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A 9-year-old boy is referred by his class teacher for "persistent inattention and disruptive classroom behaviour". His mother reports he has been "always on the go" since age 3, frequently loses his school supplies, cannot sit through homework, blurts out answers, interrupts others, and takes physical risks (climbing, running off) that have caused two fractures. His teacher independently reports identical behaviour in class. Symptoms are present every day and across home, school, and at his football club. Developmental milestones are normal; there is no mood, anxiety, psychosis, or substance use. His mother was diagnosed with adult ADHD last year. Physical examination: height on 50th centile, BP 95/60 mmHg, HR 88/min, normal cardiovascular auscultation, no tics or dysmorphism.
Questions
a) What is the most likely diagnosis, and which two DSM-5-TR criteria beyond symptom-count must be satisfied to make it? (2 marks)
The most likely diagnosis is Attention Deficit Hyperactivity Disorder (ADHD), combined presentation. Two further DSM-5-TR criteria beyond the 6+ symptom count that MUST be satisfied are: (1) Criterion B — several inattentive or hyperactive-impulsive symptoms present before age 12 (this child has been symptomatic since age 3); and (2) Criterion C — symptoms present in two or more settings (home AND school AND football club — pervasive). Criterion D (clear impairment) and E (not better explained by another mental disorder) must also hold.
b) Outline the diagnostic assessment you would perform, including the rating scales you would use. (3 marks)
- History across two or more settings — developmental (pregnancy, prematurity, milestones, early temperament), symptom history (onset, pervasiveness, impairment), family history (mother has ADHD — first-degree relatives have ~8-fold risk), comorbidity screen (ODD, conduct, anxiety, depression, tics, autism, learning disability, sleep), psychosocial.
- Standardised rating scales from BOTH parent AND teacher — SNAP-IV or Conners-3 for symptom severity; Vanderbilt to screen for comorbid ODD/conduct/anxiety/depression; Strengths and Difficulties Questionnaire (SDQ) as a universal screener.
- Physical examination — height/weight on centile chart (baseline for stimulant growth monitoring), blood pressure and heart rate, cardiovascular auscultation, neurologic screen for tics and dysmorphism, hearing and vision check.
- ECG only if cardiac symptoms, family history of sudden cardiac death under 40, or known structural heart disease (not required routinely in this well child).
- Consider TFTs, FBC/ferritin, lead level, EEG or psychoeducational assessment only if clinically indicated.
- ADHD is a clinical diagnosis — there is no blood test, genetic test, or scan that confirms it.
c) Describe the stepwise management, naming the specific drug, dose and monitoring. (3 marks)
- Step 1 — Psychoeducation for child, parents and school; address sleep, diet, exercise; environmental classroom modifications (seating near teacher, chunking tasks, movement breaks).
- Step 2 — First-line medication (he is school-age 6+, combined presentation, moderate-severe impairment): methylphenidate (start 5 mg IR bd or 18 mg OD Concerta MR, titrate weekly to ~1 mg/kg/day, max 60 mg/day IR / 54-108 mg/day Concerta), OR lisdexamfetamine (30 mg OD, titrate to 50-70 mg OD).
- Step 3 — Add behavioural therapy — parent management training (Incredible Years, Triple P, PCIT) and behavioural classroom intervention (token economy, daily report card); combined stimulant + behavioural is most effective for moderate-severe (MTA Cooperative Group trial).
- Monitoring on stimulants: height/weight at baseline and 6-monthly on centile chart; blood pressure and heart rate after each dose change and 3-6-monthly; appetite, sleep, mood and tics at every visit; ECG only if cardiac symptoms or family history. Consider drug holidays to mitigate growth/appetite effects.
- Titrate weekly until effective dose found, then 3-6-monthly specialist review with shared-care GP prescribing.
d) List four stimulant adverse effects and two circumstances in which you would favour atomoxetine instead. (2 marks)
- Stimulant adverse effects (any four): appetite suppression and weight loss; growth delay (~1 cm/year, often normalises); insomnia; headache and abdominal pain; irritability and rebound; tachycardia/hypertension; jitteriness/anxiety; tics; psychosis (rare, high-dose); bruxism/skin-picking.
- Favour atomoxetine instead (any two): comorbid tics/Tourette syndrome; comorbid substance use disorder or diversion risk; comorbid anxiety; patient/family preference for a non-stimulant; intolerable stimulant side effects. Atomoxetine is a selective NA reuptake inhibitor, non-addictive, with slower onset (4-6 weeks); it carries FDA black-box warnings for hepatotoxicity and suicidal ideation in children/adolescents.