Your patient is a 6 year old boy. He is kindergarten at Gibbs Elementary School.

His parents have made an

appointment with you today for concerns of his behavior both at school and at home. They state that their son
requires frequent reminders and instruction for good behavior. At school, he frequently rushes through his
school work, gets distracted easily, frequently squirms in seat, excessively talks to his friends, and often
interrupts the teacher. His latest report card was very poor, although his parents know that he is intelligent
and would get a better report if he “would just slow down”. At home, he has trouble listening to instruction,
often avoids doing activities that he is not interested in, and spends most of his time playing “ninja” which
includes running, jumping, action-filled play with singing, yelling, and jumping off furniture, playing x-box, or
playing on his tablet. His parents also inform you that he sometimes plays so hard that he is short of breath
and wheezes.

There were no pregnancy or birth problems. He has had all his scheduled shots. He has had no surgeries or
procedures. He was hospitalized for two days as a toddler for cellulitis of his finger. He has seasonal allergies
and takes 5mg of Singulair PO each night. He participates in speech therapy sessions at school.
 What additional information
would you have liked to have?

What else would you like to

know before you diagnose the
child with ADHD and
potentially prescribe
medication?
 Questions to ask yourself:

-What have the parents tried to help their son?

-Have the parents tried an after school activity,
such as karate to help teach discipline and
patience?
- Have the parents tried rewarding the child for
good behavior, both at home and at school?
-Have the parents tried behavioral therapy?
-Are you able to request school records?
-Are you able to carefully observe the child’s
behavior in school, home or office setting?
(Soreff, 2018)
-Have a family/teacher conference to identify strengths and weaknesses. Ask if there are any
accommodations that can be made so that the child does better in school (Ex: Sit in a different
seat, acknowledge/confront child when behaving poorly so that he can work to correct the
behavior, not allow recess if child’s behavior is poor that day, send daily/weekly reports, etc.)
-Assess your home environment. Is there any room for improvement? Set a schedule to provide
structure for child. Spend less time playing games and more time on activities that require
patience. Play outside to “run off extra energy”. Is child getting enough sleep? Is your child eating
well?
-Reward good behavior
-Find an activity that engages and disciplines the child (Ex: Karate)
-Follow up within 1-2 months to assess how child is doing
(Soreff, 2018)
 There have been little
to no changes in the
child’s behavior both
at school and at
home despite your
recommendations.

The child’s parents

are hesitant, but they
would like to try a
Follow Up: medication to help
their son.
 Diagnosis:

The following guidelines are used

to confirm a diagnosis of ADHD:
• Symptoms occur in 2 or more
settings, such as home, school,
and social situations, and cause
some impairment.
• In a child 4 to 17 years of age, 6
or more symptoms must be
identified.
• In a child 17 years and older, 5
or more symptoms must be
identified.
(American Academy of Pediatrics, 2017)
 Screening/Tests:
In addition to looking at the child's behavior, you can also do
a physical and neurologic examination. There are also
multiple screening tests to help determine your diagnosis.

(American Academy of Pediatrics, 2017)

Differential Dx:
1) Learning disability

2) Anxiety

3) Sleep disorder

4)Language or communication disorder

5) Autism spectrum disorder

6) Neurodevelopmental disorders
Pharmacologic Treatment Options for
ADHD

1) Methylphenidate (Ritalin)
2) Atomoxetine (Strattera)
3) Amfetamine (Adderall)
4) Guanfacine (Intuniv)

(Epocrates, n. d.)
Epocrates 12
(Epocrates, n. d.)
(Epocrates, n. d.)
Amfetamine
(Adderall) (Epocrates, n. d.)
Guanfacine
ADD A FOOTER 15
(Intuniv) (Epocrates, n. d.
 What would
you prescribe?
(Don’t forget to address his SOB
and wheezing with activity)
ADD A FOOTER 17
(Epocrates, n. d.)
ADD A FOOTER 18
 Dosing — Stimulants are generally started at a low dose on the
weekend so that parents can observe the child more closely. The dose
and time the medicine is taken can be titrated as needed. The child may
need to try more than one medicine or dose to find the one that works
best and has the fewest side effects. Typically, only one stimulant is
used at a time.

(Krull, 2017)
Patient Education: Stimulants may cause insomnia, so patients should not
take within 6 hours of bedtime. Abrupt cessation of stimulants may cause
extreme fatigue and depression. To reduce anorexia and growth retardation in
children, these medications should be given with or after a meal.

Monitoring: It is important to monitor for adverse reactions. Have frequent

follow ups to adjust medication as needed. Monitor patients growth closely. If
needed, monitor that the amount of the drug used is consistent with the
amounts prescribed and dispensed due to high risk of abuse.

(Epocrates, n. d.)
 References
American Academy of Pediatrics. (2017). Diagnosing ADHD in children: Guidelines & information for parents. Retrieved from https://www.healthychildren.org/English/health-issues/conditions/

adhd/Pages/Diagnosing-ADHD-in-Children-Guidelines-Information-for-Parents.aspx

Krull, K. R. (2017). Patient education: Treatment of attention deficit hyperactivity disorder in children (beyond the basics). Augustyn, M. & Torchia, M. M. (Ed.). Retrieved from https://www.up

todate.com/contents/treatment-of-attention-deficit-hyperactivity-disorder-in-children-beyond-the-basics#H3

Soreff, S. (2018). Attention deficit hyperactivity disorder (ADHD). Talavera, F. & Xiong, G. L. (Ed.). Retrieved from https://emedicine.medscape.com/article/289350-overview#a4https://online.

epocrates.com/drugs

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics: For advanced practice nurse prescribers (4th ed.). Philadelphia, PA: F. A. Davis Company.