Juan, a 9-year-old Latino male, was referred to a community clinic by his third-grade teacher for evaluation of classroom behavior problems. He is an only child and lives with both parents. At home, Juan speaks Spanish with his parents although he occasionally speaks English with his father. His father came to the U.S. from Mexico as a small child and completed the 12thgrade in the U.S. Juan's mother completed 8th grade in Mexico and immigrated to the U.S. as a teenager.
Juan's mother reported that he has had no significant medical problems. Her report of his behavior included an inability to focus on tasks at hand and easy distractibility. She was concerned that the principal of the school mentioned that Juan may be asked to repeat the 3rd grade or change schools. In the clinic, Juan sat quietly but appeared to be daydreaming and attentive to the conversation.
The pediatrician called the principal who expressed frustration with Juan's behavior. In class, he was very fidgety, did not pay attention and usually did not answer questions.
He also bothered other students when they were working. The principal explained that because Juan's school was a Spanish language immersion school, there were no special education services available. If a student at the school required special education services, he or she would be transferred to another school in the same school district.
An evaluation for an Individualized Education Plan (IEP) indicated that Juan had above average cognitive ability (90th percentile), with superior ability to problem solve and process information simultaneously (99th percentile). The Woodcock Johnson III (Spanish version) indicated average achievement in academic skills, with low average in reading fluency, comprehension and spelling. On the Test of Auditory-Perceptual Skills, Juan tested generally low average in all domains, and was at the 14 percentile for both auditory number and auditory word memory. On the Test of Visual-Perceptual Skills, Juan scored above the 92nd percentile. Juan did not qualify for special education services on the basis on the standardized tests. However, because of the individual attention required by Juan, a transfer to another school was considered inevitable if his classroom behaviors did not improve.
Juan's mother and teacher filled-out the NICHQ Vanderbilt Assessment Scale. Their responses were consistent with the diagnosis of ADHD, inattentive type. In discussion of treatment options with the family, the possibility of stimulant medication use was raised. Juan's mother was opposed to the medication because of what she had heard from her friends—that these medications had bad side effects and did not work most of the time. Juan's father, however, was in favor of the medication because it might assist Juan to stay at the school. After several clinical visits that included further information about ADHD, behavioral treatment, and reviewing information from the school, Juan's parents agreed to a trial of medication.
Juan was evaluated for a follow-up visit 2 weeks after starting fourth grade; he had been taking a stimulant medication for one month. He seemed much happier about school and was proud to report that he has completed all of his assignments in school as well as homework assignments, and he did well on a math quiz. Juan's mother was also pleased with his progress.
The pediatrician called the principal, who reported that Juan was an entirely different student. He now sat at his desk and wrote down the assignments. He seemed eager to learn and able to be attentive in the classroom. The principal was amazed at the difference.
George J. DuPaul, PhD, Professor of School Psychology, Associate Chair, Education and Human Services, Lehigh University Bethlehem, PA.
Victor H. Pérez, MD, MPH, Assistant Clinical Professor, Center for Healthier Children, Families, and Communities, Department of Pediatrics, University of California Los Angeles, Los Angeles, California.
Alice Kuo, MD, PhD, Director, Community Health and Advocacy Training Program, Assistant Professor in Pediatrics and Internal Medicine, Center for Healthier Children, Families, and Communities, Department of Pediatrics, University of California, Los Angeles, Los Angeles, CA.
Martin T. Stein, MD, Professor of Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, California.
Deborah Sedberry, MD, Walnut Creek, California, Developmental-Behavioral Pediatrics.
The case summary for the Challenging Case was posted on the Developmental and Behavioral Pediatrics web site http://www.dbpeds.org.list. Comments were solicited.