The case of a child with Attention Deficit Hyperactivity Disorder,

a Case Study

By

Dr. Rodrigo V. Lopiga, CCOP, RPSY

and Ruby Ann A. Cabrera

Abstract

A child diagnosed with Attention Deficit Hyperactivity Disorder was evaluated using
psychometric and projective tests. He also underwent clinical interview, mental status
examination, and behavioral observation. It was revealed that there were many areas of
functioning that should be addressed that may need in-house rehabilitation because of his
uncontrollable behavior. Recommendations were suggested at the end of this report

Keywords: ADHD, Bipolar, Computer gaming addiction, child rehabilitation, case management

Introduction

Attention deficit hyperactivity disorder (ADHD) is a childhood-onset neuro

developmental condition with impairing symptoms of inattention, impulsivity, and hyperactivity.
It also often co-occurs with other conditions like mood, anxiety, conduct, learning, and substance
use disorders (Faraone & Larsson, 2019). ADHD is one of the most prevalent childhood
disorders with a worldwide prevalence of around 7% with problems persisting into until
adulthood and it is associated with poor academic and social outcomes (Thomas et al., 2015 as
cited by Rubia, 2018). In this study, the patient has been diagnosed with ADHD.
The client was admitted in a rehab center on July 20, 2017 due to behavioral problem.
Specifically he had dropped out of school because of being hooked into computer games. He
started stealing money from his family to support his activities. The patient often had arguments
when confronted with his stealing. He ran away from their house several times and the last one
was in April 2017 which lasted for a month. His relationship with his mother and his siblings
were affected because of his behavior. The client was diagnosed to have ADHD in 2016 but
failed to comply with his medication prescribed by his Doctor in Philippine Children’s Medical
Center.

The client was born in January 12, 2003 in Occidental Mindoro. He is youngest of three
children, his mother who has been widowed since 2001 when her husband died due to alcohol
addiction. He has two older sisters, Jas who is a full time housewife and Jan who is working as a
secretary.

The client started schooling at age of 5 as a nursery student. He transferred from one
school to another. He went to 3 schools in high grade school. Since elementary grade, the
patient was observed to be hyperactive and was later on diagnosed to be having Attention-Deficit
Hyperactivity Disorder. He was addicted to computer games which resulted to dropping out
from school when he was in grade 7 in a school in Fairview. The client was enrolled in a SPED
section and all of his grades are passing and was found by his teacher to be having potential to
excel but needs more focus in his studies. He dropped out from school but was supposed to be
grade 8 student.

He was brought to Philippine Children’s Medical Center in June 2017 and according to
the medical abstract the client was diagnosed with Attention-Deficit Hyperactivity Disorder
combined presentation Oppositional Defiant Disorder, to consider Learning Disability (Reading).
The doctor recommends him to be enrolled in regular classes with classroom accommodations
such as having him sit in the front and giving him ample time to finish tasks. However, the
client was hooked into computer games which resulted to frequent stealing money to treat his
friends and pay in computer shop. The client also admitted drinking alcohol since he was 7 years
old. He often drinks in party / celebration where most of the visitors are drinking. According to
him, since his father died no one stops him leaving home and he is longing for someone to guide
him in making decisions. He also shows need for belongingness which he is trying to get from
his peers. His relationship with his family become distant and he often ran away from their
house so his family decided to have him undergo treatment for behavior modification.

He was also diagnosed by attending Psychiatrist to be having a mental condition which is

yet to be determined for symptoms of Bipolar II. He was prescribed to take Risdin 3mg and
Jovia 5mg (antidepressant) to help stabilize his mood. Worldwide, 10-20% of children and
adolescents experience mental disorders. Half of all mental illnesses begin by the age of 14 years
old. If untreated, these conditions severely influence children’s development, their educational
attainments and their potential to live fulfilling and productive lives (WHO, 2014). For this
reason, the researchers are interested to contribute to studies which are focusing on some mental
health disorder that started during childhood stage which is the ADHD.

Attention Deficit Hyperactivity Disorder (ADHD) is a complex neurodevelopmental

disorder that can affect a child’s success at school, and their social relationships. It is generally
diagnosed in children during their teenage years, but the average age for moderate ADHD
diagnosis begins at seven years old (Legg, 2020). ADHD is characterized by developmentally
inappropriate inattentiveness, impulsivity and hyperactivity with consequent impairment in
academic achievement and reduced success in everyday life (Marchand-Krynski, Morin-Moncet,
Belanger, Beauchamp, & Leonard, 2017). ADHD occurs more often in males than in females,
and behaviors can be different in boys and girls. For example, boys may be more hyperactive and
girls may tend to be quietly inattentive (mayoclinic.org, 2019)

Mental health is for everyone, regardless of age, gender, class, race and color. So
children also suffer from it and needed psychological assistance. Some common mental
disorders in children are neurodevelopmental disorders, anxiety disorders, pervasive
development disorders, affective (mood) disorders, eating disorders and disruptive behavior
disorders (Octaviano, 2016). Some children with ADHD also display oppositional behaviors
(under disruptive behavior disorder) at times. Oppositional defiant disorder is defined in the
American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-V) as including persistent symptoms of negativistic, defiant, disobedient, and
hostile behaviors toward authority figures. Children with ADHD can access to behavioral
techniques that can be implemented at home and at school that can deal with symptoms. Mental
health illness is not a choice and it is like any other disease but we can do something to manage
it. Aside from biological and psychological grounds, many environmental factors can also affect
mental health including exposure to violence, severe stress and loss of an important person or
trauma. In this case school, family and community should work together to assist children with
mental disorders. (Ganado & Cerado, 2015).

There are psychologists who contributed a lot in terms of developmental disorders and
the therapy to manage it. Russel Barkley, clinical psychologist in the United States and author of
books related to ADHD, proposed a model of executive functioning theory that is based in self
regulation in 1997 with four elements namely: working memory, management of emotional
responses, internalization of self-directed speech and new behavioral responses to meet a goal.
Also, Barkley’s model of Attention Deficit Disorder suggests that ADHD is linked to
inefficiencies in internalizing sensory input that then lead to deficient motor control as well as a
lack of efficacy in different cognitive capacities that include motor inhibition and the execution
of complex motor sequences requiring flexibility.

According to Barkley (1997), teaching children self-regulation strategies is a way to

improve their inhibitory control and their cognitive flexibility. It also allow children to manage
their emotional responses. These interventions include teaching children executive function-
related skills that provide the steps necessary to implement them during classroom activities and
educating children on how to plan their actions before acting upon them. Families of children
with ADHD must do something about it to help their child with ADHD to have self-regulation,
maintain everyday functioning and continue to have a good life in the future. Emotional
symptoms are common and persistent in youth and adults with ADHD. Although it is also
common in other psychiatric disorders, emotional impulsivity and deficient emotional self‐
regulation may be sufficiently specific for ADHD to function as diagnostic criteria. An
instrument to measure emotional impulsivity and deficient emotional self‐regulation could
improve the accuracy of diagnostic criteria for ADHD. (Faraone, Rostain, Blader, Busch,
Childress, Connor & Newcorn, 2018)

In terms of developmental psychology theories, attachment refers to the strong emotional

connection that develops early in life to keep infants close to their caregivers. This relationship
shapes the child’s social and emotional development and forms the foundation for social
relationships later in life. (Fest & Rosenberg, 2019). John Bowlby (1969) is considered to be
the first attachment theorist, generally defined as a psychologist who considers how early
attachments shape peoples’ lives. According to him, the earliest bonds that form are those
between child and caregiver, and these can leave a lasting impact on the rest of an individual’s
life. Attachment is responsible for improving the chance of survival for a child because it is the
psychological force that keeps a child close to his or her mother. (Kleinman, 2012). Moreover, if
attachment has then interrupted, there will be consequences to the child’s social, intellectual, and
emotional development that might be linked into symptoms of ADHD.
 In view of this theories and literature, some researches and studies have been conducted
that are relevant to the problems and issues in children with ADHD. One study about having
treatment to lessen the symptoms of ADHD was made in 2019 which was about using interactive
avatar that boost the performance of children with ADHD. This study examined both children
with attention deficit hyperactivity disorder (ADHD) and typically developing students in
dynamic measures of intelligence through the use of a virtual avatar. The interactive avatar
improved the performance of groups with ADHD in the dynamic intelligence test, improve the
attention process and, consequently, boosts performance. (Fabio, Capri, Iannizzotto, Nucita &
Mohammadhasani 2019). In case of behavioral therapy, Sprich, Burbridge, Lerner, & Safren
(2015) adapted their CBT for ADHD in adults to be used with ADHD in adolescents. The result
was well tolerated by 3 adolescent clients with ADHD, the participants and their parents reported
symptom improvement in ADHD symptoms following the CBT. A systematic review and meta
analysis of the efficacy of cognitive behavioral therapy for adults with ADHD was also
conducted and it supported that CBT is effective in reducing symptoms of ADHD (Young,
Moghadamm & Tickle, 2016).

The study of Anastopolous, King & Besecker in 2018 examined the extent to which
college students with ADHD continued to benefit from a cognitive-behavioral therapy (CBT)
program beyond the active phase of treatment. A total of 88 college students with well-defined
ADHD received CBT in an open clinical trial format that included active treatment and
maintenance phases delivered across two consecutive semesters. The results were participants
displayed statistically significant reductions in ADHD symptoms, improvements in executive
functioning, and declines in anxiety and depression symptoms. Improvements in symptom
severity, executive functioning, and educational functioning remained stable 5 to 7 months after
active treatment concluded. So the researchers supported the use of CBT interventions for
college students with ADHD.

Another therapy that can be used for children and adult with ADHD is Mindfulness-
Based Cognitive Therapy (MBCT) from Neuro psychotherapeutic perspective. It has been
proposed that mindfulness meditation can help reduce mind wandering and distractibility in
ADHD by improving the functioning. (Bachmann, Lam & Philipsen, 2016). MBCT combines
methods of cognitive behavioral therapy with mindfulness meditation. The treatment aims to
provide the patient with an explanation for his symptoms, as well as information about ADHD.
Behavioral interventions are designed to develop planning skills such as time management or
problem solving. With cognitive methods, patients learn to identify and modify problematic
thinking patterns. According to Bachmann, Lam & Philipsen (2016), MBCT helps to regulate
impaired brain functioning and improve self-regulation of attention and emotion control.

Though play therapy and behavior therapy has been proved to be effective for the
treatment of ADHD, some practitioners have studied the use of different techniques in dealing
with children with ADHD. Sibley, Comer & Gonzalez (2017) investigated parent-teen therapy
for ADHD delivered over a videoconferencing format. Acceptable therapeutic alliance was
reported and adolescent motivation to meet goals and parent strategy implementation was
evident. Families reported high satisfaction, despite minor disturbances with delivering therapy
via videoconferencing. Therapists perceived that videoconferencing enhanced treatment for 50%
of families. Reductions in participant ADHD symptoms and organization, time management, and
planning problems from the beginning to post-treatment were noted by parents and teachers.
However, more studies regarding this should be conducted and try to different places and
situations.

When it comes to parents welfare of children with ADHD, parenting healthy habits in
children with Neuro Developmental Disorder is difficult and is undermined by competing
demands on parenting resources. Effective parenting strategies included setting clear, often
structural boundaries, using positive reinforcement, allowing agency by presenting healthy
choices, and use of role modeling to promote healthy habits. (Bowling, Blaine, Kaur & Davison,
2019)

METHODOLOGY

The researchers used clinical interview, including mental status examination and
behavioral observation, Purdue Non-Language Test (PNLT) to determine the client’s intellectual
functioning, Suicide potential inventory to know the level of suicide potential if any, Sach’s
Sentence Completion Test (SSCT) and Hand test. Clinical interview helps the psychologists
and psychiatrists to have an accurate diagnosis of mental health disorders (Kelly, 2020). It
includes asking about the client’s family and medical history that can be related to illnesses and
current complaints, as well as the nature, severity, and duration of the symptoms that have
experienced by client. Moreover, the mental status examination includes general observations
made during encounter, as well as specific testing based on the needs of the patient and
psychologists. According to Trzepacz & Baker (1993), it is a structured way of observing and
describing a patient's psychological functioning at a given point in time, observation of
appearance, attitude, behavior, mood, and affect, speech, thought process, thought content,
perception, cognition, insight, and judgment.

RESULTS

During clinical interview, the client was quiet but cooperative during the test taking. He
presented himself wearing clean clothes and properly groomed. His present memory, insight and
judgment are good. Client is oriented to time, date and place. Eye contact is also noted from the
client. He was open to sharing his past experiences. He has difficulty understanding the
instructions given especially if it is discussed in English language. The client was enrolled in
SPED during his grade school and claimed to have difficulty with comprehension. He worked in
the test in an average duration after the instructions were explained simpler and in the Filipino
language.

In Purdue Non-Language Test, The client scored 50 which is verbally interpreted as

Average. This means that the client has an abstract ability similar with the majority of the
individuals in his age group. He can identify patterns, logical rules and trends in new data,
interpret information and apply it to solve problems.

Suicide Potential inventory test result was Moderate to High Negative Self-evaluation,
Suicide Ideation and Hostility, and High to Very High Helplessness. Irritable youths were at
risk of suicide and persistent criminal behaviours. Children with ADHD are three times more at
risk of suicidal ideation, suicide plans, and suicide attempts than children without ADHD after
adjusting for the effects of family dysfunction and comorbid psychiatric conditions (Chen, Ho,
Hsiao, Lu & Yen, 2020).

In Sach’s Sentence Completion Test, it was revealed that the patients’ areas of attitudes
were the following: in his Attitude towards mother, he Seek mother’s fault but accepts them and
tolerate their differences. In terms of Guilt Feelings, Has regrets about the past and seems mildly
disturbed. His Attitude towards father was that, he Admires father but wishes their relationship
was closer. His Attitude towards own ability include Feels impartially incompetent and hopeless.
His Attitude towards past was that he Feels that his past mildly affects functioning. His Attitude
towards opposite sex was that the Only criticism is minor and superficial. His Fears include
Expresses lack of overt fears. In terms of his attitude towards family units, he expresses
Instability of family domicile has had little effect in his favourable feelings toward them. In the
area of his Attitude toward heterosexual relationship shows Indication of satisfaction in this area.
In terms if Attitude towards friends and acquaintances, he Express mutual good feeling between
friends and self. For his Attitude toward people supervised, he Feels comfortable and well
accepted by subordinates. In the area of Attitude toward people superior at work and in school,
he Express no conflict with authority figure and Feels accepted by them. His Attitude towards
colleagues at work / school, he express mutual good feeling. In His Attitude towards future, he
feels his future looks good. And finally, his attitude toward Goal, he Feels that goals are
achievable without hindrances.

According to Ganado & Cerado (2015), young learners can have mental, emotional and
behavioral troubles that said to be common sources of stress for children, their families, schools
and community as well. It is estimated that 1 out of 5 children and adolescents may have a
mental health disorder that can be identified for potential treatment. Also, the parent-child
relationship is often draining within the ADHD population. Many parents struggle to find a
balance between managing challenging behavior and fostering positive relationships with their
children (Wallace, 2018)

Result of Hand Test showed that the client is highly pathological which confirms that the
client is in need of clinical treatment. The result showed high psychotic tendencies or not being
in contact with reality (E.G. delusion or hallucination). He also has developed anti-social
tendencies that explains his being defiant to authority, behave is a manner that is not normal for
his age such as running away from home and becoming uncontrollable. His coping strategy is to
withdraw from people to escape negative feelings. This may result to forming his own world in
his mind where he can escape to everytime he feels threatened or stressed that affects his
interpersonal relationship. According to (Sadek, 2018) comorbidity rates of ADHD and
Oppositional Defiant Disorder has been high and some data suggested that ODD occurs in up to
60% of individuals with ADHD.

In summary, the following were the findings in this case study. Difficulty maintaining
adequate interpersonal relationship, the result shows that the client does not have stable
interpersonal relationship. He tends to withdraw or avoid situations or conversations which
make him feel stressed or threatened. This has been manifested in several times that he ran away
from their home and cut his communication with his family. This results to unresolved conflicts
that affect the harmony of relationship between him and his family. There are factors which are
associated with the increase risk of children with conflict with the law. According to Mariano
(2019), in terms of Family‐related factors associated with conduct disorder and juvenile
delinquency include child abuse or neglect, harsh parental discipline, absence of parental
warmth, parental psychopathology, and family disruption.

Problem with Delayed Gratification / Impulsiveness. He tends to act on his thoughts

immediately especially when it focused on pleasure. He has difficulty controlling the urge to do
what makes him feel good or even in delaying thoughts that comes into his mind. He fails to see
the consequences of his actions because of poor impulse control. As what mentioned earlier,
ADHD is characterized by developmentally inappropriate inattentiveness, impulsivity and
hyperactivity with consequent impairment in academic achievement and reduced success in
everyday life (Marchand-Krynski, Morin-Moncet, Belanger, Beauchamp, & Leonard, 2017).

Severe Paranoia. He feels that others are doing things against him or will try to hurt him.
This affects his openness to build new relationship with others.

Inferiority Complex, this suggests that the client has repressed feelings of inadequacy or
inferiority which he tends to compensate by being a perfectionist or being grandiose. He use it to
cope with feelings of inferiority. He is likely to have delusion of grandeur or feeling superior to
other people. This affects his relationship primarily with his family because he becomes the
authority and act more powerful than his mother. Teenage years are the prime years of bearing
the burden of inferiority feelings. Inferiority complex is a kind of psychological obstacle that
occurs usually in puberty and its effects are negative and harmful for self-worth (Jing, 2000 as
cited by Sajjad Kabir & Rashid, 2018).

Aggressive Tendencies, he may behave aggressively especially when he has a hard time
waiting for things he wanted. This may manifest verbally or physically and as a form of
manipulation to get favorable things. No signs of aggression were observed while he is in a
controlled environment.

Discussion
To address his problem with Attention Deficit Hyperactivity Disorder, it was
recommended that the patient undergo further in-house treatment and rehabilitation due to his
unmanageable behavior, for Bipolar 2 disorder, it was recommended that the patient should
undergo psychiatric management and medication, for psychotic tendencies, it was recommended
that the patient undergo further assessment and observation. In addition, for paranoia and
inferiority complex, Rational emotive behavior therapy was recommended. In his problem with
difficulty maintaining adequate interpersonal relationship, family therapy was recommended and
improve his coping skills. Finally for his impulse control problem, aggressive tendencies, and
problem with delaying gratification, it was suggested that during in house rehabilitation, coping
skills should be developed through behavior modification and practice of delaying gratification.
There is a need to study further the patient using a longitudinal study in order to find out the
actual changes that occur in his behavior, cognition and social interaction. A more
comprehensive assessment after treatment may be done in order to prepare the patient for
aftercare program and there is also a need to increase further the patient’s recovery capital.

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