Case Summary

An 8-year-old boy is repeatedly in trouble at school with a reported incidence of verbal and
physical aggression toward his teacher. The school has identified problems with concentration
and has informed the parents and encouraged them to seek help. The child has been referred to
the school psychologist. Although the child wriggles in his seat, the mother indicates that he is
able to concentrate when playing on his computer. Overall, she is concerned that he is impulsive
and does not think before he acts which could cause great harm.
Diagnostic and Statistical Manual of Mental Disorders
The 2022 Diagnostic and Statistical Manual of Mental Disorders 5th edition text revised (DSM
5 TR) criteria for attention deficit hyperactivity disorder (ADHD) coded as F90.0 included a
persistent pattern of inattention and/or hyperactivity that interferes with functioning. The key
here is the operator ‘or’ meaning that not all patients may meet all criteria in both attention and
hyperactivity or impulsivity categories but do possess qualities within each which is considered
F90.2 combined type ADHD. A diagnosis of F90.9 unspecified ADHD may be utilized until
further details are reported. For this patient, he exhibits inattention as evidenced by his inability
to concentrate at school and high potential for wandering across street without looking per his
mother. Hyperactivity and impulsivity are demonstrated by his inability to conduct himself in the
classroom and is noted to be wriggling in his seat. His age places him in the time frame where a
diagnosis of ADHD can be made and, as noted before, the symptoms of inattention and
hyperactive-impulsivity occurred in two different situations for him. Clearly the last incident has
provided validation that symptoms are interfering with the quality of his academic and social
functioning. Based on his most recent behavior it would be reasonable to classify his severity in
the moderate to severe level as he is facing suspension. A co-diagnosis for ADHD includes
oppositional defiance disorder and conduct disorder. Oppositional defiance disorder occurs in
almost 50% of children with combined presentations and only about 25% with predominantly
inattentive presentation. Conduct disorder appears in approximately 25% of children and
adolescents (American Psychiatric Association [APA], 2022).
Pharmacological Treatment
While the duration and additional information from the school and teachers is absent from
this case study, the assumption is that behaviors, signs and symptoms have been going on for
more than 6 months per the “repeatedly in trouble at school” remark. Elementary and middle
school-aged children are recommended to be prescribed an US Food and Drug Administration
(FDA) approved medication. A short acting formulation would be recommended so the child
would have an appetite by lunch time as nutrition is important for growth and development.
Methylphenidate, also known as Ritalin, is FDA approved for the treatment of ADHD in children
and is prescribed by weight in children at a rate of 0.3-2 mg/kg/day in divided doses. Available
tablet sizes include 5mg, 10mg, and 20 mg. It also comes in chewable tablets which in a younger
patient improves ease of administration and should be consumed with at least 8 pounces of fluid.
The maximum recommended dose is 60mg/day. Most common side effects include insomnia,
headaches, nervousness, abdominal pain, nausea, vomiting, loss of appetite, weight loss, affect
lability and tics. Methylphenidate works by inhibiting the reuptake of dopamine and
norepinephrine. Metabolism occurs in the liver along the carboxylesterase CES1A1 pathway and
has a half-life of 2 to 4 hours necessitating a second dose for a school age child (Carlat and
Punzatian, 2022). Methylphenidate enhances the actions of dopamine and norepinephrine by
blocking their reuptake in the dorsolateral prefrontal cortex which controls attention,
concentration, executive function and wakefulness. The response on dopamine is also noted in
the basal ganglia and can improve hyperactivity. In the medial prefrontal cortex and
hypothalamus, dopamine and norepinephrine may improve symptoms of fatigue, drowsiness and
even depression. Effects can be seen as soon as within the first dose. Children should be
monitored periodically for height and weight. More serious side effects include priapism,
psychotic episode, seizures, rarely neuroleptic malignant syndrome, rare activation of
hypomania, mania or suicidal ideation and adverse cardiac complications including sudden
death. (Stahl, 2021; Epocrates, 2024). While there are non-stimulant choices for the management
of ADHD, the discussion of short term and long-term goals are important points to cover as the
child ages there may be a need to change the regimen. A stimulant was chosen for this patient for
a few reasons. First is the level of outburst indicating significant change needing to occur now.
Second, the child is young and at this point considered a lower risk for diversion than an
adolescent. Parent preference, after education on option choices, will also be included in the
choice of medication. Stimulant medication use is reported as a grade A recommendation,
strongly recommended, for elementary aged children as published in the American Academy of
Pediatrics clinical practice guidelines for the treatment of ADHD in children and adolescents
(Wolraich et al., 2019)
Non-Pharmacological Treatment
Developing an individualized education plan (IEP) and behavioral classroom interventions
are cornerstones of an ADHD treatment plan in the school system. The parent and school should
also discuss if the child is placed appropriately in school grade which is an uncomfortable topic
but important to ensure the best possible outcome academically and can reduce stress on the
child when not successful in current grade. The child should continue with the school
psychologist as indicated. Additionally, the parent should encourage routine physical exercise,
proper nutrition and sleep. Parents and patients can benefit from education and training in
regards to managing ADHD behaviors and reactions to behaviors (Graydanus and Patel, 2022).
Treatment Appropriateness
While good old-fashioned exercise and eat right may seem like common sense, assessing for
social service assistance or public assistance programs should not be overlooked. Gauging the
parent level of involvement and the child’s typical day of school time, after school time and
home time can also affect medication schedules, dietary choices, and activity choices. The child
would benefit from having his school day structured around when his medication is peaking as
well as when a school nurse is able to distribute his second dose if needed. Generic immediate
release methylphenidate 5mg twice daily dosing is approximately $17 to $23 for a 30-day supply
and 10mg twice daily dosing runs the same across all local pharmacies such as Publix,
Walgreens and CVS (GoodRx, 2024). Follow up with the prescriber will initially be more
frequent until stable and then follow a more routine schedule for refilling medications and could
be performed via telemedicine.
Conclusion
A thorough medical and observational history is useful in determining ADHD type which will
also help to develop treatment strategies. It is not uncommon for ADHD pediatric patients to
have a comorbid diagnosis of oppositional defiant disorder or conduct disorder. The patient’s
love of computers can also be a potential peril and pitfall as he is at higher risk for internet
gaming issues as he ages (Graydanus and Patel, 2022).

References
American Psychiatric Association. (2022). Neurocognitive disorders. In Diagnostic and
statistical manual of mental disorders (5th ed., text rev.).
https://doi.org/10.1176/appi.books.9780890425787Links to an external site.
Carlat, D., & Puzantian, T. (2022). Medication fact book for psychiatric practice (6th ed.).
Carlat Publishing.
Epocrates. (2024). Methylphenidate in Epocrates medical references (Version 24.1.0) [Mobile
app]. Apple store. https://www.epocrates.comLinks to an external site.
GoodRx. (2024). Methylphenidate. Retrieved February 19, 2024,
from https://www.goodrx.comLinks to an external site.
Greydanus, D. E., & Patel, D. R. (2022). Attention-deficit/hyperactivity disorder. International
Journal of Child Health & Human Development,
15(4), 299–342.
Stahl, S.M. (2021). Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge
University Press.
Wolraich, M. L., Hagan, J. F., Jr, Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W.,
Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R.,
Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W.,
& subcommittee on children and adolescents with
attention-deficit/hyperactivity disorder (2019). Clinical practice guideline for the diagnosis,
evaluation, and treatment of attention-
deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4),
e20192528. https://doi.org/10.1542/peds.2019-2528Links to an external site.