A clean, well-groomed, apparently healthy 6-year-old girl was accompanied by the school nurse and special education teacher to an initial visit with a consulting pediatrician. The appointment had been arranged by the principal at the child’s school who knew this clinician had a special interest in children with behavior disorders.
In preschool the child’s erratic, disruptive behavior had prompted evaluation by the school nurse and school psychologist. She was given a diagnosis of attention deficit disorder (ADD). She had been referred to the local mental health clinic but, because of her mother’s work schedule, few of the appointments were kept.
The mother was young, single, and worked at several poorly paid jobs, but had been very cooperative with the school’s recommendations that the child be evaluated and treated. Documentation confirming the child’s behavior patterns, including classroom observation, came from 2 psychologists’ reports and from several physicians. According to these reports, the child had met all the DSM-III (the edition available at the time) criteria for a diagnosis of ADD. A list of medications revealed that the child had at various points been prescribed all drugs that were FDA-approved at that time to treat the disorder, as well as other medications used off-label.
It is common for children with ADD to be subdued and relatively inhibited during a first encounter with a new physician. When the consulting pediatrician first saw her, however, this child was so disruptive that she had to be removed from the room so that the consultation could proceed. The pediatrician suggested that there could be an undetected problem with medication compliance at home. A treatment plan was developed to have all medications administered as prescribed at school by the nurse. This plan was executed, but there was no change in the child’s behavior. She was then referred to an in-patient pediatric psychiatric unit. The diagnosis of ADD was again confirmed and medication dosage was doubled. After 6 weeks of inpatient treatment, the child returned to school but the teachers complained that she was “dull” and too sleepy to do her work.
During this time the child’s mother continued to cooperate with the school’s suggestions and was supportive of the inpatient referral. She was rarely seen in person, however.
When should a behavioral disorder like ADD/ADHD be questioned as a manifestation of abuse?Click here for discussion.
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Shipman K, Taussig H. Mental health treatment of child abuse and neglect: the promise of evidence-based pratice. Pediatr Clin N Am. 2009;56:417-428.