How I Treat: Pediatric ADHD With Dr Craig Chepke Case Presentation

Becky is a 14-year-old girl brought in by her mother and father, who adopted her at birth. A child and adolescent psychiatrist had treated her for attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety for many years, but her parents felt that she was not making progress and wanted a fresh start for her treatment. They felt her ADHD was “out of control,” with not only a lack of focus, but also, she and her parents described periods where she would “hyperfocus” on certain “projects” that would consume her for prolonged periods. When I met her, she was taking fluoxetine, atomoxetine, an extended-release amphetamine, and an instant-release amphetamine booster.

They also said her impulsivity was causing substantial problems both at school, where she had “no filter,” and at home, where she and her mother would get into arguments on a daily basis. A couple times a year, Becky became physically aggressive with her mother. Becky said that during these episodes, she would be “mad all the time for no reason,” and afterward she would get so ashamed, she would get depressed for several weeks to a month.

Many of the fights Becky got into with her mother were about her adoption— constantly telling her mother that she hated her and that “she ruined her life by adopting her.” During fights, Becky would say that she wanted to go live with her biological mother. However, the biological mother lives out of state, has ADHD, bipolar disorder, and substance use disorder and has never had nor wanted any contact with Becky since the adoption. The relationships Becky had with her father and sister were much better than with her mother, but still not what any of them desired. Individual and family therapy were attempted on several occasions, but Becky would never participate in sustained and consistent therapy. 

Becky said her sleep was “fine,” but her parents were convinced she was sometimes up well past midnight and then up for school by 5:15 AM. During the first year of treatment, we switched her stimulant several times, including a trial on methylphenidate, changed her antidepressant, and discontinued atomoxetine. She would make progress for a while, but then things would fall back apart again no matter what we tried.  The potential for alcohol or illicit drug use and nonmedical use of prescriptions was screened for regularly and not felt to be a factor in her presentation at any point.

She had seemed to be doing quite well for several months while taking escitalopram 10 mg and amphetamine salts 10 mg daily when her parents called for an urgent visit. Her smartphone had been set to restrict access at a certain time every evening, and when that happened one night, she mistakenly thought that her mother had cut her access off as a disciplinary action and flew into a rage. Screams and threats to run away turned to punches and kicks, and they fell to the ground with Becky’s mother holding her in a bear hug from behind, at which point, Becky calmed down. In my office the next day, Becky was clearly anxious and irritable but not aggressive or threatening.