San Pedro College

Graduate School Studies

Department of Psychology

Case no. 03
A CASE REPORT ON
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
(Level A)

A Course Requirement on
Advance Abnormal Psychology
Master of Science in Clinical Psychology

Submitted by:
MICHAEL JOHN P. CANOY, RPm

Submitted to:
DR. ORENCITA V. LOZADA, RP, RGC, CSCLP
Professor

A.Y. 2019-2020
Michael John P. Canoy, RPm MS in Psychology

CLINICAL PROFILE

I. PURPOSE OF EVALUATION
This undertaking was originally meant to screen and assess evidences of
underlying physical, mental, and psychological dysfunctions of the client. This will
provide plausible information that will serve as a basis for full clinical diagnosis, case
management and further therapeutic interventions. This document is endorsed for
educational purposes only and will be submitted as a course requirement for PSY504 -
Advanced Abnormal Psychology in the Graduate School Program of the Psychology
Department of San Pedro College, Davao City.

II. IDENTIFYING INFORMATION

a. Demographic Profile
Name: Ken Wilson
Age: 7 Years Old
Gender: Male
Educational Attainment: Currently at 1st Grade
Religion: Not Specified
Ethnicity: Not Specified
Mother’s Name: Mrs. Wilson (First name not specified)

Mother’s Occupation: Homemaker

Father’s Name: Mr. Wilson (First name not specified)
Father’s Occupation: Business Manager

b. Medical History
Medical

Ken is the middle of three children. Her mother had a full-term pregnancy of him.
The delivery was without complication, although labor was fairly long. There were no
notable physical difficulties and problems with Ken’s growth except that her parents
 Michael John P. Canoy, RPm MS in Psychology

described as a difficult infant. He cried frequently and was described as a colicky baby by
their pediatrician. He did not eat well, and his sleep was often fitful and restless.

Psychiatric
Toward the end of kindergarten, his intelligence and academic achievement were tested.
Although his IQ was placed at 120, he did not perform very well on reading and mathematics
achievement tests. Ken’s teacher also completed a short form of the Conners Rating Scale about
Ken’s behavior which verified the picture of hyperactive behavior that had already emerged. Ken
was also referred to a clinical psychology intern for evaluation including observation from home
and from Ken’s school environment.
c. Family Background
Family Dynamics
Relationship Age/Status Occupation Medical History Psychiatric Remarks
History
Father Age was not Business Not Specified Not Specified For further
mentioned in Manager assessment to
the case gain more
information
Mother Age was not Business Had a full-term Not Specified For further
mentioned in Manager pregnancy with assessment to
the case Ken. The gain more
delivery was information
without
complication,
although labor
was fairly long.
Older Sister 9 years old Not Specified Reported to have Reported to For further
no apparent have no assessment to
problems apparent gain more
problems information
Younger 4 years old Not Specified Reported to have Reported to For further
Brother no apparent have no assessment to
problems apparent gain more
Michael John P. Canoy, RPm MS in Psychology

problems information
d. Psycho-emotional-social History
Early Development Stage

Ken is the middle of three children. Her mother had a full-term pregnancy of him.
The delivery was without complication, although labor was fairly long. There were no
notable physical difficulties and problems with Ken’s growth except that her parents
described as a difficult infant. He cried frequently and was described as a colicky baby by
their pediatrician. He did not eat well, and his sleep was often fitful and restless.

According to his parents, Ken’s current problems began in kindergarten. His

teacher frequently sent notes home about his disciplinary problems in the class- room. In
fact, there had been concerns about promoting Ken to the first grade. The final result was
a “trial promotion.” Everyone hoped that Ken would mature and do much better in first
grade, but his behavior became even more disruptive. Ken’s mother had received
negative reports about him from his teacher several times over the first 2 months of
school. His teacher reported that he didn’t complete his work, was disruptive to the class,
and behaved aggressively.

His parents described him as a difficult infant, much more so than his older sister.
He cried frequently and was described as a colicky baby by their pediatrician. He did not
eat well, and his sleep was often fitful and rest- less. As Ken grew, his mother reported
even more difficulties with him. He was into everything. Verbal reprimands, which had
been effective in controlling his sister’s behavior, seemed to have no effect on him. When
either parent tried to stop him from doing something dangerous, such as playing with an
expensive vase or turning the stove off and on, he would often have a temper tantrum that
included throwing things, breaking toys, and screaming. His relationship with his sister
was poor. He bit her on several occasions and seemed to take delight in trying to get her
into trouble.

School records generally corroborated his parents’ description of Ken’s behav- ior
in kindergarten. His teacher described him as being “distractible, moody, aggressive,”
and a “discipline problem.” Toward the end of kindergarten, his intelligence and
Michael John P. Canoy, RPm MS in Psychology

academic achievement were tested. Although his IQ was placed at 120, he did not
perform very well on reading and mathematics achievement tests.

Grade School Age

His parents described a similar pattern of aggressiveness in Ken’s behavior with

the neighborhood children. Many of the parents no longer allowed their children to play
with Ken. They also reported that he had low frustration tolerance and a short attention
span. He could not stay with puzzles and games for more than a few minutes and often
reacted angrily when his brief efforts did not produce success. Going out for dinner had
become impossible because of his misbehavior in restaurants. Even mealtimes at home
had become unpleasant. Ken’s parents had begun to argue frequently about how to deal
with him.

Ken’s parents focused on his current behavior at home. The pattern that had
begun earlier in Ken’s childhood continued. He still got along poorly with his sister, had
difficulty sitting still at mealtimes, and reacted with temper tantrums when demands were
made of him. His behavior had also taken on a daredevil quality, as illustrated by his
climbing out of his second-story bedroom window and racing his bicycle down the hill of
a heav- ily trafficked local street. Indeed, his daring acts seemed to be the only way he
could get any positive attention from his neighborhood peers, who seemed to be mostly
afraid of him. He had no really close friends.

There were sessions where the therapist need the parents to come over and talk
with Ken’s evaluation results however there were complications to realizing this because
of marital problems between Mr. & Mrs. Wilson. Mr. Wilson missed two of these
sessions because of his business schedule. Most days he had to commute to work, a two-
hour train trip each way. During a session he missed, Mrs. Wilson hinted that they had
marital problems. When this was brought up directly, she agreed that their marriage was
not as good now as it once had been. Their arguments centered on how to handle Ken.
Michael John P. Canoy, RPm MS in Psychology

Mrs. Wilson had come to believe that severe physical punishment was the only answer.
She described an active, growing dislike of Ken and feared that he might never change.

Arguments between the two of them resulted to difference in approaches in

helping Ken. Her mother usually resorts to physical punishment in addressing Ken’s
maladjustment while her father would refrain to use such as he believes that he was like
Ken when he was a child and that Ken would just outgrow these maladjusted behaviors.

III. REASON FOR REFERRAL

Ken Wilson’s mother contacted the clinic in the middle of November about her 7-year-old
son, a first-grader explaining that Ken was having trouble at school, both academically and
socially. The school psychologist had said that he was hyperactive. Thus further evaluation was
needed in order to know Ken’s definite condition as well as address these concerns in order to
help Ken as well as help their family concerns which involves marital arguments, sibling fights
that appears to be induced by Ken’s misbehaviors

IV. PROBLEMS AND SYMPTOMS

Identifying Data and Presenting Conflict
 He elicited hyperactivity
 Misbehaviors began in kindergarten
 Shows disruptive behaviors
 Presence aggressive behaviors
 Restless with the child and was reported to have low frustration tolerance and a
short attention span.
 Gotten many troubles at school and with his siblings due to misbehaviors
 Had poor peer relationships and was being distractible moody, and aggressive

V. CONTRIBUTORY AND CAUSAL FACTORS

Michael John P. Canoy, RPm MS in Psychology

Although contributory factors and/or causal factors were not fully stipulated in the
case, the diagnostician in training is looking into possibility that these difficulties may
involve the following factors:

Genetics. ADHD is elevated in the first-degree biological relatives of individuals

with ADHD. The heritability of ADHD is substantial. While specific genes have been
correlated with ADHD, they are neither necessary nor sufficient causal factors. Visual
and hearing impairments, metabolic abnormalities, sleep disorders, nutritional
deficiencies, and epilepsy should be considered as possible influences on ADHD
symptoms.
Environmental. Although ADHD is correlated with smoking during pregnancy,
some of this association reflects common genetic risk. A minority of cases may be related
to reactions to aspects of diet. There may be a history of child abuse, neglect, multiple
foster placements, neurotoxin exposure (e.g., lead), infections (e.g., encephalitis), or
alcohol exposure in utero. Exposure to environmental toxicants has been correlated with
subsequent ADHD, but it is not known whether these associations are causal.
Family interaction patterns in early childhood are unlikely to cause ADHD but
may influence its course or contribute to secondary development of conduct problems.
Gender. ADHD is more frequent in males than in females in the general
population, with a ratio of approximately 2:1 in children and 1.6:1 in adults. Females are
more likely than males to present primarily with inattentive features.

With that being said, the diagnostician in training needs to have a further
evaluation and observation to have a clear picture of the case. This may include, making
a genogram, biological checking of the parents’ DNA and other in-depth interview that
can provide relevant data pertaining Ken’s concerns.

VI. MENTAL EXAMINATION

Michael John P. Canoy, RPm MS in Psychology

The diagnostician in training conducted a Mental Status Examination to Sam and

found out the following based on the data collected:

Appearance
 The client doesn’t look physically unkept nor untidy
 Clothing is also not messy nor dirty
 There is no unusual physical characteristics

Behavior
 Posture is not seen as slumped
 There is also no rigidity in his body posture
 His posture doesn’t appear to be atypical nor inappropriate
 There were no signs of depression and sadness however his tantrums may indicate
sadness
 In his facial expressions, he doesn’t show any anxiety, fear, nor apprehension
 There is marked anger and hostility especially during his tantrums and aggressive
behaviors.
 There is no seen decreased in variability of expression
 There is no inappropriateness and bizarreness in his facial expression especially
when talking about things he likes doing
 There is marked dominance whenever he wants to do things that he wants even if
these too dangerous and inappropriate.
 Submissiveness and overly compliant is not present to the client
 Provocative behaviors were sometimes present especially when teasing and
playing with his sister.
 There is also no suspicious behavior being shown
 Client markedly uncooperative especially in doing school work and household
chores

Feeling (affect/mood)
Michael John P. Canoy, RPm MS in Psychology

 There is no inappropriateness to client’s thought content although his

misbehaviors cause significant concerns.
 Euphoria and elation is present to the client especially when climbing out of his
second-story bedroom window and racing his bicycle down the hill of a heavily
trafficked local street.
 There is marked anger and hostility especially during his tantrums and aggressive
behaviors.
 There is no fear, anxiety and apprehension shown by the client.
 There were no signs of depression and sadness however his tantrums may indicate
sadness

Perception
 There were no data in the case that can infer whether the client is experiencing
Illusions
 There were no data in the case that can infer whether the client is experiencing
Auditory hallucinations
 There were no data in the case that can infer whether the client is experiencing
visual hallucinations
Comments: Needs further evaluation

Thinking
 There is no impairment in his level of consciousness
 There is marked impairment with his attention
 Impairment in calculation ability markedly present with the client as he did not
perform very well on mathematics his school records and as described by his
teacher.
 There is also no impairment in his intelligence as has achieved developmental
milestones that his age requires except his inattention, hyperactivity and
impulsivity
 Ken doesn’t show disorientation to person
Michael John P. Canoy, RPm MS in Psychology

 He also doesn’t show any disorientation to place

 The client did not show any disorientation to time
 Initially there is difficulty in acknowledging the presence of psychological
disorder however it was eradicated as Ken later admitted that he was getting into a
lot of trouble at school.
 Blaming others for his difficulties was not present. In some occasions, he blames
his frustration to her sister.
 There is marked impairment in managing the client’s daily living activities such
as his inability to find many friends, accomplishing school-related requirements,
and poor relationship with his sister.
 Occasionally, the client shows impairment in his ability to make reasonable
decisions especially of his efforts did not produce success.
 Impaired immediate recall was not present
 Impaired recent memory was also not present
 Impaired remote memory was also not present
 Obsessions were not present with the client
 Compulsions were also not present
 There were no signs of phobias
 Depersonalization is not present with the client
 There were also no suicidal and homicidal idealization with the client
 Delusions are not present with the client
 There were also no ideas of reference nor ideas of influence
 The client also doesn’t show disturbance in association of thoughts
 Decreased and increased flow of thoughts were not seen

Although there were tendencies and other difficulties seen with the client especially in his
aggressiveness and disruptive behaviors, further evaluation and assessments are needed for a
more holistic and definitive diagnosis.
 Michael John P. Canoy, RPm MS in Psychology

VII. CASE OVERVIEW

Ken, 7-year old client, has difficulties involving malajustive behaviors including
hyperactivity, disruptive behaviors, aggressive behaviors, restless with the child and was
reported to have low frustration tolerance and a short attention span. These behaviors
often cause many troubles at school and with his siblings. He had poor peer relationships
and was being distractible moody, and aggressive. These misbehaviors began in
kindergarten which was seen by his parents, teachers, pediatrician and other significant
individuals who are in close proximity with Ken. The client is having trouble at school,
both academically and socially which needs to be addressed and intervened.

VIII. PRELIMINARY DIAGNOSIS

Based on the information provided and thorough evaluation of the data, the
symptoms and history of the client have fully met the criteria of
314.01 (F90.9) Other Specified Attention-Deficit/Hyperactivity Disorder, with
insufficient inattention symptoms, with insufficient hyperactivity & impulsivity
symptoms.
Note: The color red indicates that the presented fact(s) is present in the case. The
color green means that it is evident in the case, however, it is not directly stated. The
color blue, on the other hand, means that it is not present in the case but is probable
which will be given a remark “for further observation”

314.01 (F90.9) Other Specified Attention-Deficit/Hyperactivity Disorder, with insufficient

inattention symptoms, with insufficient hyperactivity & impulsivity symptoms.
DIAGNOSTIC CRITERIA PRESENTED FACTS
A. A persistent pattern of inattention and/or A persistent pattern of inattention and/or
hyperactivity-impulsivity that interferes hyperactivity-impulsivity that interferes with
with functioning or development, as functioning or development, as characterized
characterized by (1) and/or (2): by both Inattention and Hyperactivity

1. Inattention: Six (or more) of the Only four (4) out of nine (9) of the following
following symptoms have persisted symptoms have persisted for at least 6 months
for at least 6 months to a degree that is to a degree that is inconsistent with
Michael John P. Canoy, RPm MS in Psychology

inconsistent with developmental level developmental level and that negatively

and that negatively impacts directly on impacts directly on social and
social and academic/occupational academic/occupational activities:
activities:
Note: The symptoms are not solely a The client is eliciting the symptoms not only
manifestation of oppositional as a manifestation of a oppositional behavior,
behavior, defiance, hostility, or failure the presence following behaviors is not only
to understand tasks or instructions. For limited to hostility or failure in understanding
older adolescents and adults (age 17 tasks or instructions. And since the client is
and older), at least five symptoms are still 7 years old, atleast six of the following
required. symptoms of inattention should be present:

a. Often fails to give close attention to The symptom was not manifested by the client
details or makes careless mistakes in however, it is a duty to know its presence or
schoolwork, at work, or during other absence for sure, thus, recommended for
activities (e.g., overlooks or misses further observation.
details, work is inaccurate).

b. Often has difficulty sustaining His parents reported that he had short
attention in tasks or play activities attention span.
(e.g., has difficulty remaining focused He could not stay with puzzles and games for
during lectures, conversations, or more than a few minutes and often reacted
lengthy reading). angrily when his brief efforts did not produce
success

c. Often does not seem to listen when When his teacher spoke to him, he did not
spoken to directly (e.g., mind seems seem to hear; it was not until the teacher had
elsewhere, even in the absence of any begun yelling at him that he paid any
obvious distraction). attention.

d. Often does not follow through on Her teacher complains that Ken did not
Michael John P. Canoy, RPm MS in Psychology

instructions and fails to finish complete assignments given to him.

schoolwork, chores, or duties in the
workplace (e.g., starts tasks but
quickly loses focus and is easily
sidetracked).
Although it was mentioned that he fails to do
e. Often has difficulty organizing tasks assignments, this symptom was not clearly
and activities (e.g., difficulty manifested by the client however, it is a duty
managing sequential tasks; difficulty to know its presence or absence for sure,
keeping materials and belongings in thus, recommended for further observation.
order; messy, disorganized work; has
poor time management; fails to meet
deadlines).
Although he often turns into tantrums when
f. Often avoids, dislikes, or is reluctant demands were made of him during mealtimes,
to engage in tasks that require this symptom was not clearly manifested by
sustained mental (e.g., the client however, it is a duty to know its
effort
schoolwork or homework; for older presence or absence for sure, thus,
adolescents and adults, preparing recommended for further observation.
reports, completing forms, reviewing
lengthy papers). This symptom was not manifested by the
client however, it is a duty to know its

g. Often loses things necessary for tasks presence or absence for sure, thus,

or activities (e.g., school materials, recommended for further observation.

pencils, books, tools, wallets, keys,
paperwork, eyeglasses, mobile
telephones). On one occasion, he jumped up to look out
the window when a noise, probably a car
backfiring, was heard.
h. Is often easily distracted by extraneous
Any noise, even another child coughing or
stimuli (for older adolescents and
dropping a pencil, distracted him from his
adults, may include unrelated
Michael John P. Canoy, RPm MS in Psychology

thoughts). work

This symptom was not manifested by the

i. Is often forgetful in daily activities client however, it is a duty to know its
(e.g., doing chores, running errands; presence or absence for sure, thus,
for older adolescents and adults, recommended for further observation.
returning calls, paying bills, keeping
appointments).

Only four (4) out of nine (9) the following

2. Hyperactivity and impulsivity: Six (or symptoms have persisted for at least 6 months
more) of the following symptoms have to a degree that is inconsistent with
persisted for at least 6 months to a developmental level and that negatively
degree that is inconsistent with impacts directly on social and
developmental level and that negatively academic/occupational activities:
impacts directly on social and
academic/occupational activities: The client is eliciting the symptoms not only
Note: The symptoms are not solely a as a manifestation of a oppositional behavior,
manifestation of oppositional behavior, the presence following behaviors is not only
defiance, hostility, or a failure to limited to hostility or failure in understanding
understand tasks or instructions. For tasks or instructions. And since the client is
older adolescents and adults (age 17 and still 7 years old, atleast six of the following
older), at least five symptoms are symptoms of hyperactivity or impulsivity
required. should be present:

Even when he stayed seated, he was often not

a. Often fidgets with or taps hands or feet working and instead was fidgeting or
or squirms in seat. bothering other children.

Had difficulty sitting still at mealtimes, and

b. Often leaves seat in situations when reacted with temper tantrums when demands
remaining seated is expected (e.g., were made of him
Michael John P. Canoy, RPm MS in Psychology

leaves his or her place in the Ken’s teacher complained that he was
classroom, in the office or other frequently out of his seat, seldom sat still
workplace, or in other situations that when he was supposed to.
require remaining in place). Therapist’s observation also saw Ken was out
of his seat inappropriately six times while
observing in a classroom setting

His behavior had also taken on a daredevil

c. Often runs about or climbs in quality, as illustrated by his climbing out of
situations where it is inappropriate. his second-story bedroom window and racing
(Note: In adolescents or adults, may his bicycle down the hill of a heavily
be limited to feeling restless.) trafficked local street.

This symptom was not manifested by the

d. Often unable to play or engage in client however, it is a duty to know its
leisure activities quietly. presence or absence for sure, thus,
recommended for further observation.

Going out for dinner had become impossible

e. Is often “on the go,” acting as if because of his misbehavior in restaurants.
“driven by a motor” (e.g., is unable to Even mealtimes at home had become
be or uncomfortable being still for unpleasant
extended time, as in restaurants,
meetings; may be experienced by
others as being restless or difficult to
keep up with). This symptom was not manifested by the
client however, it is a duty to know its

f. Often talks excessively. presence or absence for sure, thus,

recommended for further observation.
Michael John P. Canoy, RPm MS in Psychology

This symptom was not manifested by the

client however, it is a duty to know its
g. Often blurts out an answer before a presence or absence for sure, thus,
question has been completed (e.g., recommended for further observation.
completes people’s sentences; cannot
wait for turn in conversation). This symptom was not manifested by the
client however, it is a duty to know its
h. Often has difficulty waiting his or her presence or absence for sure, thus,
turn (e.g., while waiting in line). recommended for further observation.

This symptom was not manifested by the

client however, it is a duty to know its
i. Often interrupts or intrudes on others presence or absence for sure, thus,
(e.g., butts into conversations, games, recommended for further observation.
or activities; may start using other
people’s things without asking or
receiving permission; for adolescents
and adults, may intrude into or take
over what others are doing).
B. Several inattentive or hyperactive- His symptoms and problems began in
impulsive symptoms were present prior to kindergarten and still bother in his period now
age 12 years. in 1st Grade
C. Several inattentive or hyperactive- Difficulties were observed by the therapist in
impulsive symptoms are present in two or Ken’s Home environment, School
more settings (e.g., at home, school, or Environment, and were also reported by her
work; with friends or relatives; in other parents and teachers which was also
activities). supported by school records and other
instruments.
D. There is clear evidence that the symptoms These difficulties and behavior lead to his
interfere with, or reduce the quality of, poor relationship with her sister and other
social, academic, or occupational classmates.
Michael John P. Canoy, RPm MS in Psychology

functioning He also did not perform very well on his

academics specifically in reading and
mathematics achievement.
Ken himself also admitted that he was getting
into a lot of trouble in school.
He had no real close friends because some
seem to be mostly afraid of him.
E. The symptoms do not occur exclusively These symptoms do not occur exclusively
during the course of schizophrenia or during the course of schizophrenia or another
another psychotic disorder and are not psychotic disorder and are not better
better explained by another mental explained by another mental disorder (e.g.,
disorder (e.g., mood disorder, anxiety mood disorder, anxiety disorder, dissociative
disorder, dissociative disorder, personality disorder, personality disorder, substance
disorder, substance intoxication or intoxication or withdrawal).
withdrawal).
Justification The client does not meet the full criteria of
Attention-Deficit/Hyperactivity Disorder
specifically insufficiency in symptoms that
includes inattention and hyperactivity and
impulsivity. The client, however, is fit for the
diagnosis of 314.01 (F90.9) Other Specified
Attention-Deficit/Hyperactivity Disorder,
with insufficient inattention symptoms, with
insufficient hyperactivity & impulsivity
symptoms.

IX. DIAGNOSTIC FEATURES

The essential feature of attention-deficit/hyperactivity disorder (ADHD) is a
persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with
functioning or development. Inattention manifests behaviorally in ADHD as wandering
Michael John P. Canoy, RPm MS in Psychology

off task, lacking persistence, having difficulty sustaining focus, and being disorganized
and is not due to defiance or lack of comprehension. Hyperactivity refers to excessive
motor activity (such as a child running about) when it is not appropriate, or excessive
fidgeting, tapping, or talkativeness. Impulsivity refers to hasty actions that occur in the
moment without forethought and that have high potential for harm to the individual (e.g.,
darting into the street without looking). Impulsivity may reflect a desire for immediate
rewards or an inability to delay gratification. Impulsive behaviors may manifest as social
intrusiveness (e.g., interrupting others excessively) and/or as making important decisions
without consideration of long-term consequences (e.g., taking a job without adequate
information). ADHD begins in childhood. The requirement that several symptoms be
present before age 12 years conveys the importance of a substantial clinical presentation
during childhood. At the same time, an earlier age at onset is not specified because of
difficulties in establishing precise childhood onset retrospectively. Manifestations of the
disorder must be present in more than one setting (e.g., home and school, work).
Confirmation of substantial symptoms across settings typically cannot be done accurately
without consulting informants who have seen the individual in those settings. Typically,
symptoms vary depending on context within a given setting. Signs of the disorder may be
minimal or absent when the individual is receiving frequent rewards for appropriate
behavior, is under close supervision, is in a novel setting, is engaged in especially
interesting activities, has consistent external stimulation (e.g., via electronic screens), or
is interacting in one-on-one situations (e.g., the clinician's office).

Although there were criteria that were fully met by the client. Criterion A was not
fully met by the client. Under Inattention of Criterion A, only four (4) out of nine (9)
symptoms were manifested by the client including difficulty in sustaining attention in
tasks or play activities; Often does not seem to listen when spoken to directly; Often does
not follow through on instructions and fails to finish schoolwork, chores, or duties in the
workplace and; often easily distracted by extraneous stimuli.
Under Hyperactivity/impulsivity of Criterion A, only four (4) out of nine (9)
symptoms were manifested by the client including his fidgeting with or taps hands or feet
or squirms in seat; Often leaves seat in situations when remaining seated is expected;
Michael John P. Canoy, RPm MS in Psychology

Often runs about or climbs in situations where it is inappropriate; and often “on the go,”
acting as if “driven by a motor”. These symptoms started during Ken’s Kindergarten and
are still present in the his current 1st Grade (Criterion B) and were observed in their home
and school environment, and were also reported by her parents and teachers which was
also supported by school records and other instruments (Criterion C). As reported by his
parents, teachers, and as observed by his therapist, these behaviors reduced the quality of
his social relationships with her friends and siblings, academic performances as shown in
his school records, and other occupational functioning observed (Criterion B). Whereas,
these symptoms do not occur exclusively during the course of schizophrenia or another
psychotic disorder and are not better explained by another mental disorder (Criterion E).

X. ASSOCIATED FEATURES
Mild delays in language, motor, or social development are not specific to ADHD
but often co-occur. Associated features may include low frustration tolerance, irritability,
or mood lability. Even in the absence of a specific learning disorder, academic or work
performance is often impaired. Inattentive behavior is associated with various underlying
cognitive processes, and individuals with ADHD may exhibit cognitive problems on tests
of attention, executive function, or memory, although these tests are not sufficiently
sensitive or specific to serve as diagnostic indices. No biological marker is diagnostic for
ADHD. As a group, compared with peers, children with ADHD display increased slow
wave electroencephalograms, reduced total brain volume on magnetic resonance
imaging, and possibly a delay in posterior to anterior cortical maturation, but these
findings are not diagnostic. In the uncommon cases where there is a known genetic cause
(e.g.. Fragile X syndrome, 22qll deletion syndrome), the ADHD presentation should still
be diagnosed.

Most of which mentioned above were reported to be experienced by the client

such as his low frustration tolerance, and irritability as seen and reported by his parents,
teachers, and therapist. Also, low academic performances were seen with the client.
However, the diagnostician in training should look more details in order to arrive at a
definitive diagnosis for the client which can include assessment in a form of medical
Michael John P. Canoy, RPm MS in Psychology

examination, interviews, and other psychological tests. For the mean time since the client
did not fully meet the full criteria for ADHD, he is fitted for the diagnosis of Other
Specified Attention-Deficit/Hyperactivity Disorder, with insufficient inattention
symptoms, with insufficient hyperactivity & impulsivity symptoms.

XI. ETIOLOGY AND PREVALENCE

Course modifiers. Family interaction patterns in early childhood are unlikely to cause
ADHD but may influence its course or contribute to secondary development of conduct
problems. There may be a history of child abuse, neglect, multiple foster placements,
neurotoxin exposure (e.g., lead), infections (e.g., encephalitis), or alcohol exposure in
utero. Exposure to environmental toxicants has been correlated with subsequent ADHD,
but it is not known whether these associations are causal.

Genetic and physiological. ADHD is elevated in the first-degree biological relatives of

individuals with ADHD. The heritability of ADHD is substantial. While specific genes
have been correlated with ADHD, they are neither necessary nor sufficient causal factors.
Visual and hearing impairments, metabolic abnormalities, sleep disorders, nutritional
deficiencies, and epilepsy should be considered as possible influences on ADHD
symptoms. ADHD is not associated with specific physical features, although rates of
minor physical anomalies (e.g., hypertelorism, highly arched palate, low-set ears) may be
relatively elevated. Subtle motor delays and other neurological soft signs may occur.
(Note that marked co-occurring clumsiness and motor delays should be coded separately
[e.g., developmental coordination disorder].)

Prevalence

Population surveys suggest that ADHD occurs in most cultures in about 5% of

children and about 2.5% of adults.
 Michael John P. Canoy, RPm MS in Psychology

XII. DEVELOPMENT AND COURSE

His parents first observe excessive motor activity when Ken was a toddler, but
symptoms are difficult to distinguish from highly variable normative behaviors before
age 4 years. ADHD is most often identified during elementary school years, and
inattention becomes more prominent and impairing. The disorder is relatively stable
through early adolescence, but some individuals have a worsened course with
development of antisocial behaviors. In most individuals with ADHD, symptoms of
motoric hyperactivity become less obvious in adolescence and adulthood, but difficulties
with restlessness, inattention, poor planning, and impulsivity persist. A substantial
proportion of children with ADHD remain relatively impaired into adulthood. In
preschool, the main manifestation is hyperactivity. Inattention becomes more prominent
during elementary school. During adolescence, signs of hyperactivity (e.g., running and
climbing) are less common and may be confined to fidgetiness or an inner feeling of
jitteriness, restlessness, or impatience. In adulthood, along with inattention and
restlessness, impulsivity may remain problematic even when hyperactivity has
diminished.

XIII. RISK AND PROGNOSTIC FACTORS

Temperamental. ADHD is associated with reduced behavioral inhibition, effortful
control, or constraint; negative emotionality; and/or elevated novelty seeking. These traits
may predispose some children to ADHD but are not specific to the disorder.

Environmental. Very low birth weight (less than 1,500 grams) conveys a two- to
threefold risk for ADHD, but most children with low birth weight do not develop ADHD.
Although ADHD is correlated with smoking during pregnancy, some of this association
reflects common genetic risk. A minority of cases may be related to reactions to aspects
of diet. There may be a history of child abuse, neglect, multiple foster placements,
neurotoxin exposure (e.g., lead), infections (e.g., encephalitis), or alcohol exposure in
utero. Exposure to environmental toxicants has been correlated with subsequent ADHD,
but it is not known whether these associations are causal.
 Michael John P. Canoy, RPm MS in Psychology

Genetic and physiological. ADHD is elevated in the first-degree biological relatives of

individuals with ADHD. The heritability of ADHD is substantial. While specific genes
have been correlated with ADHD, they are neither necessary nor sufficient causal factors.
Visual and hearing impairments, metabolic abnormalities, sleep disorders, nutritional
deficiencies, and epilepsy should be considered as possible influences on ADHD
symptoms. ADHD is not associated with specific physical features, although rates of
minor physical anomalies (e.g., hypertelorism, highly arched palate, low-set ears) may be
relatively elevated. Subtle motor delays and other neurological soft signs may occur.
(Note that marked co-occurring clumsiness and motor delays should be coded separately
[e.g., developmental coordination disorder].)
Course modifiers. Family interaction patterns in early childhood are unlikely to cause
ADHD but may influence its course or contribute to secondary development of conduct
problems.

XIV. DIFFERENTIAL DAGNOSIS

Oppositional defiant disorder. Ken’s symptoms were due to his impulsivity in and not
sole due to his hostility, defiance, and negativity. Thus this differential diagnosis is ruled
out.

Intermittent explosive disorder. Ken do experience problems with sustaining attention

which is often not seen in individuals with this disorder thus this differential diagnosis
can also be ruled out. However, the diagnostician in training may have to look into what
appears to be Ken’s aggressive behavior to ensure that this are not severe which can
coexist in his condition.

Other neurodevelopmental disorders. There are no repetitive motor behavior that

characterizes stereotypic movement disorder and some cases of autism spectrum disorder.
In stereotypic movement disorder, the motoric behavior is generally fixed and repetitive
(e.g., body rocking, self-biting), whereas the fidgetiness and restlessness in Ken’s case
are typically generalized and not characterized by repetitive stereotypic movements.
Thus, this differential diagnosis can be ruled out.
Michael John P. Canoy, RPm MS in Psychology

Specific learning disorder. Inattention in individuals with a specific learning disorder

who do not have ADHD is not impairing outside of academic work which is not the case
on Ken’s situation. His inattention is still present in his home environment. Thus, this
differential diagnosis can be ruled out.

Intellectual disability (intellectual developmental disorder). Ken’s inattention is still

present in non-academic tasks such as in his home environment. Also, his IQ was placed
120. Thus, this differential diagnosis can be ruled out.

Autism spectrum disorder. Ken’s misbehaved tantrums were due to his low frustration
tolerance, and impulsivity. Thus, this differential diagnosis is ruled out.

Reactive attachment disorder. Ken did not display other features such as a lack of
enduring relationships. Thus, this differential diagnosis can be ruled out.

Anxiety disorders. Ken’s symptoms of inattention are present because of his attraction
to external stimuli, new activities, or preoccupation with enjoyable activities which is a
definite difference between anxiety disorders which is induced by worries and
rumination. Thus, this differential diagnosis can also be ruled out.

Depressive disorders. Individuals with depressive disorders may present with inability
to concentrate. However, poor concentration in mood disorders becomes prominent only
during a depressive episode, while, Ken’s poor concentration are eminent regardless of
the situation, thus, this diagnosis can be ruled out.

Bipolar disorder. Individuals with bipolar disorder may have increased activity, poor
concentration, and increased impulsivity, but these features are episodic, occurring
several days at a time. In bipolar disorder, increased impulsivity or inattention is
accompanied by elevated mood, grandiosity, and other specific bipolar features. Ken
shows significant changes in mood within the same day; such lability is distinct from a
manic episode, which must last 4 or more days to be a clinical indicator of bipolar
disorder. His impulsivity or inattention was also not accompanied by other specific
bipolar features. Thus, this can also be ruled out.

Disruptive mood dysregulation disorder. Ken’s symptoms are better explained explain
in the ADHD due to his inattention and impulsivity. However, there is a possibility that
Michael John P. Canoy, RPm MS in Psychology

his temper can also be concerning that may appear to be coexisting with this differential
diagnosis. With that said, further evaluation and assessment is need that focuses in Ken’s
irritability and frustrations.

Substance use disorders. There were no indication and evidence of substance misuse
from informants or previous record. Thus, this differential diagnosis is ruled out.

Personality disorders. The client is still 7-year old. personality has an onset in
adolescence or early adulthood, is stable over time, and leads to distress or impairment.
Thus, this differential diagnosis is ruled out. However, further interventions are needed to
prevent the occurrence of this differential diagnosis.

Psychotic disorders. Ken’s symptoms of inattention and hyperactivity did not occur
exclusively during the course of a psychotic disorder. Thus this differential diagnosis is
ruled out.

Medication-induced symptoms of ADHD. Symptoms of inattention, hyperactivity, or

impulsivity attributable to the use of medication (e.g., bronchodilators, isoniazid,
neuroleptics [resulting in akathisia], thyroid replacement medication) are diagnosed as
other specified or unspecified other (or unknown) substance-related disorders. There
were no noted use of medication that can influence to Ken’s inattention, hyperactivity, or
impulsivity. Thus, can also be ruled out.

Neurocognitive disorders. Early major neurocognitive disorder (dementia) and/or mild

neurocognitive disorder are not known to be associated with ADHD but may present with
similar clinical features. These conditions are distinguished from ADHD by their late
onset. Since Ken is still 7 year old, it is not possible yet to consider this differential
diagnosis, thus, can also be ruled out.

XV. TREATMENT PLAN

LONG-TERM GOALS
1. Sustain attention and concentration for
consistently longer periods of time.
2. Increase the frequency of on-task behaviors.
 Michael John P. Canoy, RPm MS in Psychology

3. Demonstrate marked improvement in impulse

control.
4. Parents and/or teachers successfully utilize a
reward system, contingency contract, or token
economy to reinforce positive behaviors and deter
negative behaviors.
5. Parents set firm, consistent limits and maintain
appropriate parent-child boundaries.
6. Develop positive social skills to help maintain
lasting peer friendships.

SHORT-TERM GOALS THERAPEUTIC INTERVENTION

Client and parents describe the nature of the ADHD  Actively build the level of trust with the client
including specific behaviors, triggers, and and parents through consistent eye contact,
consequences. (1, 2, 3) active listening, unconditional positive regard,
and warm acceptance to help increase his/her
ability to identify and express feelings.
 Thoroughly assess the various stimuli (e.g.,
situations, people, thoughts) that have
triggered the client’s ADHD behavior; the
thoughts, feelings, and actions that have
characterized his/her responses; and the
consequences of the behavior (e.g.,
reinforcements, punishments), toward
identifying target behaviors, antecedents,
consequences, and the appropriate placement
of interventions (e.g., school-based, home-
based, peer-based)
 Rule out alternative conditions/causes of
inattention, hyperactivity, and impulsivity
(e.g., other behavioral, physical, emotional
problems, or normal developmental
 Michael John P. Canoy, RPm MS in Psychology

behavioral).
Complete psychological testing to measure the nature  Arrange for psychological testing and/or
and extent of ADHD and/or rule out other possible objectives measures to assess the features of
contributors. ADHD (e.g., the Disruptive Behavior
Disorder Rating Scale; the ADHD Rating
Scale); rule out emotional problems that may
be contributing to the client’s inattentiveness,
impulsivity, and hyperactivity; and/or
measure the behavior and stimuli associated
with its appearance; give feedback to the
client and his/her parents regarding the testing
results.
Provide behavioral, emotional, and attitudinal  Assess the client’s level of insight (syntonic
information toward an assessment of specifiers versus dystonic) toward the “presenting
relevant to a DSM diagnosis, the efficacy of treatment, problems” (e.g., demonstrates good insight
and the nature of the therapy relationship into the problematic nature of the “described
behavior,” agrees with others’ concern, and is
motivated to work on change; demonstrates
ambivalence regarding the “problem
described” and is reluctant to address the issue
as a concern; or demonstrates resistance
regarding acknowledgment of the “problem
described,” is not concerned, and has no
motivation to change).
 Assess the client for evidence of research-
based correlated disorders (e.g., oppositional
defiant behavior with ADHD, depression
secondary to an anxiety disorder) including
vulnerability to suicide, if appropriate (e.g.,
increased suicide risk when comorbid
depression is evident).
 Assess for any issues of age, gender, or
 Michael John P. Canoy, RPm MS in Psychology

culture that could help explain the client’s

currently defined “problem behavior” and
factors that could offer a better understanding
of the client’s behavior.
 Assess for the severity of the level of
impairment to the client’s functioning to
determine appropriate level of care (e.g., the
behavior noted creates mild, moderate, severe,
or very severe impairment in social, relational,
vocational, or occupational endeavors);
continuously assess this severity of
impairment as well as the efficacy of
treatment (e.g., the client no longer
demonstrates severe impairment but the
presenting problem now is causing mild or
moderate impairment).
 Assess the client’s home, school, and
community for pathogenic care (e.g.,
persistent disregard for the child’s emotional
needs or physical needs, repeated changes in
primary caregivers, limited opportunities for
stable attachments, persistent harsh
punishment or other grossly inept parenting).
Take prescribed medication as directed by the  Arrange for the client to have an evaluation by
physician a physician to assess the appropriateness of
prescribing ADHD medication.
 Monitor the client for psychotropic
medication prescription compliance, side
effects, and effectiveness; consult with the
prescribing physician at regular intervals
Parents and the client demonstrate increased  Educate the client’s parents and siblings about
knowledge about ADHD and its treatment.
 Michael John P. Canoy, RPm MS in Psychology

the symptoms of ADHD.

 Discuss with parents the various treatment
options for ADHD (e.g., behavioral parent
training, classroom-based behavioral
management programs, peerbased programs,
medication), discussing risks and benefits to
fully inform the parents’ decision-making.
 Assign the parents readings to increase their
knowledge of ADHD.
 Assign the client readings to increase his/her
knowledge about ADHD and ways to manage
related behavior.
Parents learn and implement Parent Management  Educate the parents about a Behavioral Parent
Training to increase prosocial behavior and decrease Management Training approach, explaining
disruptive behavior of their child/children. how parent and child behavioral interactions
can reduce the frequency of impulsive,
disruptive, and negative attention-seeking
behaviors and increase desired prosocial
behavior through prompting and reinforcing
positive behaviors as well as use of clear
instruction, time-out, and other loss of
privilege practices for problem.
 Teach the parents how to specifically define
and identify problem behaviors, identify their
reactions to the behavior, determine whether
the reaction encourages or discourages the
behavior, and generate alternatives to the
problem behavior.
 Teach parents about the possible functions of
the ADHD behavior (e.g., avoidance,
attention, to gain a desire object/activity,
 Michael John P. Canoy, RPm MS in Psychology

regulate sensory stimulation); how to test

which function(s) is being served by the
behavior, and how to use parent training
methods to manage the behavior.
 Assign the parents home exercises in which
they implement and record results of
implementation exercises.
 Refer parents to a Parent Management
Training Course
Parents work with therapist and school to implement a  Consult with the client’s teachers to
behavioral classroom management program implement strategies to improve school
performance, such as sitting in the front row
during class, using a prearranged signal to
redirect the client back to task, scheduling
breaks from tasks, providing frequent
feedback, calling on the client often, arranging
for a listening buddy, and implementing a
daily behavioral report card.
 Consult with parents and pertinent school
personnel to implement a Behavioral
Classroom Management Intervention.
Complete a peer-based treatment program focused on  Conduct or refer the client to a Behavioral
improving social interaction skills Peer Intervention (e.g., Summer Treatment
Program or after school/weekend version) that
involves brief social skills training, followed
by coached group play in recreational
activities guided by contingency management
systems (e.g., point system, timeout) and
utilizing objective observations, frequency
counts, and adult ratings of social behaviors as
outcome measures.
Parents develop and utilize an organized system to  Assist the parents in developing and
 Michael John P. Canoy, RPm MS in Psychology

keep track of the client’s school assignments, chores, implementing an organizational system to
and household responsibilities increase the client’s on-task behaviors and
completion of school assignments, chores, or
household responsibilities through the use of
calendars, charts, notebooks, and class syllabi.
 Assist the parents in developing a routine
schedule to increase the client’s compliance
with school, household, or work-related
responsibilities.
Utilize effective study and test taking skills on a  Teach the client more effective study skills
regular basis to improve academic performance. (e.g., clearing away distractions, studying in
quiet places, and scheduling breaks in
studying).
 Teach the client more effective test-taking
strategies (e.g., reviewing material regularly,
reading directions twice, and rechecking
work).
 Assign the client to read 13 Steps to Better
Grades by Silverman to improve
organizational and study skills; process the
material read and identify ways to implement
new practices.
Increase frequency of completion of school  Assist the parents in developing a routine
assignments, chores, and household responsibilities schedule to increase the client’s compliance
with school, household, or work-related
responsibilities.
Delay instant gratification in favor of achieving  Teach the client mediational and self-control
meaningful long-term goals. strategies (e.g., “stop, look, listen, and think”)
to delay the need for instant gratification and
inhibit impulses to achieve more meaningful,
longer-term goals.
 Assist the parents in increasing structure to
 Michael John P. Canoy, RPm
Learn and implement social skills to reduce anxiety
and build confidence in social interactions
Increase the frequency of positive interactions with  Explore for periods of time when the client
parents.
Increase the frequency of socially appropriate  Give homework assignments where the client
behaviors with siblings and peers.
MS in Psychology
help the client learn to delay gratification for
longer term goals (e.g., completing homework
or chores before playing).
 Use instruction, modeling, and role-playing to
build the client’s general and developmentally
appropriate social and/or communication
skills.
 Assign the client to read about general social
and/or communication skills in books or
treatment manuals on building social skills
(e.g., or assign the “Social Skills Exercise” or
“Greeting Peers” in the Child Psychotherapy
Homework Planner by Jongsma, Peterson,
and McInnis
demonstrated good impulse control and
engaged in fewer disruptive behaviors;
process his/her responses and reinforce
positive coping mechanisms that he/she used
to deter impulsive or disruptive behaviors.
 Instruct the parents to observe and record
three to five positive behaviors by the client in
between therapy sessions; reinforce positive
behaviors and encourage him/her to continue
to exhibit these behaviors.
 Encourage the parents to spend 10 to 15
minutes daily one-on-one time with the client
to create a closer parent-child bond; allow the
client to take the lead in selecting the activity
or task.
identifies 5 to 10 strengths or interests; review
 Michael John P. Canoy, RPm MS in Psychology

the list in the following session and encourage

him/her to utilize strengths or interests to
establish friendships.
 Assign the client the task of showing
empathy, kindness, or sensitivity to the needs
of others (e.g., allowing sibling or peer to take
first turn in a video game, helping with a
school fundraiser).
Increase verbalizations of acceptance of responsibility  Firmly confront the client’s impulsive
for misbehavior behaviors, pointing out consequences for
him/her and others.
 Confront statements in which the client
blames others for his/her annoying or
impulsive behaviors and fails to accept
responsibility for his/her action
Identify stressors or painful emotions that an trigger  Explore and identify stressful events or factors
increase in hyperactivity and impulsivity. that contribute to an increase in impulsivity,
hyperactivity, and distractibility.
 Explore possible stressors, roadblocks, or
hurdles that might cause impulsive and acting-
out behaviors to increase in the future.
Parents and the client regularly attend and actively  Encourage the client’s parents to participate in
participate in group therapy an ADHD support group.
Complete a course of biofeedback to improve  Conduct or refer the client to a trial of EEG
concentration and attention. Give a homework biofeedback (neurotherapy) for ADHD.
assignment where the client lists the positive and
negative aspects of his/her high energy level; review
the list in the following session and encourage him/her
to channel energy into healthy physical outlets and
positive social activities
Identify and list constructive ways to utilize energy.  Give a homework assignment where the client
lists the positive and negative aspects of
 Michael John P. Canoy, RPm MS in Psychology

his/her high energy level; review the list in the

following session and encourage him/her to
channel energy into healthy physical outlets
and positive social activities

XVI. REFERENCES

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: Author

Jongsma, A. E. Jr. (2014). The Child Psychotherapy Treatment Planner. 5th Edition, 425-434
Jongsma, A. E. Jr. (2014). The Child Psychotherapy Treatment Planner. 4th Edition, 305-312

XVII. ATTACHMENTS
CASE STUDY

Reporter: Kristianne T.Tabaranza

Topic: Attention Deficit / Hyperactivity Disorder

Ken Wilson’s mother contacted the clinic in the middle of November about her 7-year-old son, a
first-grader. She explained that Ken was having trouble at school, both academically and
socially. The school psychologist had said that he was hyperactive. The clinic scheduled an
initial appointment for Ken and both parents.

Social History

The case was assigned to a clinical psychology intern, who met the family in the clinic’s waiting
room. After a brief chat with all of them, he explained that he would first like to see the parents
alone and later spend some time with Ken.

Mr. and Mrs. Wilson had been married for 12 years. He was a business manager, and she was a
homemaker. Ken was the middle of three children; his older sister was 9, and his younger brother
was 4. Neither sibling was having any apparent problems. Mrs. Wilson had a full-term
Michael John P. Canoy, RPm MS in Psychology

pregnancy with Ken. The delivery was without complication, although labor was fairly long. The
therapist explained that he would like to get an overview of the problem as it existed now.

According to his parents, Ken’s current problems began in kindergarten. His teacher frequently
sent notes home about his disciplinary problems in the class- room. In fact, there had been
concerns about promoting Ken to the first grade. The final result was a “trial promotion.”
Everyone hoped that Ken would mature and do much better in first grade, but his behavior
became even more disruptive. Ken’s mother had received negative reports about him from his
teacher several times over the first 2 months of school. His teacher reported that he didn’t com-
plete his work, was disruptive to the class, and behaved aggressively.

The therapist then asked about the parents’ perception of Ken at home and his developmental
history. They described him as a difficult infant, much more so than his older sister. He cried
frequently and was described as a colicky baby by their pediatrician. He did not eat well, and his
sleep was often fitful and rest- less. As Ken grew, his mother reported even more difficulties
with him. He was into everything. Verbal reprimands, which had been effective in controlling his
sister’s behavior, seemed to have no effect on him. When either parent tried to stop him from
doing something dangerous, such as playing with an expensive vase or turning the stove off and
on, he would often have a temper tantrum that included throwing things, breaking toys, and
screaming. His relationship with his sister was poor. He bit her on several occasions and seemed
to take delight in trying to get her into trouble.

His parents described a similar pattern of aggressiveness in Ken’s behav- ior with the
neighborhood children. Many of the parents no longer allowed their children to play with Ken.
They also reported that he had low frustration toler- ance and a short attention span. He could not
stay with puzzles and games for more than a few minutes and often reacted angrily when his
brief efforts did not produce success. Going out for dinner had become impossible because of his
misbehavior in restaurants. Even mealtimes at home had become unpleasant. Ken’s parents had
begun to argue frequently about how to deal with him.

Toward the end of the first session, the therapist brought Ken to his office while his parents
remained in the clinic waiting room. Ken initially maintained that he did not understand why he
was at the clinic, but later he admitted that he was getting into a lot of trouble at school. He
agreed that it would probably be a good idea to try to do something about his misbehavior.
Michael John P. Canoy, RPm MS in Psychology

Ken and his parents were brought together for the final minutes of the first session. The therapist
explained that the next several sessions would be devoted to conducting a more thorough
assessment, including visits to the Wilson’s home and Ken’s school. The parents signed release
forms so the therapist could obtain information from their pediatrician and the school. The
following infor- mation was gathered through these sources and from further interviews with the
parents.

The Current Problem

School records generally corroborated his parents’ description of Ken’s behav- ior in
kindergarten. His teacher described him as being “distractible, moody, aggressive,” and a
“discipline problem.” Toward the end of kindergarten, his intelligence and academic
achievement were tested. Although his IQ was placed at 120, he did not perform very well on
reading and mathematics achievement tests. An interview with Ken’s first-grade teacher
provided information that agreed with other reports. Ken’s teacher complained that he was
frequently out of his seat, seldom sat still when he was supposed to, did not complete assign-
ments, and had poor peer relations. Ken seemed indifferent to efforts at disciplin- ing him. Ken’s
teacher also completed a short form of the Conners Rating Scale (Sprague, Cohen, & Werry,
1974) about Ken’s behavior. The instrument verified the picture of hyperactive behavior that had
already emerged (see Table 22.1).

The therapist arranged to spend a morning in Ken’s classroom. During that time, Ken was out of
his seat inappropriately six times. On one occasion, he jumped up to look out the window when a
noise, probably a car backfiring, was heard. He went to talk to other children three times. Ken
got up twice and just began walking quickly around the classroom. Even when he stayed seated,
he was often not working and instead was fidgeting or bothering other children. Any noise, even
another child coughing or dropping a pencil, distracted him from his work. When his teacher
spoke to him, he did not seem to hear; it was not until the teacher had begun yelling at him that
he paid any attention.

Subsequent sessions with Ken’s parents focused on his current behavior at home. The pattern
that had begun earlier in Ken’s childhood continued. He still got along poorly with his sister, had
difficulty sitting still at mealtimes, and reacted with temper tantrums when demands were made
of him. His behavior had also taken on a daredevil quality, as illustrated by his climbing out of
Michael John P. Canoy, RPm MS in Psychology

his second-story bedroom window and racing his bicycle down the hill of a heav- ily trafficked
local street. Indeed, his daring acts seemed to be the only way he could get any positive attention
from his neighborhood peers, who seemed to be mostly afraid of him. He had no really close
friends.

Mr. Wilson missed two of these sessions because of his business schedule. Most days he had to
commute to work, a two-hour train trip each way. During a session he missed, Mrs. Wilson
hinted that they had marital problems. When this was brought up directly, she agreed that their
marriage was not as good now as it once had been. Their arguments centered on how to handle
Ken. Mrs. Wilson had come to believe that severe physical punishment was the only answer. She
described an active, growing dislike of Ken and feared that he might never change.

The next time Mr. Wilson was present, the therapist asked him about his child-rearing
philosophy. He admitted that he took more of a “boys will be boys” approach. In fact, he
reported that as a child, he was like Ken. He had “grown out of it” and expected Ken would, too.
As a result, he let Ken get away with things for which Mrs. Wilson would have punished him.
The couple’s argu- ments, which had recently become more heated and frequent, usually
occurred after Mr. Wilson had arrived home from work. Mrs. Wilson, after a particularly
exasperating day with Ken, would try to get Mr. Wilson to discipline Ken. “Just wait until your
father gets home” was a familiar refrain. But Mr. Wilson would refuse and accuse his wife of
overreacting; the battle would then begin.

The next week, the therapist visited the Wilson home, arriving just before Ken and his sister got
home from school. The first part of the visit was unevent- ful, but at about 4:30 p.m., Ken and his
sister got into a fight over who was win- ning a game. Ken broke the game, and his sister came
crying to her mother, who began shouting at Ken. Ken tried to explain his behavior by saying
that his sister had been cheating. His mother ordered him to his room; shortly thereafter, when
she heard him crying, she went up and told him he could come out.

The children ate their dinner at 5:30 p.m.; Mrs. Wilson planned to wait until her husband came
home later to have hers. The meal began with Ken complain- ing that he did not like anything on
his plate. He picked at his food for a few minutes and then started making faces at his sister. Mrs.
Wilson yelled at him to stop making the faces and eat his dinner. When she turned her back, he
began shoving food from his plate onto his sister’s. As she resisted, Ken knocked over his glass
Michael John P. Canoy, RPm MS in Psychology

of milk, which broke on the floor. Ken’s mother was enraged at this point. She looked as if she
was ready to hit Ken, but she calmed herself, perhaps because of the therapist’s presence.
Although she told Ken that he would be in big trouble when his father got home, nothing
happened. When Mr. Wilson came home, he made light of the incident and refused to punish
Ken. Even though Mrs. Wilson’s exasperation was obvious, she said nothing.