Psychiatry · Year 2 · from Psychiatry
Case 1: Attention-Deficit/Hyperactivity Disorder (ADHD), Combined Presentation
Patient Presentation
Demographics: 8-year-old male
Chief Complaint: "His teacher says he can't sit still and is disrupting the class. He's failing second grade."
History of Present Illness: An 8-year-old boy is brought by his mother after repeated calls from his teacher. He has been struggling in school since kindergarten but "the teacher said boys mature slower." Now in second grade, he cannot sit through a lesson, frequently leaves his seat, talks out of turn, and interrupts other students. He fidgets constantly, "like he's driven by a motor." At home, he cannot complete homework without constant redirection - a 20-minute assignment takes 2 hours with his mother sitting beside him. He loses homework, forgets to bring books home, and his backpack is "a disaster." His room is always messy despite repeated instructions. He is easily distracted - if someone walks by while he's doing homework, he forgets what he was working on. He blurts out answers before questions are finished and interrupts family conversations. He has difficulty waiting his turn in games and activities. His mother notes these behaviors have been present "since he could walk" and occur in all settings - home, school, sports, and church. He has no friends his age because he "doesn't follow the rules of games" and is "too rough." He sleeps well (but fights bedtime), has a good appetite, and denies sad mood. He does not appear anxious.
Developmental History:
- Full-term birth, normal delivery
- Motor milestones on time
- Language: First words at 12 months, sentences by 2 years
- "Always active" - walked at 10 months, running by 11 months
- No history of abuse or trauma
- Parents divorced when patient was 4 (amicable)
Family History: Father has "trouble focusing" (never evaluated), paternal uncle treated for ADHD
Physical Examination:
- Vital signs: Normal for age
- General: Active boy, difficulty sitting in chair during interview
- Neurological: Normal, no focal deficits
- Dysmorphic features: None
Mental Status Examination:
- Appearance: Age-appropriate, slightly disheveled clothing
- Behavior: Constantly fidgeting, got up 4 times during 30-minute interview, touched objects around the room
- Speech: Rapid, interrupted interviewer multiple times
- Mood: "Fine"
- Affect: Bright, full range
- Thought process: Easily derailed, jumped between topics
- Thought content: No suicidal/homicidal ideation, no psychotic symptoms
- Cognition: Alert, oriented, seemed intelligent but distractible
- Insight: Limited - "I don't have a problem, school is boring"
- Judgment: Impaired for age - acts without thinking
Collateral Information:
- Vanderbilt Parent Rating Scale: Inattention 8/9 symptoms positive, Hyperactivity-Impulsivity 7/9 positive
- Vanderbilt Teacher Rating Scale: Inattention 9/9 positive, Hyperactivity-Impulsivity 8/9 positive, significant functional impairment
- School records: Below grade level in reading and math, frequent behavioral referrals
Workup:
- Vision and hearing: Normal
- Review of school records confirms symptoms present in multiple settings
- No evidence of learning disorder (IQ testing: FSIQ 108, no significant discrepancies)
Diagnosis: Attention-Deficit/Hyperactivity Disorder, Combined Presentation, Moderate
Treatment:
- Psychoeducation for parents and child about ADHD
- Parent management training recommended
- School accommodations requested (504 plan):
- Preferential seating (front of class, away from distractions)
- Break tasks into smaller chunks
- Extended time on tests
- Daily homework communication log
- Started methylphenidate extended-release 18 mg every morning
- Baseline: Height 50th percentile, weight 55th percentile
- HR 82, BP 102/65
- Follow-up at 2 weeks:
- Teacher reports "dramatic improvement" - able to complete classwork
- Mother notes homework now takes 30-40 minutes
- Appetite slightly decreased at lunch, eating well at dinner
- No sleep problems
- Dose increased to 27 mg due to end-of-day symptom return
- At 3-month follow-up:
- Grades improved to B's
- Made two friends
- Height/weight stable, HR/BP stable
- Continuing 504 accommodations and medication
Clinical Pearl: ADHD is a neurodevelopmental disorder requiring symptoms before age 12, present in multiple settings, and causing functional impairment. Stimulant medications are first-line pharmacotherapy and are among the most effective treatments in all of psychiatry (effect size 0.8-1.0). Behavioral interventions (parent training, classroom accommodations) are essential adjuncts. The diagnosis requires information from multiple informants (parents AND teachers) - this is not optional. Vanderbilt scales are free, validated, and include DSM-based criteria. Always monitor height, weight, HR, and BP on stimulants. ADHD has 75% heritability - always ask about family history.