A 12-Year-Old Boy With Falling Grades and Forgetful Behavior

Stephen Soreff, MD; Foad Afshar, PsyD, EdM

Disclosures

June 25, 2019

Regarding its epidemiology, ADHD is more common in boys than in girls (13.2% vs 5.6%, respectively). The rate at which the condition is diagnosed has increased dramatically, from 7.8% of children aged 4-17 years in 2003 to 11% in this same age group in 2011.[8] Various theories suggest why this may be the case. For example, a greater focus on early education may mean that behaviors that would frequently be tolerated at home are attracting more notice in preschool or kindergarten classes. Moreover, when medication is available to treat a condition, such as ADHD, then that condition tends to be diagnosed more often; this may itself be associated with academic pressures on children to succeed and the desire to obtain ADHD treatment for students if it will better enable that success.

Studies suggest that childhood ADHD is a risk factor for subsequent conduct and substance abuse problems, which can lead to significant morbidity and mortality and to involvement with the criminal justice system. The condition may also lead to academic and employment difficulties and to social problems that greatly impact normal development.[9] The course of ADHD varies among patients. Some persons outgrow their symptoms, while others have lifelong symptoms and require treatment into adulthood.[10] Still others are not diagnosed with and treated for ADHD until adulthood.

In diagnosing ADHD, differential diagnoses must be considered first to ensure that a treatable medical condition or another possible psychiatric diagnosis is not missed. The first evaluation phase begins with a complete medical history, a physical examination, and appropriate laboratory tests. Many classic symptoms of ADHD can individually be attributed to numerous other causes (eg, inattention may occur in relation to a learning disability, boredom, or a hearing difficulty). In addition, numerous psychiatric disorders can mimic many ADHD symptoms; these conditions include affective bipolar disorder, schizophrenia, posttraumatic stress disorder (PTSD), and Tourette syndrome. Key symptoms of ADHD may also arise from a learning disability.[9,11]

In this specific case, Michael did not appear to have any physical or medical conditions that could manifest as ADHD-like symptoms. He also failed to meet the criteria for any of the major psychoses associated with childhood or with a conduct disorder; also, no significant family or personal disruptions had occurred over the past year that would have caused a change in his behavior.

Michael was reported by his teachers and parents to generally be a jovial and friendly child with many friends. He was reported to be helpful in school and to be the "runner" for teachers, getting them supplies and delivering messages to the main office regularly and with great reliability. Michael did not exhibit hypomania or any other symptoms associated with mood or anxiety disorders. He did not report racing thoughts, denied having problems sleeping, and also denied being particularly afraid of anything. In addition, his emotional range was congruent with circumstances and situations. Hence, Michael’s problem was less likely to have a psychodynamic etiology. Testing, moreover, suggested that he did not have a learning disorder.

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