CASE: Tony is an 11-year old boy in the fifth grade whose mother describes him as “really a good kid who is bright and tries to be friendly. But he's always doing things that get him in trouble at school and sometimes at home.” Tony was diagnosed with ADHD (combined type) 2 years ago. Stimulant therapy improved his attention and concentration during school, decreased hyperactivity in the classroom and improved educational achievements. However, Tony is oppositional and disruptive on the playground, during team sports and at home. His teacher observed that he wants to fit in, but he quickly gets in arguments with other children. He has difficulty sustaining friendships because he typically annoys others with unreasonable demands. He often has temper tantrums when things do not go his way; the tantrums are not prolonged but frequent. At home, on several occasions Tony hit his younger sister, and he once threw a dinner plate against the wall during a family meal. Although his mother describes these behaviors as present for many years, they seem to be escalating. Tony lives with both parents and his younger sister. There is no history of marital discord or major life event change in the past year. Standardized achievement tests demonstrate average to above average achievement scores. He continues to get mostly B grades and an occasional C. Tony's parents have tried to limit television time as a punishment for disruptive behaviors without any apparent effect. His mother reports that she yelled at him on several occasions when he refused to carry out household chores. “He gets angry at the simplest request for help.” After meeting with Tony and his mother and completing a normal physical examination, the pediatrician referred Tony to a child psychologist for behavioral therapy.
Ann Garland, PhD, Professor of Psychiatry, University of California San Diego.
Marilyn Augustyn, MD, Associate Professor, Boston University School of Medicine.
Martin T. Stein, MD, Professor of Pediatrics, University of California San Diego.
The case summary for the Challenging Case was posted on the Developmental & Behavioral Pediatrics web site. Comments were solicited.