Attention-Deficit/Hyperactivity Disorder

The Case of Zuhair:

Concentration Issues and Restlessness

Presenting Problem
Zuhair, an eleven-year-old boy, is prone to misbehavior at school. As many as three or
four incidences of fighting, kicking, and fleeing in the hallways are reported to his
mother each week by his school's teachers. According to his mother, "it has always
been normal for me to go off to his school when the guidance office contacts me. He
always gets into fights with his classmates." He has been unable to finish the task
assigned to him and easily becomes distracted.

At home, “my son seems unable to sit still for any length of time, has had several falls
when climbing trees and needs endless prompts to tidy his toys.” His mother also
revealed that he won’t sleep early despite his gadgets being confiscated. “Although
everyone is asleep and no one is awake, he plays around the living room and can’t sit
still in one place.”

During the session, Zuhair was observed to be quite active, always fidgeting with his
hands, tilting his head to all directions, waving his arms, jumping on his place, and was
constantly around the room. He displayed an appropriate affect and would frown a lot
during the sessions with narrowed eyes when he made eye contact, which was very
infrequent. 

At school, he annoys his classmates by his constant interruptions. However, as stated

by his teacher, “whenever he has one-to-one attention from a student teacher who
happens to be in his class on a placement, he is able to settle and finish the work set.” 
I asked Zuhair’s mother to list the behaviors that most concern her. She was
encouraged to “accept others like making noises or climbing as part of my son’s
development as long as it is safe.”

Now, when Zuhair’s fights, kicks others or takes risks like running into the road he is
given “time-out” which isolates him for a short time and allows him and his parents or
teacher to calm down. To reduce aggression and impulsivity, Zuhair is taught by his
parents to respond verbally rather than physically and channel energy into activities
such as sports or energetic percussion playing. Over time, Zuhair’s parents have
become skilled at picking their battles. Home is more harmonious. They fenced their
garden, fitted a childproof gate and cut some branches off a tree preventing him
climbing it. His parents are concerned about Zuhair’s use of bad language. They have
been supported to allow verbal responses as a short-term interim. Whilst these might be
unacceptable in other children, they are preferable to physical aggression.

Performing additional research through the use of Zuhair’s school records yielded some
more, helpful data. As soon as he entered primary school, his teachers began to show
their frustration. From kindergarten until the current grade, Zuhair's prior instructors and
other subject tutors, particularly mathematics lecturers, have complained about his
inattentiveness, impulsiveness, and inability to remain seated. His classroom adviser
before opted to provide him a statement of special educational need as a result of his
violent outbursts, and he now works well with a classroom assistant. The instructor has
relocated him to the front of the classroom, where she can keep a close watch on him,
and assigned him one job at a time. For example, whenever a paper is needed to be
passed on to the principal’s office, his adviser would give him the responsibility in order
to avoid long periods of sitting in class. "Due to the presence of an attendant, his
behavior has stabilized considerably this year but it requires further improvement." His
adviser observed, "His difficulties appear to worsen when he is without his assistant."

Background Information
Zuhair is the youngest child in the family, he has a 13-year-old brother and 15-year-old
sister. During pregnancy, the boy’s mother said that “I was diagnosed as pregnancy
induced hypertension after 15 weeks of gestation. Due to preeclampsia, an emergency
caesarean section was done before the due date (i.e. in 36 weeks of gestation).” Boy’s
birth weight was very low (i.e. 1.2 Kg) and was really difficult to handle since early
childhood and needed “repeat instructions over and over ''. He was breast-fed for up to
three years. His first eye contact, smile, relation sign had appeared within the first two
months after birth. He began to sit at the age of 6 months, started crawling at the age of
7 months, stood up at the age of 11 months and walked at 13 months. 

From when Zuhair was 3 years of age, his parents became increasingly aware of his
hyperactivity, impulsivity, and inability to follow directions. As the boy was quite active,
was sent to school earlier than other children the same age. At school, from the very
beginning, he had poor relationships with his classmates and teachers, and had an
average rather below average level of performance. He couldn’t follow the steps to
complete the tasks and performance got worse each year. 

During the session, I learned that Zuhair constantly craves eggs and would eat them 1-2
times a day. He also craved ice-cold popsicles. He would chew the icy popsicles one
after another and if his mother gave him an endless supply, he would eat them all day
long. At night it was very difficult to get him to go to sleep because he would be wide-
awake and want to play until at least 1am, which was exhausting for his mother. When
he finally fell asleep, he would kick off his covers and tear off all his clothes because he
would get hot. He didn’t like to wear shoes around the house because he liked his bare
feet on the cold tile. At the time of his initial visit, he did not perspire abnormally. He was
afraid of the dark so he had to sleep with a night-light on. In the dark he had a fear that
there were ghosts under his bed and that he could see their shadow on the wall. In
general, he preferred to be out in the open air. Zuhair’s mother was beside herself. Her
other children all had normal temperaments and she didn’t know what had gone wrong
with Zuhair. His parents decided to send him to the local hospital for an evaluation. The
hospital kept him and involved Zuhair in its early childhood intervention program. He
made some progress, but his progress was hampered by their financial problems, “we
couldn't provide for his needs at that time because my husband and I were unemployed
and we only relied on the help of my parents.”
Zuhair also happened to have an eyesight problem. In their family, both his mother and
father wear corrective lenses. His mother suffers from myopia (nearsightedness) while his
father suffers from hyperopia (farsightedness). By the age of four, they noticed that
Zuhair was struggling to see things that were far away. They brought him to the optical
clinic and he was diagnosed with myopia, same with her mother. From then on, the
doctor advised him to wear corrective glasses which he found uncomfortable at first. It
could also be the reason why he easily gets bored at school because he can’t clearly
see the things written on the blackboard. 

The family history suggested that his father also had symptoms of inattention and
hyperactivity-impulsivity. His mother said that “Zuhair’s father was said to have been a
‘lively’ child, then a ‘bright underachiever’ who occasionally fell foul of the law.” 

Assessment and Evaluation

Zuhair was assessed with an unstructured diagnostic interview, an examination of
his school and hospital records, and previous reports. I worked closely with Zuhair's
tutor at home on this case to know how he performs during their class hours. I also
decided to continue questioning Zuhair's mother. I continued to question Zuhair further in
order to try to make an accurate diagnosis. Through these means, I learned a lot of
additional, important information about Zuhair. 

I asked Zuhair about his experiences at school before the pandemic, which was two
years ago. "The kids pick on me because I wear glasses and I talk loud. They pick on me
because I can’t answer whenever the teacher asks me. So I hit them as a response. They
don't pick on me after that.” I also asked him about how he acts in class. "I am a good boy
in class. But if a kid picks on me I fight back regardless of the consequences. Recently, I
saw a big kid picking on me while my mother and I were buying food for dinner, so I went to
him and hit him with force on the face using my shirt, which I removed, because he’s tall
and I can’t reach him. I just don’t have patience when other kids are picking on me.”  I also
interviewed his previous teachers through online calls, who reported similar incidents.
Zuhair was getting into many fights at school, especially during recess and school yard. He
would indeed hit kids, even if it seemed like they were not picking on him. I returned to the
issue of him not paying attention in class. "Well, anything about school is kind of hard for me
sometimes. I don't like it much, but it's hard to get what the teachers say, you know?." I then
asked specifically which subjects he likes and dislikes. "Well, I hate all of them, to tell you
the truth, especially mathematics. I don’t get how numbers work, really.” While our
questions were going on, Zuhair was often out of his seat and was pacing around the room
where we did our interview, looking at books and trying to open the cabinet drawers. I asked
Zuhair if she had a tendency to lose things. “Happens all the time. I tend to forget where I
put my money and I can’t help but to accuse my siblings for stealing, even if I'm not sure
about it.” 

We then spoke briefly with Jackie's mother. We asked Jackie's mother about her behavior
issues. "Well, I get called into school all the time. His teachers are fed up with her attitude.
I’m trying to discipline him but he would rather shout at me." We were curious now so we
asked Zuhair’s mother to clarify his remarks. "Well, Zuhair was always a bit of a problem
and, as you know, her behavior has gotten a lot worse lately. His grades have fallen as per
according to her tutor at home, and my husband and I are concerned that his behavior is
getting too extreme. We're worried that he'll be thrown out of school once the face-to-face
class happens because she's become so disruptive. He rarely completes his homework and
often comes to class unprepared before. He's always losing things or forgetting them.” I also
asked his tutor regarding his performance, “He’s very inattentive during our session. He
rarely listens to what I’m discussing and would sometimes attempt to talk about things that
aren’t inclined with our lesson. He gets easily distracted by trivial things.” Her tutor also
revealed “he can’t sit still in his position; he paces around the room while our class is going
on.”

I continued to examine Zuhair’s medical history. He was diagnosed as being nearsighted

along with having astigmatism. Up to this day, his eyes still need the aid of corrective
lenses. This condition may have impacted development.”

Additionally, his mother stated, "When he was younger, his class adviser thought a visit to
the GP might be a good idea. He was referred to me for an assessment. After a careful
assessment, which included collecting information from school, questionnaires and
observations of Zuhair, a diagnosis of ADHD was made. That was not quite surprising as
his father has a history of ADHD, so it could be that inherited it from him. Following a
discussion of the treatment options, however, my husband and I decided that we did not
want any medication.” The family doesn’t want to try a pharmaceutical, a psychological
intervention alone is offered but drug treatment has more benefits and is superior to
other treatments for children with severe ADHD.

At this point, I felt like I had enough information to make a preliminary diagnosis for Zuhair.
Preliminary diagnosis: 
Attention-Deficit/Hyperactivity Disorder,
Predominantly Hyperactive-Impulsive Type