Case of the month: 

Childhood ADD worsened by stimulants

A 10 year-old male is brought by his mother for consultation. He has been treated with Focalin, Concerta, Adderall, methylphenidate, and Dexedrine. He also has received aripiprazole and olanzapine, added to the above agents. His main problems involved not being able to pay attention in school, and being aggressive and agitated toward other children. In two years of treatment, he had not improved, and was forced to change schools multiple times. At one point, while at a restaurant with his parents, he bolted out the door and tried to run down the street. On other occasions, he tried to open the car door on the highway. His parents were concerned about these impulsive behaviors, which had not improved with multiple amphetamines. 

He was markedly anxious and had marked insomnia, but his family denied increased or a high level of energy. They also denied any observable depressive symptoms such as suicidality or noticeable sadness or anhedonia. He was adopted and biological family history was unknown.  He lived in an intact and loving family with two parents and an older adopted sister, who had no psychiatric problems and was very successful in school and social life. 

He was observed to be very short for his age, and very thin.

On mental status examination, he was polite but played mostly with a video game, answering questions briefly. He was frustrated about his poor social and academic skills and how it harmed his friendships with his peers. He expressed this frustration appropriately and rationally during the interview. He said he wanted to come off his current medications of methylphenidate 60 mg/d and aripiprazole 5 mg/d.  

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