# Clinical Cases: Child and Adolescent 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. --- ## Case 2: Autism Spectrum Disorder ### Patient Presentation **Demographics:** 3-year-old male **Chief Complaint:** "He doesn't talk and doesn't play with other kids." **History of Present Illness:** A 3-year-old boy is referred by his pediatrician after failing the M-CHAT-R/F screening at his 24-month well-child visit. His parents had noticed he was "different" from his older sister at the same age but hoped he would "catch up." He has approximately 10 single words but does not combine words into phrases. He rarely uses words communicatively - mostly labels objects. He does not point to show things to his parents and does not follow a point when they try to show him something. He makes limited eye contact, often looking past people rather than at their faces. He does not respond to his name consistently - parents initially thought he might be deaf, but hearing test was normal. He prefers to play alone, lining up his toy cars in precise rows for extended periods. If someone moves his cars, he becomes extremely distressed and has prolonged tantrums (30-60 minutes). He is fascinated by spinning wheels and will spin the wheels of toy cars while lying on his side watching them for long periods. He flaps his hands when excited. He is very particular about food textures - only eats smooth, pureed foods and gags on anything with lumps. He becomes upset with changes in routine - if they take a different route to grandmother's house, he cries the entire way. He does not engage in pretend play - does not feed dolls or pretend a block is a phone. **Developmental History:** - Full-term, uncomplicated pregnancy and delivery - Motor milestones: Sat at 6 months, walked at 14 months (normal) - Language: Babbled normally, first words around 12 months, but language seemed to plateau - Social: Parents note he "never really reached for us to be picked up" as a baby - Regression: Parents uncertain - "He may have lost a few words around 18 months" **Family History:** Maternal cousin with autism, father describes himself as "socially awkward" **Physical Examination:** - Growth parameters: Normal - Dysmorphic features: None - Neurological: Normal tone, no focal deficits - Head circumference: 75th percentile (macrocephaly noted) **Behavioral Observations During Assessment:** - Limited eye contact with examiner - Did not respond to name despite 5 attempts - No joint attention - did not look where examiner pointed - Lined up toys meticulously, became distressed when examiner moved one - Hand flapping observed when excited - No spontaneous vocalizations directed at people - Explored room by running along walls, did not interact with examiner or mother **Diagnostic Assessment:** - **M-CHAT-R/F:** Positive (failed at 24 months) - **ADOS-2 (Module 1):** Total score 18 (autism cutoff = 11), classification: Autism - **ADI-R:** Exceeds diagnostic threshold for ASD - **Developmental Assessment (Bayley-III):** - Cognitive: 75 (borderline) - Language: 60 (delayed) - Motor: 85 (low average) - **Audiological evaluation:** Normal hearing **Diagnosis:** Autism Spectrum Disorder, Level 2 (requiring substantial support), with accompanying language impairment and without intellectual impairment **Treatment:** - Early intervention referral for intensive services: - Applied Behavior Analysis (ABA) - 25 hours/week recommended - Speech-language therapy - 3 sessions/week - Occupational therapy for sensory processing - 2 sessions/week - Parent training in ABA principles - Special education evaluation for IEP when entering school - Visual schedules at home to help with transitions - Social stories for routine changes - Referral to developmental pediatrician for coordination of care - At 6-month follow-up: - Now using 50+ words and some 2-word combinations - Beginning to point to request (protoimperative pointing) - Tolerates brief interactions with therapists - Tantrums reduced with visual schedules and preparation for transitions - Parents report improved ability to manage behaviors - Sleep remains problematic - started melatonin 1 mg at bedtime with improvement **Clinical Pearl:** ASD diagnosis requires deficits in all three areas of social communication (reciprocity, nonverbal communication, relationships) PLUS at least 2 of 4 types of restricted/repetitive behaviors. Early identification through screening at 18 and 24 months allows for early intervention, which has the best evidence for improving outcomes. The M-CHAT-R/F is the standard screening tool. ADOS-2 is the gold-standard diagnostic observation. ABA is the most evidence-based intervention. No medication treats core ASD features - medications target associated symptoms like irritability (risperidone, aripiprazole), ADHD symptoms (stimulants), anxiety (SSRIs), or sleep (melatonin). ASD has ~90% heritability - recurrence risk in siblings is 10-20%. --- ## Clinical Image ![Dopamine pathways in ADHD](case_01_image.jpg) **Image Description:** Educational diagram showing the dopaminergic pathways of the brain relevant to ADHD, illustrating the mesocortical pathway (prefrontal cortex involvement in attention and executive function), mesolimbic pathway (reward processing), and nigrostriatal pathway (motor control). Highlights the prefrontal cortex hypofunction and dopamine/norepinephrine signaling deficits associated with ADHD. **Attribution:** Educational diagram of dopaminergic pathways relevant to ADHD neurobiology. Wikimedia Commons, CC BY-SA 4.0. **Image Source:** Adapted from Wikimedia Commons dopaminergic pathways diagram for educational purposes.