CASE HISTORY
The 5-year-and 6-month-old boy was first referred to our outpatient clinic with complaints of being too stagnant compared to their peers, not looking at someone when his name was called, slow-moving, absent-mindedness, fear of darkness, and not being able to go to the toilet alone. It was learned that there had been a neurological application for him before and that there were no findings in favor of epilepsy in the electroencephalography (EEG) examination. In order to investigate autism spectrum disorder (ASD), he was observed by a pedagogue in a playroom observation. However, no additional clinical findings related to ASD were observed. After his adaptation to the primary school, he learned to read and write without any delay, and his academic achievement was at the level of the class average. When he was seven years old, he filled the Children Depression Inventory (CDI) (9, 10) in order to be examined for the presence of depression. He got 4 points from this scale (the cut-off point is 19). Clinical psychiatric examination of the case revealed that there were not enough signs of attention deficit that would affect his daily functionality, and also there were no signs of hyperactivity and impulsivity. The observation reports of his teacher stated that he used to move very slowly, look at something at a long time with empty eyes, daydream, but academically did not have problems in his lessons. During this period, the case was followed by a treatment strategy plan including behavioral interventions without medication.
When he was 7-years and 4-months old, he received 30 points from the Barkley Child Attention Survey (Barkley SCT Screening Scale - BCAS) filled by the parents. The BCAS score filled by the teacher was 27. He got 6 points from parent-rated 4 SCT-scanning items (SCT-CBCL) of Child Behavior Check List (CBCL) (12, 13), and 5 points from teacher-rated 4 SCT-scanning items (SCT-TRF) of Teacher’s Report Form (TRF) (13, 14). A semi-structured interview to identify comorbidities that may accompany his psychopathology, Schedule for Affective Disorders and Schizophrenia for School-Age Children -Present and Lifetime Version (K-SADS-PL) (15, 16) was applied to the case and the parents. According to the K-SADS-PL, subthreshold inattentive symptoms not meeting ADHD diagnostic criteria were detected. Inattention scores of parent and teacher-rated DSM-IV Based Screening and Evaluation Scale for Disruptive Behavioral Disorders (ADHD Rating Scale – IV, ADHD-RS-IV) (17, 18) were 14 and 7 points, whereas hyperactivity/impulsivity scores were 1 and 0, respectively. The Weschler Intelligence Scale for Children - Revised Version (WISC-R) (19, 20) was applied to evaluate the intelligence capacity of the case. According to the test, it was established that he had normal intelligence capacity with a verbal Intelligence Quotient (IQ) score of 88, a performance IQ score of 128, and a total IQ score of 108. In order to treat his subthreshold ADHD symptoms, Immediate Release Methylphenidate was started at a dose of 10 mg/day. After two months, it was determined that the case benefited from the drug in terms of moderate attention problems, but the SCT symptoms did not diminish. The dose of methylphenidate was increased to 15 mg/day. Within the next 6 months, SCT symptoms, such as daydreaming, staring with empty eyes and slow-moving remained at similar severity. Within this particular process, the dose of methylphenidate was increased up to 30 mg/day. During this period, parent-rated and teacher-rated BCAS scores were 26 and 25 points, respectively. He got 4 points from parent-rated SCT-CBCL scale and 6 points from teacher-rated SCT-TRF scale. After 27 months of methylphenidate use, although the moderate inattentive symptoms almost completely declined, clinical psychiatric examinations determined that this treatment could not be sufficiently effective on SCT symptoms. Indeed, reports from the teacher and parents confirmed this condition. The pharmacotherapy table and the graphs regarding the scores obtained from the scales are shown in Figure – 1.
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Figure – 1: Graphs of the patient’s pharmacological treatment history and scores from scales
Figure legend: ADHD-RS-IV: DSM-IV Based Screening and Evaluation Scale for Disruptive Behavior Disorders (IN: Inattention subscale (scoring between 0 and 27 points), HI: Hyperactivity/impulsivity subscale (scoring between 0 and 27 points), BCAS: Barkley Child Attention Survey (scoring between 12 and 48 points), SCT-CBCL: SCT-related 4 items of the Child Behavior Check List (scoring between 0 and 8 points), SCT-TRF: SCT-related 4 items of Teacher’s Report Form (scoring between 0 and 8 points).
When the patient was 9-years and 7-months old, methylphenidate treatment was discontinued and switched to atomoxetine. The starting dose of atomoxetine was 10 mg/day and the drug dosage was increased up to 43 mg/day within 3 months. The dosage of atomoxetine was fixed at a dose of 43 mg/day and followed for two months at this dose. The family and the patient reported that he had a headache and dizziness as side effects. For this reason, the dose of atomoxetine was slightly reduced to 36 mg/day. After two months of using the drug at this dose, headaches disappeared, and dizziness complaints decreased significantly. He used atomoxetine for 7 months in total. Clinical examinations and the observation notes obtained from the teacher and his family indicated that there was a more significant improvement in SCT symptoms compared to the period when methylphenidate was used. It was determined that moderate inattention problems almost disappeared, and there were noticeable improvements in SCT symptoms such as absent-mindedness, long reaction time when his name was called, and staring with blank eyes. The BCAS scores filled by the family and the teacher decreased to 20 points and 16 points, respectively. Eventually, parent-rated SCT-CBCL scale score was 0, and teacher-rated SCT-TRF scale score was 1 point (Figure – 1). K-SADS-PL was re-administered approximately 3 years after the first practice. No additional diagnostic comorbidity was detected, except subthreshold inattentive symptoms. The case and his parents were informed of the case study and written inform consents were obtained from them. This case study was approved by Ethical Committee of Medical Researches of Ege University (decision no: 20-2T/7).