Psychiatry - August 2008 - (Page 45)

managing to climb over the railing and fall out of his crib. They finally purchased a bed for him. One of his first words was “climb.” They had advised their pediatrician of his unusually high level of physical activity, and she had suggested that they keep her apprised of his developmental progress. Unfortunately, when their insurance plan changed, they were forced to seek a new primary care provider (PCP), and this matter was not pursued. When induced to share his feelings in the emergency room, Mr. S said he hated his life. His mood was angry and depressed. He denied any problems sleeping, except that he liked to stay up late and get up late, which made his already poor school performance even worse, since he was late a lot. His appetite was good, as was his energy. School was an incredible burden to Mr. S. He disliked most of his classes, and since grade school he had never gotten more than Cs or an occasional B. It was hard to pay attention to what the teachers were saying, and he often got into trouble for provoking other students in class or making comments under his breath when the teacher was talking. Sitting still in most classes made him “crazy,” and he often found himself thinking about “lots of other things.” Mr. S was in danger of being put in the “slow” class, and some of his friends were making fun of him because of this. Mr. S expressed that he felt his parents preferred his younger brother to him because his brother made good grades and did not cause them trouble. Mr. S was now spending a lot of time in his room playing video games because that was the only thing that made him feel “ok.” Mr. S always had friends, but also had difficulties with them because he would be “hyper” around them, and not conform to rules of games or play. Mr. S’s parents mentioned that a number 45 of Mr. S’s former friends, including a girlfriend, had begun avoiding him because of his school problems and problems with the police. His parents worried about his new peer group, who were the “troublemakers” and were known to use drugs. Mr. S’s parents were worried that he was using marijuana and other drugs, too. Mr. S admitted to smoking marijuana with his friends that night and one other time, and he said that it helped his thoughts slow down. He said he felt like a loser. PRACTICE POINT: RECOGNIZING THE SYMPTOMS OF ADHD Such an early history of attention issues and hyperactivity should be a red flag to PCPs. PCPs provide the bulk of psychiatric care for these patients. Their roles include not only early identification, but early preparation, education, and reassurance of parents. Unfortunately, in the case of Mr. S, this opportunity was lost.13,14 Mr. S described the cardinal symptoms of ADHD and their consequences in a traditional academic setting.1 Mr. S exhibited inattention, distractibility, impulsivity, and hyperactivity. Some students may learn to suppress their physical hyperkinesis to some degree, but may do so at the cost of “feeling crazy,” not unlike a patient with akathisia. Assigning a student with ADHD to the “slow” class, unfortunately, is not an infrequent response of some school systems, especially if a child with ADHD has not been diagnosed. The student’s condition may be attributed by the school to cognitive impairment or to delinquency, and these may in turn lead to the system tacitly “giving up.” In this case example, such a placement would be associated with social opprobrium and rejection. This is a typical history. Children with ADHD are valued by peers for their energy and vivacity, but over time they may “wear out” their companions. As they grow older, their social skills deficits may become more apparent and consequential.15 They may benefit from social skills training, although the preferred modality and effectiveness is controversial. Often patients with ADHD are well served by having multiple social groups: different sets of friends for different aspects of their lives, such as school, neighborhood, and extracurricular activities. Self-medication is common among these patients, most especially for relief of anxiety. It may lead to the elevated rate of substance abuse seen in adults with this condition, especially if it is untreated.13 CASE EXAMPLE, CONTINUED Mr. S liked and excelled in art class, particularly sculpture. He was an accomplished gymnast, but he was dropped from the team because of his failing grades. Being dropped from gymnastics considerably upset Mr. S because it was one of the few things he liked, but he didn’t talk much about it with his parents. PRACTICE POINT: RECOGNIZING STRENGTHS IN INDIVIDUALS WITH ADHD Individual sports can address a number of problems, such as concentration, self esteem, and depression. It is frequently a destructive mistake to drop patients with ADHD from these activities. But without a diagnosis, this is a common occurrence.21 CASE EXAMPLE, CONTINUED A conference with Mr. S’s school had been held a few months earlier regarding Mr. S’s learning and behavioral problems. It was recommended that Mr. S get special tutoring, which had just started, and that he see a physician for a medication evaluation. After an office visit with a practitioner who had never before met Mr. S, he [AUGUST] Psychiatry 2008 45

Table of Contents Feed for the Digital Edition of Psychiatry - August 2008

Psychiatry - August 2008 Editor’s Message Editorial Advisory Board Contents Borderline Personality Disorder: Are Proliferative Symptoms Characteristic? Short-acting versus Long-acting Medications for the Treatment of ADHD Baby Stimuli and the Parent Brain: Functional Neuroimaging of the Neural Substrates of Parent-Infant Attachment These Boots Are Made for Stalking: Characteristics of Female Stalkers Managing Attention Deficit Hyperactivity Disorder in the Emergency Department Obstructive Sleep Apnea, Hypoxia, and Metabolic Syndrome in Psychiatric and Nonpsychiatric Settings Improving the Quality of Life in Patients with Alzheimer’s Disease The Process of Getting New Drugs to Market Journal Watch Classified Advertising Information for Authors

Psychiatry - August 2008

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