Case 14: Disruptive Child

Elliot is a seven year old boy who is causing his teachers difficulties due to his poor behaviour. He rarely seems to pay any attention to his teachers, is generally clumsy, and has few friends in his class. Elliot comes to clinic today accompanied by his mother and father.

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Question 1:What information should you consider when coming up with a differential diagnosis list?

Further Information:

Presenting complaint

Duration of symptoms

Elliot has always been described as “difficult to manage”. Probably since he could move about and crawl

ADHD symptomatology questions

Inattention

Elliot frequently fails to complete activities (school and home). He starts an activity but becomes sidetracked, leaving it unfinished

He is very forgetful. He forgets where he has left his toys in the house and often leaves clothes from his games kit at school.

In lessons he is easily distracted by other children or outside noises and doesn’t appear to listen. He often doesn’t finish tasks

Hyperactivity

Elliot struggles to sit still in class. He prefers to wander from his seat (at the back of the room) to the front to speak to the teacher directly.

When trying to complete tasks, he is much louder than his peers and tends to talk through the task.

Impulsive

He won’t take turns in “circle time” at school or during board games at home. He always wants to be first.

In class, he often interrupts other students to give answers and find it hard to put up his hand and wait to be picked.

Teachers and parents struggle to stop Elliot talking at inappropriate times, for example during a film.

Friendship groups

Elliot can make friends but other children find him too demanding. He quickly bounces between children so others don’t like to play with him

Full assessment of medical history

PMHx and PSHx

No significant past medical history of note.

No dysmorphic features, nothing to suggest chromosomal syndromes such as William’s

Neither the school nor the family are aware of any vocal or motor tics.

Drug history

None of note. Not currently taking any medication. No known drug allergies.

Family History

History of atopy in the family. No neurodevelopmental or significant psychiatric conditions.

Older sister (10 years old) has showed none of Elliot’s behaviours

Development

Term baby 39/40 weeks, spontaneous vaginal delivery, no SCIBU, no possibility of brain injury.

Mother smoked prenatally: approximately five cigarettes a day. Stopped during pregnancy.

No concerns raised by paediatricians, midwives, or health visitors regarding his development

Walked at 13/12 and spoke at 20/12, language below average for age. No SALT invovlement

Elliot has a tendency to drop things, and fell over more than his peers as a toddler. This is improving with age, and is not believed to be related to cerebral palsy or another neurological disorder.

Differential diagnosis

Stress/ anxiety/ depression

Home life described as generally good.

School: Elliot has a couple of close friends who are in the year below him. No signs that Elliot is being bullied, or bullying others.

Nothing to suggest stress, anxiety or depression is the cause of his current problems.

Problems with learning and attention due to physical disability

Eyesight and hearing within normal range on formal testing.

Elliot is bright and works well when given one-on-one attention; no evidence of any specific learning difficulties such as dyslexia.

Age appropriate behaviour

This could be considered immature but non-pathological behaviour but Elliot is very disruptive when compared to the rest of his classmates, particularly as Elliot was born in September so is one of the oldest in his class.

He appears to be aware of his behaviour and it’s implication but can’t stop himself from doing these things.

Conduct/ Oppositional Defiant Disorder

Elliot doesn’t like being told off, and can be very naughty on certain days.

He has not shown any particularly destructive behaviour. No excessive fighting or harm to others, or attempting to harm animals.

Autism Spectrum Disorder

Elliot engages in imaginative play and has varied interests: mainly sports, especially football and swimming, and painting

Elliot seems to benefit from a routine, especially in the morning before school. However he is not distressed by changes to these routines

He prefers not to play alone and will seek out friends (children his own age) to play with.

No hypersensitivity to sensory modalities have been noted.

Absence Seizures

No family history of note. EEG not consistent with absence seizures.

Elliot and ADHD

ADHD, also known as hyperkinetic disorder in the UK, is a psychiatric disorder of the neurodevelopmental type

It should be assessed by someone trained in the diagnosis of ADHD either by: community paediatricians or child psychiatrists who will take a detailed history from parents and child preferably separately then together; talk to school teacher to ascertain their concerns.

Diagnosis rarely made before the age of seven years old, as difficult to differentiate ADHD with age appropriate behaviour.

Must include full developmental and psychiatric history; consider any physical issues such as eyesight and hearing.

Must show triad of symptoms:

  1. Inattention
  2. Hyperactivity
  3. Impulsivity

These must be shown in more than one environment e.g. home/school/social.

School observation by a person not known to Elliot; observe him in both a lesson and at playtime. Focus on his behaviour and interactions with teachers and peers.

It was noted that Elliot was very disruptive in class always out of seat, walking around and shouting. Always had an excuse as to why he was standing up. Wouldn’t take turn in art class, instead of waiting for colouring pencils would snatch off his neighbours.

Parents second that this is the sort of behaviour they see with Elliot at home.

Conner’s rating scale one for each parent and one for the school. (Forms are different for both)

Long versions have 60-90 questions.

Score 0 not true → 3 very true/ frequently occurring.

Results show in graph measuring four categories:

  1. Hyperactivity
  2. Impulsivity
  3. Inattention
  4. ADHD symptomatology

Conner’s rating scales questionnaires should not form a strong basis for diagnosis by themselves, but is an important adjunct. Helps to highlight objective and subject concerns.

Discuss now on Twitter, using the hashtag #quclms. Follow @quclms for updates. Further information and follow-up questions will appear on Twitter throughout the week.

Question setter: Laura Massey , Final Year Medical Student, UCL

Expert: Dr Gil Myers , ST6 in Child and Adolescent Psychiatry

For tips on following hashtags read more, and try one of our recommended Twitter plugins.

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