Example Case

John: A Child with AD/HD

Mr. and Ms. Smith have brought their 8 year old son John to the clinic to discuss difficulties with his behavior at school. John is now midway into second grade. John's teacher has frequently expressed concerns about John's behavior in the classroom. John just cannot seem to get his work done. He is always daydreaming. His assignments are often incomplete and he seems to have trouble following directions. He often talks out of turn and must be reminded to raise his hand. He gets out of his seat and wanders over to the bulletin board instead of doing his work. At recess he has difficulty interacting socially with other children. It seems that they just don't like to play with him---perhaps because he often refuses to wait his turn and butts into other children's games when he is not invited. First grade and kindergarten were equally difficult for John. In fact, he repeated kindergarten because his teacher had felt that he was "immature".

John's behavior at home is also difficult to manage. He demands constant attention. He enjoys watching television and playing video games but otherwise he is unable to play by himself for any period of time. The Smiths have bought him many toys they felt would sustain his interest but it seems they are quickly discarded, often broken. When playing outside he must be constantly supervised. He has wandered out of the yard on several occasions to the park down the street. His parents have punished him each time by taking away TV time but this has had little impact. On several occasions John has hurt himself by climbing up where he should not. Last year John fell out of a tree and hit his head requiring a visit to the emergency room. When asked to clean his room or set the table, John complies but quickly gets distracted. He requires multiple reminders to complete tasks.

The Smiths describe John as a smart caring child and wish he would just "apply himself." Over the past two months he has begun to "hate" school and every morning is a battle to get him out of bed. They wonder why they have not been able to effectively improve John's behavior despite using time-out, removal of privileges and rewards and are now spanking him.

This case demonstrates several important features a physician should document when making a diagnosis of AD/HD.

1. The symptom complex of inattention, impulsivity and increased activity should cross environments and be present since early childhood. If behavior problems are only occurring at home (or at school) or are a relatively new development, then an alternative etiology must be sought.
2. If a child is diagnosed with AD/HD, other factors may be contributing to the academic and behavior difficulties.

   Learning disabilities often accompany AD/HD.

   Psychosocial factors can inhibit the development of coping mechanisms.

   Repeated failures can lead to school avoidance, low self-esteem and depression.

   Parents of children with AD/HD often experience a sense of failure.

   Stress in the home may be extremely high by the time families arrive in the office.

These comorbid conditions must be identified and addressed to design an appropriate treatment plan. Clinicians must identify the appropriate resources in their community to ensure thorough evaluation and treatment. Testing to rule out a comorbid learning disability can often be arranged with the school psychologist or local private psychologist. Family counseling can often be arranged through the local community services agency or a private psychologist. Many communities have parent support organizations (e.g. CHADD) and published materials abound which provide education for the parents.. School counselors can be involved to provide supportive counseling to the child. Some children may need referral to a mental health professional for treatment of anxiety, depression or other comorbid conditions.

Table of Contents