Beyond “Bad Behavior”: ADHD in Clinical Practice – Psychiatric Times

Take a look at this bread-and-butter case of ADHD from a child psychiatry clinic.


-Series Editor Nidal Moukaddam, MD, PhD

In this installment of Tales From the Clinic: The Art of Psychiatry , we look at the bread-and-butter case of attention-deficit/hyperactivity disorder (ADHD) from a child psychiatry medical center. Although very common, this disorder is surrounded by multiple questions that research is just beginning to unravel. It is subject to gender-norming and differential referral and diagnosis rates within females versus males, plus even though it is highly heritable, ADHD is still labeled as “bad behavior” in many families. Resistance to initiating psychotropic ADHD medications is prevalent despite extensive proof that treatment can successfully alter a child’s life trajectory in terms of academic achievements, interpersonal relationships, substance use, and criminal history.

Case Study

“Sophie” was an 8-year-old girl with no known psychiatric history who presented in order to the center for initial psychiatric evaluation accompanied simply by her mother, who had concerns about Sophie’s educational performance plus behavior in school. Her mother related that Sophie had always been an active child, but there were no concerns until she entered preschool. Since then, teachers had expressed growing concern regarding Sophie’s behavior in the classroom. Teachers previously had recommended seeking psychiatric evaluation for possible ATTENTION DEFICIT HYPERACTIVITY DISORDER, but her mother declined. The school provided accommodations under the 504 Plan, yet Sophie continued to have a difficult time. The girl current teacher reported that will Sophie experienced significant difficulty sustaining attention and needed frequent redirection because associated with her off-task and disruptive behavior. In addition, the teacher recently notified Sophie’s mother that Sophie was not performing from grade level and was at risk of repeating the grade. Consequently, Sophie’s mother decided to seek psychiatric evaluation.

On exam, Sophie was a well-nourished child without evidence of developmental delays. She discussed having trouble making friends at college because kids thought she was “weird. ” The girl explained that will she has been easily distracted and found it difficult to stay within her seat during class, and that educators often redirected her because she talked out of turn or loudly. She went on to discuss that the girl felt nervous at school sometimes due to the fact she worried about making mistakes and being ridiculed by classmates. The lady denied having other anxiety symptoms and described getting euthymic mood except with regard to occasionally feeling sad plus lonely with school since she did not have any close friends. Psychiatric review of symptoms had been otherwise negative. Sophie’s medical history was unremarkable. Regarding family history, it too was negative regarding medical or psychiatric illness except for father and paternal cousins with history of ADHD.

Collateral information was obtained by speaking to instructors and reviewing ADHD rating scales. History obtained through Sophie, the girl parents, and the teachers was indicative of ATTENTION DEFICIT HYPERACTIVITY DISORDER combined type. Although teachers also reported that Sophie was not performing on grade degree, they stated that the lady did really well when given 1-to-1 instruction and additional time in order to complete tasks.

After discussing treatment options, Sophie’s mother gave consent to begin a trial of methylphenidate hydrochloride ER. Sophie tolerated the 18-mg dose but remained symptomatic. The dose was gradually increased in order to 36 mg every morning, which controlled ADHD symptoms adequately in the morning, but she still required redirection intended for off-task behavior in the particular afternoon. Methylphenidate immediate-release 5 mg has been added at noon, plus teachers documented resolution of ADHD signs and symptoms in the afternoon. Sophie’s academic performance improved, and she was now receiving A’s and B’s. However, her mother had been concerned that Sophie got suppressed appetite during the day. Her mother was advised to give medication only on college days and to provide calorically dense meals and snacks to prevent weight loss. The patient’s weight remained stable and within normal range, so the girl mother decided to continue the medication regimen.


ADHD is a “persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or even development. ” 1 It will be subclassified into 3 types: combined presentation, predominantly inattentive presentation, and predominantly hyperactive presentation. ADHD is one of the most common neurodevelopmental disorders associated with childhood, with a prevalence of over 5%. 2 ADHD is highly heritable (80%), 3, 4 plus males are more likely to receive a diagnosis of ADHD. The particular gender difference is presumably due to higher incidence of impulsive and bothersome behavior in boys, which leads in order to more frequent referrals. 5 Girls with ADHD , on the other hand, are more frequently described as unperceptive ( Figure ). Reasons for misdiagnosis or underdiagnosis link to referral and diagnostic bias, but parents also often tend to rate ATTENTION DEFICIT HYPERACTIVITY DISORDER symptoms as milder within girls unless accompanied by associated emotional dysregulation (eg, anxiety). five

Although the exact cause associated with ADHD has yet in order to be identified, it offers been associated with multiple neurophysiological deficits. Theoretical approaches integrate clinical symptoms and neuropsychological difficulties within a framework of certain brain dysfunctions. Cognitive deficits may surface from dysfunctions particularly in fronto-striatal or meso-cortical brain networks, whereas problems with reward processing may be linked with dysfunctions within the mesolimbic dopaminergic system. 6 Notwithstanding, deficits in ADHD may already be seen in the resting brain, and a more fundamental neuronal network approach suggests that in individuals with ADHD, default-mode-network activity in particular may interfere with activity within neuronal systems engaged in task digesting, resulting in difficulties in state regulation plus periodic interest lapses. 6 Heritability of different aspects of cognitive and executive dysfunction varies from 10% to 88% in twin studies. 7

ADHD is really a clinical analysis, meaning there are no standard laboratory or even imaging studies in ATTENTION DEFICIT HYPERACTIVITY DISORDER. 8 Evaluation to get ADHD should consist associated with clinical interviews with the parent and patient; obtaining information about the particular patient’s school or day care functioning; assessment for comorbid psychiatric disorders; and overview of the patient’s medical, social, and family histories. The most common comorbidities include oppositional defiant disorder (ODD), conduct disorder, anxiety , depressive problems, and learning or language disorders. It has been found that will individuals along with ADHD have a higher occurrence of educational problems, material use disorders , relational problems, and criminal activity. 9

Fortunately, treatment for individuals with ADHD is tremendously effective. Stimulant treatment is one of the best-studied interventions in kid psychiatry, and the response rate can become as high as 90%. Stimulants are classified within 2 categories: amphetamines plus methylphenidates ( Tables 1 and two ). Amphetamines stimulate release of dopamine and, to a lesser extent, norepinephrine through presynaptic sites and inhibit dopamine reuptake. Methylphenidate blocks dopamine and norepinephrine transporters in the presynaptic neuron, thereby inhibiting reuptake plus leading to increased concentrations of these neurotransmitters. Other medicine options consist of α agonists (ie, clonidine and guanfacine) and atomoxetine (Strattera) ( Table a few ). However , these are usually not as effective as stimulants. For instance, the particular response price for atomoxetine is 60%. Clonidine and guanfacine possess an agonist effect associated with pre- plus postsynaptic α2 receptors, which are believed to play the role in attentional and organizational functions in the prefrontal cortex. Atomoxetine inhibits norepinephrine reuptake. 10

Time needed to reach a therapeutic dose of medication may be affected by multiple factors such because adverse effects , difficulty obtaining collateral info from educators to assess response to medication, and nonadherence to medicine or inconsistent attendance to return appointments. However, if medication is usually tolerated as well as the patient remains symptomatic, the particular stimulant dose can end up being adjusted every 7 days. Generally speaking, dosage increases should be conservative. For example , if the patient has been taking methylphenidate 27 magnesium every early morning, it would be improved to 36 mg. Within my experience, in patients with mild to moderate ADHD with no comorbidities and consistent adherence in order to treatment, adequate symptom control can be achieved in a few visits. Nonetheless, if the particular patient is definitely seen more frequently (every 1 to 2 weeks as opposed to monthly), perhaps symptoms can be controlled within 1 to 2 months.


Nevertheless , for severe cases or in people with significant comorbidities (eg, ODD, mood or even anxiety problems, autism , etc), response to medication can vary significantly. Medication adjustments might be needed as the child grows older, yet not usually. Treatment expectations should become addressed starting at the preliminary appointment while establishing the particular treatment plan. This will help build trust along with the individual and mother and father, and this can avoid undue stress. In regard to treatment duration, this particular too differs from situation to case. However , ADHD is considered a chronic condition and symptoms are often still experienced in adulthood. The decision to continue treatment will depend on the individual.

It is not uncommon for children to experience adverse effects from psychotropic medications. With stimulating drugs, the majority of common negative effects include hunger suppression plus insomnia . In regard to urge for food, changes within routine and diet can help offset appetite suppression. Nevertheless , if the child provides experienced significant weight reduction, it might end up being necessary to consider trying the different medicine such since a nonstimulant. Sleep disturbances might be a medication adverse effect but frequently the problem precedes the particular medication trial. If serious, alternative therapy should become considered. Otherwise, improving sleep hygiene can resolve insomnia. Sleep aids also may be considered. In the event that rest disturbance is due to delayed circadian rhythm, improvements in sleep hygiene plus light therapy can end up being helpful. It is essential that rest disturbance be addressed to avoid exacerbation associated with ADHD signs and symptoms.

Behavioral surgery for ADHD include evidence-based parenting interventions such as parent-child interaction therapy and the Incredible Years program. The core features of these are positive interventions that differentially reinforce desired behaviors and improve the quality of the parent-child attachment relationship. These interventions are indicated because first-line treatment for toddlers and kindergarten children. They are also indicated pertaining to older children with comorbid UNUSUAL or other behavioral or parenting issues that are not really core ATTENTION DEFICIT HYPERACTIVITY DISORDER symptoms. Within addition, college interventions such as the 504 Plan and individualized education system (IEP) are often utilized. The particular 504 Strategy provides accommodation and support to allow students in order to make use of the general education setting. For those students recognized as requiring special education, an IEP is drafted. An IEP outlines the particular special schooling instruction, supports, and services a student needs to succeed in school. Diagnosis plus persistence associated with ADHD into adulthood is a different topic altogether, and much studies going on in that field.

Concluding Thoughts

ATTENTION DEFICIT HYPERACTIVITY DISORDER is one of the most common neurodevelopmental disorders of childhood. It is extremely heritable and more diagnosed in males. However , the precise cause meant for it is not known. The diagnosis associated with ADHD can be a clinical one; therefore , it is certainly necessary to obtain a thorough background from moms and dads, patients, and teachers. Treatment is the particular same regardless of the patient’s ADHD subtype, plus stimulant medications are usually the particular most efficient form of therapy. For individuals with comorbidities, psychotherapy (ie, individual treatment, group therapy, parent management training) will likely become essential to achieve adequate behavioral control.

As mental health providers, it is imperative that all of us educate families about the importance of managing ADHD. We must serve since advocates designed for our sufferers to ensure that they receive an adequate education and have access to resources in order to reduce the incidence of comorbid psychiatric illness, compound use disorders, relational or even legal problems, and employment and financial instability.

Dr Nazario is a good assistant professor of psychiatry and behavior sciences in Baylor College of Medicine in Houston, Texas.


one. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association; 2013.

2. Drechsler R, Brem S, Brandeis D, et al. ADHD: current concepts plus treatments within children and adolescents. Neuropediatrics . 2020; 51(5): 315-335.

3. Grimm O, Kranz TM, Reif A. Genetics of ATTENTION DEFICIT HYPERACTIVITY DISORDER: what ought to the clinician know?   Curr Psychiatry Rep . 2020; 22(4): 18.

4. Mowlem F, Agnew-Blais J, Taylor E, Asherson P. Do different factors influence whether girls compared to boys meet ADHD diagnostic criteria? Sex differences among children along with high ADHD symptoms. Psychiatry Res . 2019; 272: 765-773.

5. Slobodin O, Davidovitch M. Gender differences in objective plus subjective measures of ATTENTION DEFICIT HYPERACTIVITY DISORDER among clinic-referred children. Front Hum Neurosci . 2019; 13: 441.

6. Albrecht B, Uebel-von Sandersleben H, Gevensleben They would, Rothenberger A. Pathophysiology associated with ADHD and associated problems-starting points just for NF surgery?   Front side Hum Neurosci . 2015; 9: 359.

7. Arnett AB, McGrath LM, Flaherty BP, et al. Heritability and clinical characteristics of neuropsychological profiles in youth with and without elevated ADHD symptoms. M Atten Disord . 2022; 26(11): 1422-1436.

8. Wolraich ML, Hagan JF Jr, Allan C, et ing; Subcommittee on Children plus Adolescents With Attention-Deficit/Hyperactive Disorder. Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity problem in kids and adolescents. Pediatrics . 2019; 144(4): e20192528.

nine. Shaw Meters, Hodgkins G, Caci L, et ‘s. A systematic review and analysis associated with long-term outcomes in attention deficit hyperactivity disorder: effects of treatment plus non-treatment. BMC Med . 2012; ten: 99.

10. Stahl SM. Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, Fifth Edition. Cambridge University Press; 2021.

Leave a Reply

Your email address will not be published. Required fields are marked *