# Clinical Cases: Child and Adolescent 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):* 1. Fails to give close attention to details, makes careless mistakes 2. Difficulty sustaining attention in tasks 3. Does not seem to listen when spoken to directly 4. Does not follow through on instructions, fails to finish tasks 5. Difficulty organizing tasks and activities 6. Avoids tasks requiring sustained mental effort 7. Loses things necessary for tasks 8. Easily distracted by extraneous stimuli *Hyperactivity-Impulsivity Symptoms (6 or more required, 8 present):* 1. Fidgets with hands or feet, squirms in seat 2. Leaves seat when remaining seated expected 3. Runs about or climbs in inappropriate situations 4. Unable to play quietly 5. "On the go," acts as if "driven by a motor" 6. Talks excessively 7. Blurts out answers before question completed 8. 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 --- ## Case 2: Autism Spectrum Disorder ### Patient Demographics - **Age:** 4 years old - **Sex:** Male - **Grade:** Preschool ### Chief Complaint Per parents: "He doesn't talk like other kids his age, and he doesn't seem interested in playing with other children." ### History of Present Illness The patient is a 4-year-old boy brought by his parents after his preschool teacher recommended evaluation. The teacher noted he rarely interacts with peers, preferring to play alone and becoming very distressed when other children try to join his activities. His language is limited compared to classmates, and he often repeats phrases from TV shows rather than engaging in conversation. Parents report concerns began around 18 months when he was not pointing to objects or responding to his name. His first words emerged at age 2, later than his older sibling. He currently speaks in short phrases but rarely initiates conversation. When he wants something, he often leads his parents by the hand to the desired object rather than asking verbally. He makes limited eye contact. He does not show objects to share interest (joint attention). He has intense, focused interests in trains and ceiling fans. He can identify and name over 100 trains but has little interest in other toys. He lines up his trains in specific orders and becomes very upset if the order is changed. He flaps his hands when excited. He insists on sameness in daily routines - taking the same route to school, eating from the same plate. Transitions between activities are very difficult and often trigger tantrums. He is sensitive to loud sounds (covers ears, becomes distressed) and has restricted food preferences, eating only about 5 foods (all similar textures). ### Developmental History - Sat independently: 7 months - Walked: 13 months - First words: 24 months (delayed) - Phrases: 36 months (delayed) - Regression: None - Birth: Full-term, no complications ### Observation During Evaluation **Social-Emotional Reciprocity:** - Made eye contact briefly when name called but did not sustain - Did not engage examiner in reciprocal play - Limited range of facial expressions - Did not share enjoyment when playing with preferred toy (train) **Nonverbal Communication:** - Minimal use of gestures - Did not point to show interest - Limited integration of eye contact with speech **Developing Relationships:** - No interest in examiner or other children in waiting room - Parallel play only **Restricted, Repetitive Behaviors:** - Lined up trains by size and color repeatedly - Distressed when examiner moved a train - Hand flapping observed when excited - Repeated phrases from TV show multiple times **Sensory Sensitivities:** - Covered ears when phone rang - Mother reports strong texture preferences for food ### Standardized Assessment **Autism Diagnostic Observation Schedule, Second Edition (ADOS-2):** - Module 1 (pre-verbal to phrase speech) - Social Affect score: 14 (cutoff for autism: 11) - Restricted and Repetitive Behaviors: 5 (cutoff: 3) - Total: 19 (cutoff for autism: 16) - Classification: Autism **Vineland Adaptive Behavior Scales:** - Communication: 68 (moderately low) - Daily Living Skills: 75 (moderately low) - Socialization: 62 (low) - Motor: 85 (adequate) - Adaptive Behavior Composite: 70 ### Diagnosis **Autism Spectrum Disorder, Requiring Substantial Support (Level 2) (F84.0)** **DSM-5 Criteria Met:** *A. Persistent deficits in social communication/interaction (all 3 required):* 1. Deficits in social-emotional reciprocity: Limited back-and-forth conversation, reduced sharing of interests/emotions, failure to initiate social interaction 2. Deficits in nonverbal communicative behaviors: Poor integration of eye contact, reduced gestures, limited facial expressions 3. Deficits in developing/maintaining relationships: No interest in peers, no imaginative play with others *B. Restricted, repetitive patterns (2+ required, 4 present):* 1. Stereotyped motor movements: Hand flapping 2. Insistence on sameness: Rigid routines, same route, distress with changes 3. Highly restricted, fixated interests: Intense focus on trains 4. Sensory sensitivities: Auditory hypersensitivity, food texture aversions *C. Symptoms present in early developmental period:* YES *D. Symptoms cause significant impairment:* YES *E. Not better explained by intellectual disability:* Intellectual testing needed but social deficits exceed expected for cognitive level **Severity Level:** Level 2 - Requiring substantial support (marked deficits in social communication, restricted/repetitive behaviors obvious to casual observer, distress with change) **Specifiers:** - Without accompanying intellectual impairment: To be determined by cognitive testing - With accompanying language impairment: YES (significantly below age level) ### Treatment Plan **Early Intervention - Applied Behavior Analysis (ABA):** - 20-25 hours per week of intensive behavioral intervention - Focus on communication, social skills, and reducing challenging behaviors - Evidence-based, most effective intervention for young children with ASD **Speech and Language Therapy:** - 2-3 sessions per week - Focus on functional communication - Consider augmentative and alternative communication (AAC) if needed - Pragmatic language goals **Occupational Therapy:** - Address sensory processing differences - Work on daily living skills - Food/feeding therapy for restricted diet **Educational Services:** - Individualized Education Program (IEP) through school district - Specialized instruction in structured setting - Visual supports and schedules **Parent Education and Support:** - Training in ABA principles for use at home - Understanding of autism and developmental expectations - Connection with Autism Society and parent support groups - Respite care resources **Additional Evaluations:** - Formal cognitive testing when able to cooperate - Audiology evaluation (to rule out hearing as contributing factor) - Genetics consultation (chromosomal microarray, Fragile X testing) **Follow-up:** - Developmental pediatrics in 3 months - Ongoing monitoring of progress with therapy - Regular team meetings to coordinate care --- ## Case 3: Major Depressive Disorder in Adolescence ### Patient Demographics - **Age:** 15 years old - **Sex:** Female - **Grade:** 10th grade ### Chief Complaint Per patient: "I don't know. My parents made me come." Per parents: "She's not herself. She's irritable, her grades dropped, and she stays in her room all the time." ### History of Present Illness The patient is a 15-year-old female brought by her parents for evaluation of mood and behavior changes over the past 4 months. Previously an honor roll student and varsity volleyball player, she has shown declining function across multiple domains. Her grades dropped from A's and B's to C's and D's. She quit the volleyball team, stating "I just don't care anymore." She has withdrawn from friends, rarely responding to texts and declining all social invitations. She spends most of her time in her room, often sleeping. Parents describe her as increasingly irritable, "snapping" at family members over minor issues and frequently arguing. She has stopped activities she previously enjoyed, including drawing and playing guitar. She complains of frequent headaches and stomachaches, leading to multiple school absences. When interviewed alone, the patient tearfully admits she feels "empty" and "worthless." She reports persistent sad mood for most of the day, nearly every day, for over 3 months. She has difficulty concentrating on schoolwork ("I read the same page over and over"). She sleeps 12+ hours on weekends but still feels tired. Her appetite is decreased, and she has lost 8 pounds. She has passive suicidal ideation, stating "Sometimes I think everyone would be better off without me" but denies any plan, intent, or access to means. She has not engaged in self-harm. She identifies a specific trigger: her best friend moved away at the start of the school year, and she has struggled to adjust. She also reports increasing conflict with her parents about grades and extracurriculars. ### Past Psychiatric History - No prior psychiatric treatment - No history of mania or hypomania - No prior suicide attempts - Positive family history: Mother treated for depression, maternal aunt with bipolar disorder ### Mental Status Examination **Appearance:** Adolescent female, minimal makeup, wearing dark hoodie with hood up, poor eye contact **Behavior:** Slow to warm up, initially guarded with parents present, more open when alone; psychomotor retardation noted; tearful when discussing feelings **Speech:** Decreased rate and volume, increased latency to respond **Mood:** "Empty" and "nothing matters" **Affect:** Depressed, constricted range, tearful, irritable when discussing school/parents **Thought Process:** Linear, slowed, ruminative on negative themes **Thought Content:** - Feelings of worthlessness ("I'm a failure") - Hopelessness ("Things will never get better") - Passive suicidal ideation (wishes she didn't exist) without plan, intent, or means - No homicidal ideation - No psychotic symptoms **Perceptions:** No hallucinations **Cognition:** Alert, oriented; concentration impaired by interview **Insight:** Fair - recognizes something is wrong but uncertain about cause **Judgment:** Fair - agreed to come to appointment, willing to engage in treatment ### Screening Measures **Patient Health Questionnaire - Adolescent (PHQ-A):** - Score: 18 (moderately severe depression) **Columbia Suicide Severity Rating Scale (C-SSRS):** - Passive ideation present - No active ideation, plan, intent, or preparatory behaviors - No lifetime history of attempts ### Diagnosis **Major Depressive Disorder, Single Episode, Moderate (F32.1)** **DSM-5 Criteria Met:** A. Five or more symptoms during same 2-week period, representing change from baseline: 1. Depressed mood most of the day, nearly every day (can be irritable in adolescents): YES 2. Markedly diminished interest/pleasure: YES (quit volleyball, stopped hobbies) 3. Weight loss when not dieting (>5% in month): YES (8 lbs) 4. Insomnia or hypersomnia: YES (hypersomnia - 12+ hours) 5. Psychomotor retardation: YES 6. Fatigue: YES 7. Feelings of worthlessness: YES 8. Diminished ability to concentrate: YES 9. Recurrent thoughts of death: YES (passive suicidal ideation) B. Symptoms cause significant distress/impairment: YES (academic, social, family) C. Not attributable to substance/medical condition: YES D. Not better explained by other disorder: YES E. No history of manic/hypomanic episode: YES **Severity:** Moderate (5+ symptoms with moderate impairment) ### Treatment Plan **Safety Assessment and Planning:** - Currently at low-to-moderate risk - Safety plan developed collaboratively: - Warning signs (isolating more, feeling hopeless) - Coping strategies (music, drawing, walking dog) - People to contact (friend from volleyball, aunt) - Crisis resources (988 Suicide & Crisis Lifeline) - Means restriction: Parents to secure any medications in home - Parents educated on warning signs and when to seek emergency care **Psychotherapy - First-Line Treatment:** - Cognitive Behavioral Therapy (CBT) for depression - Weekly sessions x 12-16 weeks - Focus on: - Behavioral activation (re-engaging in activities) - Cognitive restructuring (addressing negative thoughts) - Problem-solving skills - Interpersonal skills **Pharmacotherapy:** - Given moderate severity and patient/family agreement, start fluoxetine 10 mg daily - Most evidence for fluoxetine in adolescent depression - Increase to 20 mg after 1 week if tolerated - Black Box Warning discussion: Risk of increased suicidal ideation in first weeks of treatment (monitor closely) - Family education about activation side effects **School Support:** - Letter to school counselor regarding diagnosis and treatment - May need academic accommodations during recovery - Regular check-ins with school counselor **Family Involvement:** - Family psychoeducation about adolescent depression - Address family conflict contributing to symptoms - Supportive communication strategies **Follow-up:** - Weekly therapy sessions - Psychiatry in 1 week (increased monitoring per Black Box Warning) - Phone check-in at 72 hours - Monthly psychiatry visits once stable - PHQ-A at each visit for measurement-based care --- ## Image Attribution ![Child Psychiatry Developmental Assessment](case_01_image.jpg) *Image: Diagram showing developmental assessment domains in child and adolescent psychiatry including cognitive, social-emotional, language, and adaptive functioning. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.*