Hyperactivity is not always ADHD (Attention deficit hyperactive disorder)

Dr.J C. Wickrematunga MBBS (Registrar in Psychiatry)
Dr.DH.Karunatilaka MBBS,MRCPsych (Consultant psychiatrist)
Dr.B. Karunatilaka MBBS, MD,MRCP(Consultant paediatrician)
Lady Ridgeway Hospital for Children, Colombo

A nine year old girl who was a grade Four student from a town which was about 10km away from Colombo, Sri Lanka was referred to the child guidance clinic of Lady Ridgeway Children’s Hospital,Colombo. She was referred by a general practitioner with a history of hyperactive behaviour and deterioration of school performance of five months duration.

The girl was always on the go and did not stay at one place for long. She started going to neighboring houses and was over familiar with them which was out of her character. In school her school performance deteriorated. She wanted to finish the given work quickly and at times did not finish it. She disturbed other children in her class so that the teacher had to punish her at several occasions. At times she went around hugging other children. She became irritable in school and at times started quarrelling with the other students. Mother was informed about her behaviour and she thought it was due to the new class. She was not sent to school for three weeks prior to the presentation because of her hyperactive behaviour was uncontrollable.
She started to talk in a babyish way and at times asked the mother to carry her and to feed her. At times she started using filthy words to address her parents and her mother used to punish her. She became aggressive at times to the point that she hit her parents. She was easily distracted and didn’t do any home work given to her by her teacher.

On close questioning, parents revealed that in addition to hyperactivity the child had been having excessive sleepiness, bed wetting at night and day time incontinence. She has had early morning headaches with vomiting in addition to loss of appetite and has lost considerable amount of weight. Mother used to feed her forcefully. There was no history of any febrile illness or significant psychological precipitant prior to the onset.

Her father was a carpenter and mother is a homemaker. She has a 12 year old sister. Both the parents thought that she is misbehaving and did not think it is because of any illness. There was no family history of epilepsy, alcoholism, or any other significant illnesses as hyperactivity or learning difficulty.
She was of average build and was extremely hyperactive and was running around in the clinic room. She was disinhibited, over familiar and at times was aggressive towards her parents. She talked in a babyish way and sometimes used obscene language. She was irritable at times but was oriented in time, place and person. Intelligence was normal.
Since she was having symptoms other than those of hyperactivity, an organic cerebral pathology was suspected and was referred to a pediatrician. Her physical examination was unremarkable except for marked pappiliedema and a CT scan of brain was done.

Contrast CT Brain
There is a large 7. 5cm (transverse)6.9cmAntero posterior×7.5cm cranio-caudal solid lesion with profound contrast enhancement in the Anterior Cranial fossa mainly on the right side. The mass extends to the left inferior to the falx. Small area of calcification is seen on left side of the mass. Marked oedema is present.Anterior horns of lateral ventricles are compressed Rest of the ventricles are normal.

CT of child with apparent ADHD presentation

Large neoplasm in the anterior
Cranial fossa, most likely a meningioma of falx cerebri.

neoplasm in anterior cranial fossa

She was referred to the neuro surgical unit and a MRI scan was done. She underwent neurosurgery without major complications. Histology revealed a fibrous meningioma
This case highlights the importance of considering an organic pathology in all children presenting with hyperactivity and behavioral disturbance.

First Published March 2007

© Priory Lodge Education Limited 2007

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