CASE NO.
Identifying Information
John, a 10-year-old boy, lives with his parents, an older sister, and a younger brother.
History of Present Illness
John’s behaviors of concern have been present since early childhood. He is easily distracted,
fidgety, always out of his seat, and unable to wait his turn. The compulsive and rigid behaviors
that he has exhibited since he was much younger have become more pronounced. He does not
do well if there are changes in his routine. He becomes upset if his mother does not always drive
the same route, and he flies into a rage if she changes their afternoon schedule. John’s early
preoccupation with cars has intensified. At school he responds angrily if rules are not followed
exactly as he thinks they should be.
John’s parents feel that his play behavior has always been unusual. He is more interested in
taking toys apart than engaging in pretend play. John makes no effort to interact with children in
the neighborhood and does not know how to respond when they approach him. He struggles to
share and take turns at school. His teacher and the principal view his behavior as oppositional.
His parents, however, suspect that he has difficulty understanding the give-and-take in
relationships.
Past Psychiatric History
John’s parents had vague concerns during his first year because it was difficult to get him to smile
back at them. Also, he did not look at them when babbling during his first year and continues to
have poor eye contact. He never pointed to things of interest and from early on has had a limited
range of facial expressions. His parents note that from the time he was a toddler, he seemed less
emotionally expressive and “harder to read” than his siblings. As a preschooler he did not enjoy
playing dress-up or other imaginative games. He did not seek his parents’ praise when he made
elaborate constructions with his Lego blocks. He displayed no empathy toward children who may
have injured themselves while playing or who were emotionally upset, and he made no efforts to
comfort them.
When he entered kindergarten at age 5, John behaved aggressively toward classmates when
they invaded his physical space. He appeared not to understand how to engage with other
children in conversation or in play. He did not participate in group games such as hide-and-seek
and did not join in when the other children were pretending to be superheroes. At recess he
usually went off by himself. As John progressed through the early elementary grades, his behavior
problems worsened. He was frequently suspended from school because he would become
agitated and aggressive, especially in loud and overstimulating settings such as the playground
at recess.
Medical History
Over the years, John’s parents obtained several evaluations for him, including psychoeducational
testing. A psychiatrist prescribed several trials of medications, including clonidine, stimulants, and
paroxetine. None were effective, and each caused unpleasant side effects.
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A neurologist evaluated John at age 6 because his parents reported that he periodically
“spaced out.” The results of the electroencephalogram and hearing and vision tests were normal.
The neurologist noted motor clumsiness, difficulty holding a pencil correctly, and poor handwriting.
Developmental History
John was the product of a normal, full-term pregnancy and uncomplicated delivery. No problems
were noted during his early infancy. He walked at age 12 months and began using single words
between 24 and 28 months. He rapidly progressed from using single words to using complex
sentences. Although grammatically correct, his speech had a stilted and pedantic quality. He often
greeted other people by asking them what make and model cars they owned and then reeled off
a list of facts about them. His parents often had to prompt him to respond to others’ comments
and to look at them while speaking.
Finding adequate educational services for John has been difficult. On numerous
psychoeducational assessments, his IQ has been in the average range with superior to gifted
abilities in information and block design. Despite John’s high cognitive abilities, he was withdrawn
from a regular classroom because of his behavior problems, including inattention and impulsivity,
and placed in an alternative program for children with severe behavior disturbances. He was lost
in this program and was easily targeted for teasing by his more
socially competent classmates.
Social History
John’s parents are college-educated professionals. There are no significant family stressors and
no history of abuse or neglect.
Family History
A second-degree relative on the paternal side has ADHD. No other psychiatric or learning
problems are present in either parent or the extended family.
Mental Status Examination
John was an appropriately dressed, attractive 10-year-old boy. He appeared restless, fidgeting
in his seat. He was not interested in answering questions and instead asked the interviewer what
type of car she drove. Once she responded, he immediately listed all of her vehicle’s design
features and commended her on her choice. When John talked about the technicalities of cars,
his eye contact improved and his tone of voice became more expressive.
Otherwise, it was difficult to engage John in conversation. He acknowledged that he did not have
many friends but could not explain why this was so. Given his limited range of facial expressions
and inability to describe his feelings, it was difficult to assess the quality of John’s mood. He
denied ever wanting to hurt himself, and his mother never observed him losing interest in favorite
activities. Sleep and appetite were normal. John denied hearing voices or seeing things that were
not present, and his mother never observed him responding to internal stimuli.
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