that tonsillar hypertrophy leads to snoring

which may be indicative of obstructive sleep apnea. He has never been evaluated for attention

deficit hyperactivity disorder (ADHD). He has a positive family history of ADHD (2nd degree

relative), nocturnal enuresis (father), and sleep disturbance (mother). His hearing and vision

exam are within normal limits.

Assessment/Impressions

1. Tonsillar hypertrophy 2. Nocturnal Enuresis 3. Attention Deficit/Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder is the most common psychiatric condition of

childhood and affects almost two million children in the United States (McGuinness, 2008).

Diagnosing ADHD can be a challenge as it is thought to be among a group of conditions instead

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of a distinct process and is frequently seen with other behavior disorders such as oppositional

defiant disorder, anxiety disorder and depression (Spencer, 2006). It is also seen with other

genetic disorders such as fragile X, Williams syndrome, Angelman syndrome, Kleinfelter’s

syndrome and Turner’s syndrome (Hay, Levin, Sondheimer, & Deterding, 2009). Thus, organic

causes for ADHD must be ruled out.

ADHD has a definite genetic component with several different genes identified as

candidates. It is thought, however, that multiple genes are responsible for the disorder.

ADHD is expressed with great variability among children. There is a triad of symptoms

associated with ADHD: impulsivity, inattention, and hyperactivity. Some children experience

more inattentiveness without hyperactivity while others express inattentiveness, defiance, and

hyperactivity. In order to meet the diagnostic criteria for ADHD, symptoms must be present for

at least six months, appear prior to the age of seven years, and impair the child’s academic,

social, and familial environments (National Institute of Mental Health, 2008).

Differential Diagnoses:

1. Obstructive sleep apnea 2. Learning disability

Chronic Diagnoses:

1. Strabismus 2. Amblyopia

Plan

Laboratory Tests:

None.

Diagnostic Tests:

1. NICHQ ADHD Primary Care Initial Evaluation

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2. NICHQ ADHD Teacher Informant Evaluation 3. NICHQ ADHD Parent Informant Evaluation 4. Hearing Screen 5. Vision Screen 6. Sleep Study

Health Maintenance:

Up to date

Medications:

1. Omega 3 vitamin chews x 2 po daily

Education:

During the visit, mom was instructed regarding possible diagnoses as all co-morbid

factors were discussed (snoring, bedwetting, fatigue, and behavior problems). Education was

also provided with regard to medical management of ADHD as well as sleep-disordered

breathing or obstructive sleep apnea. The patient’s mom and dad are both in favor of medication

for ADHD should the diagnosis be made. A review of the role of the ENT physician was

provided specifically regarding tonsillectomy and adenoidectomy. In addition, a brief overview

of a sleep study was given along with its purpose in determining the presence of obstructive

sleep apnea. It is important to maintain open communication with families who are dealing with

ADHD so that they are comfortable with alternative plans, medications, and adjuvant care or

therapies available.

Referral:

1. ENT

2. Pulmonolgy—Sleep study

Follow-up and Continuity of Care:

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The patient’s mother was provided with forms for completion (NICHQ ADHD Parent &

Teacher Informant) to determine the presence of Attention Deficit Disorder. She was instructed

to proceed with scheduling an appointment with the ENT specialist and the pulmonology sleep

study specialist. Once the forms are complete, they will be returned to the office for scoring and

determination for the need for medication.

Update:

The patient’s mother and teacher completed the NICHQ forms. See Appendix A. The

forms were scored to reveal low scores in all categories. Thus, a diagnosis of ADHD was not

made. The family proceeded with consultation with the ENT for tonsillar hypertrophy. On exam,

the ENT explained to parents that he was 50/50 regarding surgery

(tonsillectomy/adenoidectomy) and was guarded in terms of whether or not the surgical

intervention would eliminate his symptoms of attention deficit and bedwetting. The ENT

encouraged the parents to proceed with the sleep study. A sleep study is scheduled for mid-

February.

Discussion

In the United States almost 60% of children diagnosed with ADHD are treated with

pharmacotherapy as opposed to only 1% of Finnish youth with ADHD being medicated

(McGuinness, 2008). In a study of 457 children in Finland, researchers found that by late

adolescence, children who had been treated with medications for ADHD were on track to

perform as well as those who did not receive medications both academically and socially

(Smalley et al., 2007). In the United States, researchers with the National Institute of Mental

Health Collaborative Multisite Multimodal Treatment Study of Children With Attention-

Deficit/Hyperactivity Disorder evaluated 579 children with ADHD. The children were randomly

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assigned to four treatment groups with medication only, intensive behavior therapy, combination

medication and behavior therapy, and a community treatment control group. While all groups in

the study improved, the most improvement was seen in the children receiving a combination of

medical management and behavioral therapy with regard to social skills, aggressive behaviors,

and parent-child relationships. Thus, the role of behavioral management for children with ADHD

is further established.

Parents of children with ADHD often struggle with the decisions regarding treatment.

This is especially true for the first child in the family being diagnosed with the disorder.

Stimulant medications have been used for many years and are effective for 70-90% of the

children who take them (Hay et al., 2009). The side effects of stimulant medications are often

what concern parents the most. The most common side effects are insomnia and anorexia or

appetite suppression. Less common side effects are tics, seizures, and sudden cardiac death. It is

for the latter that the recommendation for a pre-treatment EKG was made by the American

Academy of Pediatrics (American Academy of Pediatrics, 2001).

Long-acting stimulants and short-acting forms of stimulants are available to use with

ADHD. Often the long-acting dose will allow symptom control through mid- to late-afternoon. If

parents find that children are unable to complete homework or are unable to pay attention during

afternoon sports practices, they may find it necessary to administer a short-acting dose in the

early afternoon (from noon to two o’clock). Alternative medications such as clonidine and

guanfacine (α2-adrenergic presynaptic agonists) may be used to decrease norepinepherine levels

which can be helpful in decreasing motor tics in children with Tourette syndrome and help those

children who are hyper-reactive to certain stimuli (Hay et al., 2009). Non-stimulant medications

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(e.g., Strattera®) are also available but with mixed results regarding efficacy and control of

symptoms.

Sleep disordered breathing represents a group of diagnoses that includes primary snoring,

obstructive sleep apnea, and upper airway resistance. Obstructive sleep apnea is the most severe

of the disorders. It is estimated that the prevalence of sleep disordered breathing and primary

snoring is around 11% while obstructive sleep apnea is only around 3% of children (Wei, Mayo,

Smith, Reese, & Weatherly, 2007). The American Academy of Pediatrics issued clinical

practice guidelines for diagnosis and management of uncomplicated sleep apnea in children in

2002. The three signs and symptoms most indicative of sleep apnea are habitual snoring with

gasping or struggling to breathe, enlarged tonsils (see Appendix B), and daytime symptoms

including unrefreshed sleep, attention deficit, daytime fatigue, emotional lability, and

hyperactivity. When all three signs are present, it is not unreasonable for clinicians to proceed

with surgical intervention without having sleep study results (Hay et al., 2009). Many surgeons,

however, will obtain the gold standard polysomnography (sleep study) prior to any surgical

intervention.

Nocturnal enuresis is a condition that is common in childhood with an unclear etiology. It

affects boys three times more frequently than girls. Additionally, a family history reveals a

parent (usually the father) with prolonged night time bedwetting (Hay et al., 2009). It is

important to determine whether or not the child has neurological impairment, structural

abnormalities, urinary tract infection or diabetes that could contribute to or cause nocturnal

enuresis. (In this patient’s case, a previous provider completed a workup for organic causes of

his enuresis and all findings were negative.) The treatment for nocturnal enuresis places

emphasis on the fact that time and maturation often are the “cure” for enuresis. If, however,

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children and parents would like to proceed with therapy, several options exist. The first is to

reduce fluid intake prior to bedtime. The second is to employ strategies to improve bladder

capacity by having the child hold his urine as long as possible during the day. Prompted voiding

is another option for children with bedwetting but has mixed results. In fact, using any of these

options may result in a disappointing outcome with less than 60% success rate (Hay et al.).

Another option is the bedwetting alarm. Anecdotal reports from parents state the child who is

using the alarm is typically the last family member to wake when the alarm sounds. In other

words, the sound sleeper is likely not to benefit from the alarm. Desmopressin (DDAVP) is a

pharmacologic option that may be given intranasal or oral. It is an antidiuretic hormone analog

that prevents urination. (Intranasal preparations have been unavailable for the past two years

(personal communication, D. Naylor, February 4, 2010)). Its use can result in complete remission

of bedwetting in as much as 50% of children for the duration of using the product. This is an

excellent option for use with children attending summer camp and sleepovers. Counseling for

parents should emphasize the need to allow the child time to outgrow the behavior. There is

some discussion in the literature discussing the relationship between nocturnal enuresis and

attention deficit (Elia et al., 2009). The frequent co-occurrence of the two conditions is

suggestive of genetic crossover in children.

Ultimately, clinicians must consider several factors in the diagnosis and management of

attention deficit/hyperactivity disorder. The presence of comorbid symptoms such as sleep

apnea, tonsillar hypertrophy, daytime fatigue, and nocturnal enuresis, may prompt parents and

clinicians to proceed with surgical intervention (tonsillectomy and adenoidectomy) to decrease

problems associated with tonsillar hypertrophy and sleep disordered breathing. If, however,

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surgical intervention is not recommended, parents and clinicians may wish to proceed with

pharmacologic treatment for attention deficit/hyperactivity disorder.

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References

American Academy of Pediatrics (2001). Clinical practice guideline: Treatment of the school

aged child with attention-deficit/hyperactivity disorder. Pediatrics, 108, 1033

Elia, J., Takida, T., Daberadinis, R., Burke, J., Accardo, J., & Ambrosini, P. et al. (2009).

Nocturnal enuresis: A suggestive endophenotype marker for a subgroup of attention

deficity/hyperactivity disorder. The Journal of Pediatrics, 155, 239-245.

Hay, W. W., Levin, M. J., Sondheimer, J. M., & Deterding, R. R. (Eds.). (2009). Current

diagnosis & treatment: Pediatrics (19th ed.). New York: McGraw Hill.

McGuinness, T. M. (2008). Helping parents decide on ADHD treatment for their child. Journal

of Psychosocial Nursing, 46(8), 23-27.

National Institute of Mental Health. (2008). Attention deficit hyperactivity disorder [Fact sheet].

Retrieved from http://www.nimh.nih.gov/health/publications/adhd/complete-

publication.shtml

Smalley, S. L., McGough, J. J., Moilanen, I. K., Loo, S. K., Taanila, A., & Ebeling, H. et al.

(2007). Prevalence and psychiatric comorbidity of attention-deficit/hyperactivity disorder

in an adolescent Finnish population. Journal of the American Academy of Child and

Adolescent Psychiatry, 46, 1575-1583.

Spencer, T. J. (2006). ADHD and comorbidity in childhood. Journal of Clinical Psychiatry,

67(Suppl. 8), 27-31.

Wei, J., Mayo, M., Smith, H., Reese, M., & Weatherly, R. (2007). Improved behavior and sleep

after adenotonsillectomy in children with sleep disordered breathing. Archives of

Otolaryngology Head & Neck Surgery, 133, 974-979.

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Appendix A

NICHQ forms.

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Appendix B

Tonsillar hypertrophy.