James (not his true name) was referred to me some 10 years ago, aged seven, in his grade two year. He is the middle child of three, from an intact nuclear family.
His teacher was concerned about his poor concentration in the classroom, to the extent that he was missing out on important learning. She further reported that he was very easily distracted in class and would often not follow through on instructions. His planning and organisational skills were very poor and he would often make careless mistakes. He was also highly impulsive at school, and was as a consequence involved in frequent altercations with his peers. His grade one teacher had described him as a ‘vibrant child,’ who often seemed to ‘bounce off the walls.’ James’ parents reported similar difficulties at home, that he would often lash out impulsively at his older sister. There were frequent, fairly volatile altercations with his father, who himself recalled similar difficulties at school, describing himself as the ‘class clown’ in his formative years.
An educational assessment undertaken earlier had revealed above average intelligence, but a marked discrepancy between his scores, with his verbal ability much stronger than his non-verbal functioning. He was in occupational therapy at the time I saw him.
James presented as an endearing, extroverted boy. He was very talkative and spontaneous, constantly interrupting my conversation with his parents. He was restless and fidgety throughout the assessment. When I questioned him about his school experience, it was clear that he was aware of his concentration difficulties, and did not enjoy his school day. He reported being frequently reprimanded by his teacher.
I made the diagnosis of Attention Deficit Hyperactivity Disorder (combined subtype) in view of the characteristic symptoms of inattentiveness, hyperactivity and impulsivity, of sufficient duration, and causing significant impairment in school and at home. I was concerned that James’ symptoms were causing him to become demoralised and to affect his attitude to school.
I started James on a trial of methylphenidate (Ritalin), increasing to 10mg at breakfast, followed by 5mg at 11.30am. The response was very positive, with favourable comments from his school teacher. His school work was much better, in particular his handwriting, and his peer interactions were significantly improved. He started to win awards at school and it was clear to all that he was now enjoying his school day. His parents initially preferred not to use the medication over weekends and holidays, and family interactions remained problematic. Apart from stomach cramps initially, he experienced no side-effects.
James continued to do well on this medication, and by the middle of the following year he had discontinued occupational therapy. Grade four was also a positive year, but in James’ grade five year a family member passed away in a freak accident. This precipitated a crisis in the family and James became depressed and anxious, to the point that he was school refusing. He started seeing a psychologist and I added citalopram (Cipramil) to his treatment, increasing to 10mg daily. James responded well to the combination of therapy and medication, although there were some concerns that the Cipramil might have aggravated his impulsivity to some extent. Within six months the antidepressant was discontinued and he has not had another depressive relapse. In James’ grade six year he started taking his medication on weekends and holidays, with an almost immediate consequent improvement in family interactions, especially in his relationship with his father.
By the time James entered high school, it became increasingly difficult for him to take his top-up dosage of Ritalin, for mainly logistical reasons. I therefore switched him to oros methlyphenidate (Concerta), increasing to 54mg daily. James and his parents expressed satisfaction with the simplicity of this arrangement, and the improved carryover into the afternoons.
James is now in grade 11, his penultimate year of school. I have had to periodically increase his dosage of Concerta to the current 90mg daily, but he continues to tolerate this medication well. He is making excellent progress academically, scoring on average 80% for (core) Mathematics. He is well-liked socially and, in the main, experiences warm, healthy relationships with his parents and siblings.
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