‘How I Treat’ Pediatric ADHD | Navigating Setbacks to School: A Complex Pediatric Case Study Case Presentation
The Case:
Thomas is a 12-year-old male just starting the sixth grade. He and his family were referred to me by his pediatrician. About 7 weeks into the school year, Thomas has had several worrisome interactions with his schoolteachers, which precipitated meetings with his parents. Apparently, he refused to follow his teachers’ instructions and was engaged in drawing instead of participating in the assigned classwork. Attempts to redirect often resulted in shouting and disruptive behaviors in class. Some of Tom’s drawings depicted weapons in bright red color. His parents shared that Tom had difficulty making friends at a new school and often cried and screamed in the morning requesting that he stay at home. He insisted that there were 2 or 3 other children teasing him and bullying him almost daily. The school authorities intervened with some success as an effort was made to minimize contact with these children. Thomas relayed that it takes him a while to fall asleep and that he often has headaches. His appetite is “not great,” and he often skips lunch.
When I asked about his mood, he replied, “what do you mean?” After I further inquired about his feelings, he responded by saying that he feels “sad and angry” most of the time. His parents were very concerned because Tom, on several occasions, said that he wished he “would have never been born.” Tom admitted that he feels hopeless at times but would never do anything to hurt himself.
He and his sister, who is 3 years older, don’t have the easiest time getting along. Tom indicated that he gets tired easily, which his parents disputed by saying that if he was allowed, he would spend half a night playing video games. Attempts to curtail Tom’s screen time often led to “temper tantrums,” tears and screaming protests. He has a few friends in the neighborhood whom he sees mostly during the weekend because they attend different schools.
Tom’s early development was remarkable for speech delay and delayed toilet training. When Tom was not in the room, his mom indicated that he still had occasional “accidents” at night, which he tries to disguise by hiding his wet underwear. Tom had a difficult time learning to ride a bicycle and allowing training wheels to be removed. As a youngster, he insisted that a nightlight be kept on and often came to his parent’s bedroom complaining of “bad dreams.”
In general, a change in his daily or school routine would provoke negative emotional responses from Tom. As an example, his family shared that even when they had visitors, Tom always insisted on sitting in “his chair.” He also preferred to wear the same clothes because others would “itch” him. Putting on his shoes when he was a toddler was always “a ritual” because he had to get all the wrinkles out of his socks.
Tom was treated for behavioral issues by his pediatrician since he was 7 years old. As he was often daydreaming and distracted in class, his teachers asked that he be evaluated for ADHD. His parents indicated that early on, his homework assignments were a struggle that would sometimes evolve into emotional outbursts. At times, Tom would get up from his desk in the middle of the class and had a hard time refraining from fidgeting.
After a diagnosis of ADHD, combined type was made, treatment with stimulant medication was initiated. Use of short-acting stimulants BID did not provide adequate coverage as there were “dips” in the late morning and a pronounced rebound around dinner time. A long-acting methylphenidate-based preparation provided better coverage but may be associated with some of the described adverse reactions.
Several months ago, psychotherapy was initiated to help Tom with his social issues and to prepare him for the transition to middle school. Tom likes his therapist, and his parents believe that he has noticeably benefitted from treatment as he had an easier time getting along with peers during summer camp.
