Psychiatry · Year 3 · from Psychiatry
Case 1: Attention-Deficit/Hyperactivity Disorder, Combined Presentation
Patient Demographics
- Age: 8 years old
- Sex: Male
- Grade: 3rd grade
Chief Complaint
Per mother: "His teacher says he can't sit still and won't pay attention. He's constantly in trouble at school."
History of Present Illness
The patient is an 8-year-old boy brought by his mother for evaluation after repeated concerns from his teacher about behavior and academic performance. The teacher reports he is "constantly out of his seat," talks excessively, interrupts other students, and has difficulty completing assignments. He frequently loses homework and school supplies. His grades have dropped from A's and B's in first grade to C's and D's. He was recently placed on a behavior plan but has not improved.
At home, mother reports he has always been "high energy" but symptoms have worsened as academic demands increased. He cannot sit through dinner, often jumping up multiple times. He loses belongings regularly - jackets, toys, lunch boxes. He starts tasks but rarely finishes them, moving from one activity to another. He blurts out answers to questions before they're completed and has difficulty waiting his turn in games, leading to conflict with siblings and peers.
Mother notes symptoms have been present "since he could walk" but were attributed to him being "all boy." Symptoms are present in all settings - home, school, sports practices, church. He struggles to make and keep friends because he doesn't follow rules in games and is "too much" for other children.
Despite struggles, he is described as smart, creative, and enthusiastic when interested in a topic. He can focus on video games for extended periods (hyperfocus on preferred activities).
Developmental History
- Met motor milestones on time
- Language development normal
- No history of significant medical illness or head injury
- Sleep: Difficulty falling asleep, "mind racing"
- No history of abuse or trauma
Assessment Sources
Parent Rating Scales (Vanderbilt ADHD Assessment - Parent):
- Inattention symptoms: 8/9 endorsed as "often" or "very often"
- Hyperactivity/Impulsivity symptoms: 8/9 endorsed as "often" or "very often"
- Performance: "Somewhat of a problem" in all academic areas
- Behavior: "Somewhat of a problem" in peer relationships
Teacher Rating Scales (Vanderbilt ADHD Assessment - Teacher):
- Inattention symptoms: 7/9 endorsed as "often" or "very often"
- Hyperactivity/Impulsivity symptoms: 9/9 endorsed as "often" or "very often"
- Academic performance: Below grade level in reading, writing, math
- Classroom behavior: Significant concerns
Mental Status Examination
Appearance: Age-appropriate boy, disheveled appearance, shirt untucked, shoelaces untied
Behavior: In constant motion throughout interview - fidgeting, swinging legs, getting up to examine objects in the room. Required multiple redirections. Interrupted examiner frequently. Engaged and friendly.
Speech: Rapid rate, loud volume, often off-topic
Mood: "Good!"
Affect: Bright, enthusiastic, some frustration when discussing school
Thought Process: Tangential, difficult to keep on topic, jumps between subjects
Thought Content: Age-appropriate; discusses interests in dinosaurs and video games; expresses frustration that "everyone is always mad at me"
Perceptions: No hallucinations
Cognition: Alert, oriented; attention severely impaired (unable to sustain focus during interview); age-appropriate general knowledge
Insight: Limited (developmentally appropriate) - does not understand why he gets in trouble
Judgment: Immature - acts without thinking of consequences
Diagnosis
Attention-Deficit/Hyperactivity Disorder, Combined Presentation, Moderate (F90.2)
DSM-5 Criteria Met:
Inattention Symptoms (6 or more required, 8 present):
- Fails to give close attention to details, makes careless mistakes
- Difficulty sustaining attention in tasks
- Does not seem to listen when spoken to directly
- Does not follow through on instructions, fails to finish tasks
- Difficulty organizing tasks and activities
- Avoids tasks requiring sustained mental effort
- Loses things necessary for tasks
- Easily distracted by extraneous stimuli
Hyperactivity-Impulsivity Symptoms (6 or more required, 8 present):
- Fidgets with hands or feet, squirms in seat
- Leaves seat when remaining seated expected
- Runs about or climbs in inappropriate situations
- Unable to play quietly
- "On the go," acts as if "driven by a motor"
- Talks excessively
- Blurts out answers before question completed
- Difficulty waiting turn
Additional Criteria:
- Several symptoms present before age 12: YES (since early childhood)
- Symptoms in 2+ settings: YES (home, school, other settings)
- Clear evidence of interference with functioning: YES (academic, social, family)
- Not better explained by another disorder: YES
Severity: Moderate (symptoms between mild and severe)
Treatment Plan
Parent and Patient Education:
- ADHD is a neurodevelopmental condition, not a character flaw or bad parenting
- Brain differences in areas controlling attention and impulse control
- Highly treatable with medication and behavioral interventions
- Long-term management required
Pharmacotherapy - Stimulant Medication:
- Start methylphenidate extended-release (Concerta) 18 mg every morning
- Provides 10-12 hour coverage
- Titrate based on response every 1-2 weeks
- Target dose typically 36-54 mg for this age/weight
- Monitor: Height, weight, blood pressure, heart rate at each visit
Behavioral Interventions:
- Parent training in behavioral management:
- Clear, consistent expectations
- Immediate positive reinforcement for desired behaviors
- Consistent consequences for misbehavior
- Structured routines
- School accommodations (504 Plan):
- Preferential seating (front of class, away from distractions)
- Extended time on tests
- Break tasks into smaller chunks
- Homework assignment notebook checked by teacher daily
- Movement breaks
Follow-up:
- Phone check-in in 1 week to assess tolerability
- Office visit in 3-4 weeks with repeat Vanderbilt scales
- Ongoing quarterly visits once stabilized