A 7-year-old boy is brought into clinic by his parents who are concerned about his academic performance. They state that he is constantly in trouble for not paying attention in class and has received numerous detentions for being “off task.” The parents say he is generally well-behaved at home, although he does sometimes take a long time to complete his homework assignments because he is very meticulous and checks his work multiple times to make sure it is correct. Birth history and past medical history are unremarkable. During the office visit, the patient is well-behaved in the exam room and sits in the corner coloring. Occasionally, he stares into space for 8-10 seconds, making a slight smacking motion with his lips.
Which of the following would be the best treatment for the condition that is most likely affecting this patient?
D) Ethosuximide
The vignette describes the classic findings of absence seizures which generally last < 10 seconds, involve staring spells, and can include rhythmic movements (such as smacking of the lips). Ethosuximide is the first line treatment for absence seizures. Valproic acid is another common treatment that is generally second line. Absence seizures and attention-deficit/hyperactivity (ADHD) are often confused; however, this patient does not show any signs of hyperactivity and no signs of inattention other than the "staring spells." Additionally, he is only experiencing difficulties in one setting (school) and would need to be experiencing problems in at least 2 settings to be diagnosed with ADHD.
Choice A: Carbamazepine, is a useful anti-epileptic but is not successful in treating absence seizures.
Choice B: Clonidine, is an appropriate treatment for Tourette syndrome. Although the patient is exhibiting some tic-like movements, he does not meet the criteria for Tourette syndrome as this requires two or more motor tic and at least one vocal tic.
Choice C: Cognitive behavioral therapy, is helpful in treating obsessive-compulsive disorder (OCD). Although this patient is meticulous about his homework, this is not enough to suggest a diagnosis of OCD.
Choice E: Methylphenidate, would be the appropriate treatment for ADHD. Absence seizures and ADHD are often confused; however, this patient does not show any signs of hyperactivity and no other signs of inattention other than the "staring spells." Additionally, he is only experiencing difficulties in one setting (school) and would need to be experiencing problems in at least 2 settings to be diagnosed with ADHD.
Key Learning Point
Ethosuximide is the first line treatment for absence seizures. Valproic acid is another common treatment that is generally second line.
