Disruptive Behavior, Global Developmental Delay, and Obesity in a 5-Year-Old Boy with a Chromosome Microduplication.

CASE: Ryan is a 5-year-old boy who was seen in a Developmental Behavioral Pediatrics clinic for disruptive behavior and developmental delay. His medical history was notable for a tethered spinal cord repaired at age 4 months, alternating exotropia with multiple surgeries, and obesity (body mass index at 99%). Ryan's development was globally delayed. He sat at age 10 months and walked at 24 months. An Autism Diagnostic Observation Schedule-Toddler module (ADOS-T) was completed at age 19 months and demonstrated little-to-no concern for autism spectrum disorder.Ryan's parents described behavioral challenges including hyperactivity, impulsivity, aggression toward him self and others, severe tantrums, a short attention span, and difficulty sleeping. They also endorsed repetitive behaviors including head rocking, walking in circles, and perseverative speech. Expressive language was significantly limited. There was no family history of autism or intellectual disability.Ryan's physical examination was notable for alternating exotropia, hypertelorism, upslanting palpebral fissures, and obesity. His speech was limited to 1-word utterances. Neurological and general examinations were normal.He was referred for repeat psychological testing at age 5 years. The ADOS-2 (Module 2) was consistent with a classification of autism with a high level of autism-related symptoms. A fragile X test was negative, and microarray demonstrated a microduplication in the region of 2p25.3 including the myelin transcription factor 1-like gene.

Inattentive Attention-Deficit/Hyperactivity Disorder, Stimulant Medication, and Weight Loss in a 15-Year-Old Girl: Are We Enabling the Development of an Eating Disorder?

CASE: Nicole is a 15-year-old girl presenting to the Developmental Behavioral Pediatrics Clinic with symptoms of the inattentive type of Attention-Deficit/Hyperactivity Disorder (ADHD) and declining school performance over the last year. She expressed frustration over her inability to concentrate on schoolwork. Assuming that her poor grades were secondary to lack of effort, her parents withdrew privileges. Nicole became increasingly depressed. She stopped participating in activities, she previously enjoyed, and her parents reported that she stopped singing in the shower. After talking to a cousin with ADHD, Nicole concluded that she had ADHD as well. She asked her parents to arrange for an evaluation.Nicole met DSM-5 criteria for the diagnosis of inattentive ADHD and was started on a stimulant medication (mixed amphetamine salts). She had symptoms of a coexisting depression, although she did not meet criteria for diagnosis of a depressive disorder. At a 3-week follow-up visit, she showed improvement in targeted ADHD symptoms; homework was now easier and her grades improved. At a 2-month follow-up, Nicole's weight dropped from 53 kg (47th percentile) prestimulant treatment to 49 kg (31st percentile). She reported appetite suppression after taking the stimulant but did not feel that her eating habits had changed significantly. Her father reported that she had a preference for junk food and snacks. Nicole did not enjoy exercising and did not participate in extracurricular sports.She weighed herself several times a day, as she was worried about losing too much weight. Nicole's mood continued to be low, despite the fact that her grades improved, and her parents were more understanding of her challenges. She was otherwise healthy and reported regular menstrual cycles. Nicole requested an increase in the dose of stimulant medication for greater improvement in concentration during homework and in school.Her pediatric clinician was concerned about the possibility of an eating disorder in addition to depression. She asked herself, "Are we treating inattentive ADHD effectively or are we enabling an eating disorder?"

Acute Agitation and Self-Injury in a 5-Year Old with Autism.

CASE: A 5-year-old nonverbal child with autism spectrum disorder (ASD) was admitted to inpatient pediatrics with new onset agitation and self-injurious behavior. His parents described him as a pleasant child without previous episodes of self-injury. Four days before admission, the parents noted new irritability followed by 2 days of self-injury to the face without clear precipitant. His hitting intensified with closed fist to face, and he required parental physical restraint to prevent further injury. Car rides and ibuprofen provided only temporary relief. He consumed minimal liquid and ate no solid food for 2 days. The parents denied any changes to the environment or routine and denied recent travel, sick contacts, fevers, cough, otalgia, vomiting, diarrhea, and constipation. The patient had been diagnosed with ASD at age 18 months old but had no other significant medical history.On examination, the child was alert but distressed and restless, wearing padded mitts as his parents attempted to calm him by pushing him in a stroller. He had multiple areas of severe bruising and facial swelling in the right periorbital area, cheek, and jaw. The rest of the physical examination was unremarkable. Laboratory results included a leukocytosis with left shift, a normal metabolic panel, and an elevated creatine kinase. Other investigations included a normal lumber puncture, chest radiograph, head and face computerized tomography without contrast, and brain magnetic resonance imaging. A dentist consultant examined him and noted an erupting molar but no decay or abscesses. A psychiatric evaluation was requested as there was no clear medical source for the patient's distress.

Acute Agitation and Self-Injury in a 5-Year Old with Autism.

CASE: A 5-year-old nonverbal child with autism spectrum disorder (ASD) was admitted to inpatient pediatrics with new onset agitation and self-injurious behavior. His parents described him as a pleasant child without previous episodes of self-injury. Four days before admission, the parents noted new irritability followed by 2 days of self-injury to the face without clear precipitant. His hitting intensified with closed fist to face, and he required parental physical restraint to prevent further injury. Car rides and ibuprofen provided only temporary relief. He consumed minimal liquid and ate no solid food for 2 days. The parents denied any changes to the environment or routine and denied recent travel, sick contacts, fevers, cough, otalgia, vomiting, diarrhea, and constipation. The patient had been diagnosed with ASD at age 18 months old but had no other significant medical history.On examination, the child was alert but distressed and restless, wearing padded mitts as his parents attempted to calm him by pushing him in a stroller. He had multiple areas of severe bruising and facial swelling in the right periorbital area, cheek, and jaw. The rest of the physical examination was unremarkable. Laboratory results included a leukocytosis with left shift, a normal metabolic panel, and an elevated creatine kinase. Other investigations included a normal lumber puncture, chest radiograph, head and face computerized tomography without contrast, and brain magnetic resonance imaging. A dentist consultant examined him and noted an erupting molar but no decay or abscesses. A psychiatric evaluation was requested as there was no clear medical source for the patient's distress.

Inattentive Attention-Deficit/Hyperactivity Disorder, Stimulant Medication, and Weight Loss in a 15-Year-Old Girl: Are We Enabling the Development of an Eating Disorder?

CASE: Nicole is a 15-year-old girl presenting to the Developmental Behavioral Pediatrics Clinic with symptoms of the inattentive type of Attention-Deficit/Hyperactivity Disorder (ADHD) and declining school performance over the last year. She expressed frustration over her inability to concentrate on schoolwork. Assuming that her poor grades were secondary to lack of effort, her parents withdrew privileges. Nicole became increasingly depressed. She stopped participating in activities, she previously enjoyed, and her parents reported that she stopped singing in the shower. After talking to a cousin with ADHD, Nicole concluded that she had ADHD as well. She asked her parents to arrange for an evaluation.Nicole met DSM-5 criteria for the diagnosis of inattentive ADHD and was started on a stimulant medication (mixed amphetamine salts). She had symptoms of a coexisting depression, although she did not meet criteria for diagnosis of a depressive disorder. At a 3-week follow-up visit, she showed improvement in targeted ADHD symptoms; homework was now easier and her grades improved. At a 2-month follow-up, Nicole's weight dropped from 53 kg (47th percentile) prestimulant treatment to 49 kg (31st percentile). She reported appetite suppression after taking the stimulant but did not feel that her eating habits had changed significantly. Her father reported that she had a preference for junk food and snacks. Nicole did not enjoy exercising and did not participate in extracurricular sports.She weighed herself several times a day, as she was worried about losing too much weight. Nicole's mood continued to be low, despite the fact that her grades improved, and her parents were more understanding of her challenges. She was otherwise healthy and reported regular menstrual cycles. Nicole requested an increase in the dose of stimulant medication for greater improvement in concentration during homework and in school.Her pediatric clinician was concerned about the possibility of an eating disorder in addition to depression. She asked herself, "Are we treating inattentive ADHD effectively or are we enabling an eating disorder?"

Cardiac autonomic dysfunction and arterial stiffness among children and adolescents with attention deficit hyperactivity disorder treated with stimulants.

OBJECTIVE: To compare markers of cardiovascular health in youth diagnosed with attention deficit hyperactivity disorder (ADHD) by the use of stimulant medication with healthy controls. STUDY DESIGN: Children and adolescents (n = 85; mean age 11.2 ± 2.8 years; 66 boys) diagnosed with ADHD using a stimulant and 53 siblings without ADHD (mean age 11.1 ± 3.8 years; 28 boys) were included in this cross-sectional study. Measured variables included blood pressure, heart rate (HR), HR variability: SD of the RR interval and low frequency to high frequency ratio, carotid-radial pulse wave velocity, carotid artery augmentation index (AIx), radial artery AIx, brachial artery flow-mediated dilation, and digital reactive hyperemic index. RESULTS: Compared with control patients, participants with ADHD had greater resting systolic blood pressure (3.9 mm Hg, 95% CI [1.2-6.7], P = .005), diastolic blood pressure (5.5 mm Hg, 95% CI [3.2-7.8], P < .001), HR (9.2 beats/min, 95% CI [6.0-12.3], P < .001), low frequency to high frequency ratio (0.55, 95% CI [0.22-0.89], P = .001), carotid AIx (7.2%, 95% CI [1.9-12.5], P = .008), and pulse wave velocity (0.36 m/s, 95% CI [-0.05, 0.78], P = .089), and lower SD of the RR interval (-33.7 milliseconds, 95% CI [-46.1, -21.3], P < .001). Neither flow-mediated dilation nor reactive hyperemic index was significantly different. CONCLUSIONS: Children and adolescents being treated with a stimulant medication for ADHD exhibited signs of altered cardiac autonomic function, characterized by increased sympathetic tone, and showed evidence of arterial stiffening.

Attention-deficit/hyperactivity disorder evaluation and diagnosis: a practical approach in office practice.

Attention-deficit/hyperactivity disorder is the most common neurobehavioral disorder of childhood, with most children maintaining symptoms of ADHD as adolescents and as adults. It is among the most common chronic conditions that primary care pediatricians see. Progress in brain imaging, genetics, neuropsychology, and molecular biology of ADHD reveals complex interactions between neurologic mechanisms, genetics, and environmental influences. Core behaviors seen in children with ADHD include hyperactivity, impulsivity, and inattention. The DSM-IV standard for diagnosis emphasized the importance of documenting that these behaviors occur at school and in the home, the chronicity of symptoms, and the connection between the behaviors and impairments in educational achievement or social development. The complex nature of this disorder is indicated by the observation that children and adolescents with ADHD have associated conditions, such as learning disorders, anxiety, oppositional behaviors, and depression. The AAP practice guideline on the evaluation and diagnosis of school-aged children with ADHD provides primary care pediatricians with a scientific foundation for assessing children with behavior and learning problems. Attention to accurate documentation of behaviors, coexisting learning disorders and mental health conditions, and the development of office practices that support the diagnostic process will ensure that children receive an appropriate and comprehensive assessment.