Patient evaluation on intake

Nine-year-old presents with his parents who note that they are having a hard time managing him at home and at school

He is “not like their other kids”

Psychiatric history

At age six, they noticed increasing anxiety regarding things such as attending school, death, dying, and incurring illnesses

He would often walk in circles and flap both arms intermittently throughout the day in response

• – This increases as his anxiety escalates

• – He is “thinking about things” and is restless

• – Thoughts may be positive, have a fantasy component, or be daydream-like while walking

• – Denies having negative, hostile thoughts

• – Does not feel controlled, like he is being forced or told to do this

• – Does not have hallucinations or delusions

• – Walking in circles does not seem to foster a reduction in anxiety and does not seem repetitive enough where he loses hours of productivity

• – He has no other stereotypic movement or functional fixedness issues

• – He does have tactile sensitivity with certain food textures and does not like to be hugged or touched, but is amicable and affable

• – He does not appear to be rigid or oppositional

Around this age, he developed greater inattention, inability to focus, hyperactivity, and impulsivity, which have gradually escalated over the last two years

• – These symptoms now interfere with schooling and have caused him to be held back to repeat one grade

He is a gregarious child who has friends and sustains reciprocal friendships and relationships

There is no evidence of combativeness or violent behavior

Walking in circles occurs at home only now as he is able to control this at school. However, his inattentive and hyperactive symptoms continue and are apparent at home, school, soccer, at the mall, etc., and are pervasive

Recently, the patient is more aware that he is impaired and not moving through school at the same rate as other children

He now finds things to be “difficult,” “boring,” problematic, and his self-esteem is suffering

• – At times he is sad, but there is no evidence of MDD, psychotic disorder, or bipolar disorder

Social and personal history

Patient is a third grader

Parents are married and he has three younger siblings

He likes some sports, reads a lot, and plays video games

He was born by normal delivery and reached usual developmental milestones

Medical history

There are no acute medical problems

Used to be roughly at the 50th percentile for height and weight, but since medications were issued by his pediatrician one year ago, he has dropped gradually toward the 10th percentile

The pediatrician is not currently concerned as the family has shorter stature and feels the patient has not lost significant enough weight or “fallen off the growth curve”

There is no personal, nor any family medical history of cardiac issues

The patient does not have any tics or other abnormal involuntary movements

Family history

Mother may suffer from GAD

There is no clear family history of ADHD, intellectual or developmental disorders

Medication history

Started an SSRI, fluoxetine (Prozac), 20 mg/d given by his pediatrician one year ago for the anxious symptoms

• – This has been moderately effective

• – Dose was lowered to 10mg/d two months ago as he developed enuresis, anorexia, and weight loss

Started lisdexamfetamine (Vyvanse) 20mg/d three months ago in addition to the SSRI

• – Tolerating this well, but with minimal additional effectiveness

• – Previously, D-methylphenidate-XR (Focalin-XR) 10–20mg/d caused him to become sad and emotionally labile

• – Methylphenidate transdermal (Daytrana) patch caused heart palpitations and increasing anxiety at 20 mg/d, and was discontinued

• – The parents do not attribute his anorexia and gradual weight loss to these stimulant trials as this began earlier with the SSRI monotherapy