An 8-year-old boy is brought to the clinic by his mother with complaints of difficulty concentrating in school, frequent fidgeting, and inability to sit still during class. His teacher reports that he often interrupts other children, blurts out answers without raising his hand, and struggles to follow multi-step instructions. His parents note similar behaviours at home—he loses his belongings frequently, forgets chores, and has difficulty organizing tasks. There is no history of seizures, head injury, or developmental delay. Hearing and vision are normal. On examination, the child is restless, makes poor eye contact, and shows difficulty sustaining attention during the assessment. What is the most likely diagnosis?

Explanation

## Diagnosis: ADHD, Combined Presentation ### Clinical Features Matching DSM-5 Criteria **Key Point:** This child meets criteria for ADHD by exhibiting symptoms across all three domains: inattention, hyperactivity, and impulsivity. | Feature | Observed in Case | |---------|------------------| | **Inattention** | Difficulty concentrating, loses belongings, forgets chores, struggles with multi-step instructions | | **Hyperactivity** | Fidgeting, inability to sit still, restlessness on exam | | **Impulsivity** | Interrupts peers, blurts out answers, poor self-control | | **Onset** | Early childhood (age 8, symptoms likely present before age 12) | | **Duration** | Persistent across multiple settings (school and home) | | **Functional impairment** | Academic and social difficulties | ### DSM-5 Diagnostic Criteria for ADHD **High-Yield:** ADHD requires ≥6 symptoms of inattention OR ≥6 symptoms of hyperactivity-impulsivity in children (age <17); symptoms must be present for ≥6 months, onset before age 12, and cause functional impairment in ≥2 settings. ### Combined vs. Other Presentations - **Combined Type:** ≥6 inattention symptoms AND ≥6 hyperactivity-impulsivity symptoms (this case) - **Predominantly Inattentive Type:** ≥6 inattention symptoms only - **Predominantly Hyperactive-Impulsive Type:** ≥6 hyperactivity-impulsivity symptoms only **Clinical Pearl:** The presence of symptoms in both school and home settings is critical for diagnosis; symptoms confined to one setting suggest environmental or situational factors rather than ADHD. ### Differential Diagnosis Exclusion **Key Point:** Organic causes (seizures, hearing loss, developmental delay) and other psychiatric conditions must be ruled out before diagnosing ADHD. - No history of seizures, head injury, or developmental delay - Normal hearing and vision - Symptoms not attributable to anxiety, learning disorder, or oppositional defiance alone