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.
(Insert Figure – 1 about here)
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).