A HYPERACTIVE CHILD
History
Richard is a 6-year-old boy who is brought to the community paediatric clinic by his mother. She asked her GP to refer Richard because she thinks he is hyperactive. She describes him as ‘always on the go’, unable to sit still or concentrate on anything, and never seeming to think before he acts. He is particularly difficult at home in the evenings and rarely goes to bed before midnight. His behaviour has been getting worse over the last year. His mother says that she just can’t cope with his behaviour any more and would like him to be put on some medicine to calm him down. Richard was born at 35 weeks’ gestation, and his only medical problem has been eczema. This has been difficult to control and he is under follow-up by a paediatric dermatologist. He currently uses a combination of emollients and a topical steroid. He has two teenage half-brothers and a 1-year-old half-sister. His mother is separated from her partner and now looks after the children alone. She works part-time as a beautician. The family lives in a small flat and Richard attends his local primary school. There have been problems with anti-social neighbours, and Richard’s oldest brother has recently been in trouble with the police. Richard sits quietly whilst his mother gives this history. When asked directly, he says that he enjoys school and gets on well with his brothers and sister. He misses his father, whom he doesn’t see anymore. His mother says that he’s better behaved when he is outside the home, and other people don’t see what he’s really like.
Questions
• What is attention deficit hyperactivity disorder (ADHD)?
• What additional questions will help to determine if this is the diagnosis?
• What treatment can be used for ADHD?
Medicine
Attention deficit hyperactivity disorder is characterized by inattention, hyperactivity and/or impulsiveness, which are excessive for the child’s developmental age and cause significant social or academic problems. The problems must have begun before 7 years of age, have been present for at least 6 months, and must be present in more than one setting, which usually means at home and at school. Children often appear to be constantly ‘on the go’, fidgety, unable to sustain concentration or organize themselves and unable to wait their turn. ADHD affects 2–5 per cent of school-age children with boys four times more commonly affected. In later life it is associated with an increased risk of unemployment, criminality and substance misuse. Many children have behaviour which overlaps with some of the features of ADHD. It is important to distinguish between overactivity, one end of the normal spectrum, and hyperactivity. Rarely, a physical disorder such as thyrotoxicosis will be misdiagnosed as ADHD. In Richard’s case the history indicates that there are lots of potential psychosocial and emotional stresses that could cause difficult behaviour: a new sister, separated parents, a mother trying to divide her attention between four children of very different ages, disturbances by neighbours, poor sleep and a chronic medical problem. It is important to establish when the problems first started, and how the behaviour problems have evolved in each of the domains of inattention, hyperactivity and impulsiveness. It is essential to discover whether the problems also occur at school, and this is best done by contacting Richard’s teacher (with parental consent). There are standardized questionnaires that can be completed by parents and teachers to assess his behaviour more objectively. More family and social history will be useful to determine the impact of all of the different stresses in his life. His bedtime routine and sleep patterns need to be addressed because children who do not get enough sleep can often behave in a hyperactive way. Richard’s progress at school, his development and his hearing need to be carefully assessed. Finally, his mother’s agenda must be explored. Often the child’s behaviour is more of a problem for the parents than the child. In fact, Richard’s behaviour at school was fairly normal and he did not have ADHD. His problems were attributed to his family circumstances and dynamics, and he was referred to a child psychologist. Treatments for ADHD are pharmacological and behavioural. Paradoxically, stimulant medication helps to keep the child focused on a task and relieves many of the symptoms of ADHD. Methylphenidate is the usual first choice, but should only be commenced under specialist supervision. Side-effects include loss of appetite, poor sleep and abdominal pain. Behavioural treatment aims to help the child and family modify their behaviour to minimize the impact of ADHD. Changes to how the child is dealt with in the home and school environments may be needed.
KEY POINTS
• Attention deficit hyperactivity disorder (ADHD) is a common condition.
• Similar symptoms can have many other causes.
• Stimulant medication should only be commenced under specialist supervision.
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