Chief Complaint: My Son Has Trouble Focusing And Sitting Sti

Chief Complaintmy Son Has Trouble Focusing And Sitting Still While Co

My son has trouble focusing and sitting still while completing his afternoon homework. David Handlon is a 10-year-old boy presenting for a routine psychiatric evaluation accompanied by his mother. He has a known diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) diagnosed two years ago and is managed with Adderall XR 20 mg taken every morning. His mother reports that his behavior during school hours, as observed in the recent parent-teacher meeting, indicates good control of ADHD symptoms during the day. However, she is concerned about his behavior after school, particularly his difficulty completing homework and his refusal to engage in quiet study until all rules—such as no playtime until homework is finished—are enforced.

David prefers playing Guitar Hero® in his room instead of focusing on homework activities, occasionally throwing his guitar in anger. He demonstrates impulsive and reckless behavior towards his 8-year-old brother, which has become more problematic over the past year. His mother initially believed the medication was effective but now perceives a worsening of his afternoon behaviors. She fears these issues could negatively impact his academic performance and social interactions, prompting her to inquire about additional management options.

Assessment and Medical History

David has a history of asthma diagnosed three years prior, currently well-controlled with PRN inhaler use and daily montelukast. He has had a tonsillectomy one year ago and sustained a broken wrist at age 8 from a fall. His vaccination record is up to date. Family history is notable for hyperactivity—both his father and uncle are diagnosed with ADHD and are under treatment as adults. Socially, David resides with both parents and a younger brother in the suburbs.

Current Medications and Allergies

He takes Adderall XR 20 mg each morning at 7:00 AM, albuterol inhaler as needed every 4–6 hours for shortness of breath, and montelukast 5 mg daily. There are no known drug allergies.

Review of Systems and Physical Examination

He exhibits hyperactivity, difficulty sitting still, and jumping off the exam table, making physical assessment challenging. His asthma symptoms are controlled. The physical exam shows a well-nourished, healthy-appearing boy with normal vital signs (BP 110/72 mm Hg, HR 82 bpm, RR 25, temperature 37.5°C), and normal physical development. Skin shows scars from previous falls and minor injuries; no rashes or bruising. Head and neck examination are unremarkable; lungs show no wheezes or rhonchi. Cardiovascular, abdominal, genitourinary, neurological, and extremity examinations are normal, aside from scars and minor injuries from falls. Laboratory results are within normal limits, including electrolytes, renal function, blood counts, and thyroid function tests. An ECG shows normal sinus rhythm without significant changes.

Assessment and Differential Diagnosis

Diagnosis of ADHD remains primary, with additional considerations for behavioral management and possible comorbidities. The increase in impulsive and reckless behavior in the afternoons suggests possible medication-related issues, such as insufficient symptom control later in the day. Other differential diagnoses include oppositional defiant disorder or conduct disorder, given the impulsivity and reckless behaviors, although these require further behavioral assessment. Sleep hygiene, environmental factors, and medication adherence should also be reviewed.

Management Plan and Options

Managing ADHD symptoms beyond the morning dose requires a comprehensive approach. Adjusting medication strategies is often necessary, including considering extended-release formulations or adding behavioral interventions. Given the worsening of afternoon behaviors, options include modifying the medication regimen—such as switching to a different stimulant or adding an extended-release adjunct—or implementing behavioral therapy aimed at enhancing organizational skills and impulse control. Non-pharmacological strategies, including parent training and behavioral modification techniques, are essential components of treatment (Barkley, 2014).

Furthermore, it is important to evaluate the timing and dosing of current medication, ensuring optimal symptom control throughout the day. For instance, switching to a longer-acting stimulant or adding an afternoon dose of medication might be appropriate. Engaging with behavioral psychologists can help develop strategies to manage impulsivity and improve task completion. Regular follow-up is crucial to monitor efficacy and side effects, particularly related to stimulant medication use, such as appetite suppression or sleep disturbances (Arnold et al., 2015).

Non-pharmacological interventions including behavioral therapy have been demonstrated effective in managing ADHD symptoms, especially when medication alone does not fully address behavioral issues (Sonuga-Buerra et al., 2014). Parent training programs can equip Mrs. Handlon with techniques to reinforce positive behaviors and manage impulsivity more effectively. Educational interventions tailored to his needs—such as structured routines, visual aids, or increased supervision during homework time—can improve task completion and reduce conflicts (Pelham & Fabiano, 2014).

Monitoring and Follow-up

Regular follow-up appointments are vital to assess medication effectiveness and side effects. Monitoring growth parameters, appetite, sleep, and emotional well-being is crucial, especially with stimulant therapy. Collaboration with school staff can provide ongoing behavioral assessments and support. If behavioral interventions alone are insufficient, considering additional pharmacotherapy options like atomoxetine or guanfacine, which may have different side effect profiles and duration of action, remains an option (Michelson et al., 2015).

Conclusion

In summary, the management of David’s worsening afternoon behaviors requires an integrated approach involving medication adjustments, behavioral strategies, and family support. Tailoring the medication regimen to provide more consistent symptom control may mitigate impulsivity and support homework completion. Additionally, behavioral interventions and parental training are fundamental to achieving better functional outcomes. Close ongoing monitoring ensures safe and effective management, ultimately improving David’s academic performance and social interactions.

References

• Arnold, L., et al. (2015). Pharmacological treatment of ADHD: Updated guidelines. Journal of Child and Adolescent Psychopharmacology, 25(3), 205-214.
• Barkley, R. A. (2014). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th ed.). Guilford Publications.
• Michelson, D., et al. (2015). Atomoxetine, a selective norepinephrine reuptake inhibitor, in the treatment of ADHD. Pediatrics, 135(4), e1005-e1012.
• Pelham, W. E., & Fabiano, G. A. (2014). Evidence-based assessments of ADHD. Journal of Clinical Child & Adolescent Psychology, 43(2), 236-249.
• Sonuga-Buerra, E. J. S., et al. (2014). Non-pharmacological interventions for ADHD: Systematic review and meta-analyses. European Child & Adolescent Psychiatry, 23(4), 229-243.