Case 21: A boy who cannot sit still in class

01The case

The parents of a 7-year-old boy are asked to come in by his teacher. She tells them that he is very noisy in lessons: he gets up and walks around the classroom, and he shouts out answers before she has chosen who should reply. He keeps disrupting the class and gets in the way of the other children's work. He also makes many mistakes when solving problems, and he finds reading hard.

02Summary

Diagnosis

Attention deficit hyperactivity disorder (ADHD), in ICD-10 a hyperkinetic disorder.

What points to it

• Hyperactivity: he cannot stay in his seat and walks about the room.
• Impulsivity: he answers before he is asked and cannot wait his turn.
• Poor sustained attention: careless mistakes in his work.
• Onset in early school years, which is typical.

The diagnosis needs more than a teacher's report: the symptoms must have lasted at least six months, have begun in childhood, and be present in more than one setting, so his parents and school are both asked, ideally with rating scales.

What else it could be

His reading difficulty may be a specific learning disorder such as dyslexia, alongside ADHD or instead of it. Other possibilities are poor hearing or eyesight, a mild intellectual disability, autism, anxiety, or a stressful situation at home. Oppositional and conduct problems often come with ADHD.

Management

• Assessment by a child psychiatrist or paediatrician with expertise in ADHD, with information from home and school.
• Information and support for his parents about ADHD and how to manage it, and parent training, especially if he is also defiant.
• Work with the school: changes in the classroom (where he sits, short tasks, clear routines) and an individual education plan, with help for his reading.
• If he is still significantly impaired once these are in place, a stimulant: methylphenidate is first line from age 5. Before starting, record height, weight, pulse and blood pressure and ask about heart problems, then monitor growth and appetite.

Outlook

Guarded without treatment. Hyperactivity tends to lessen with age, but inattention and impulsivity often persist into adulthood. Children with ADHD have higher rates of later conduct problems, alcohol and drug misuse and mood disorders, and treatment improves how they manage at school and at home.