Treatment Process in the Case with SCT
The case was followed without medication for about two years after the
first application. In the following process, the drug treatment began,
and he has been receiving drug treatment for approximately three years.
He had subthreshold ADHD symptoms as well as SCT symptoms. Although the
patient did not fulfill the diagnostic criteria of ADHD accurately, we
did not want to allow his subthreshold ADHD symptoms to remain
untreated. An open-label clinical trial suggests that subthreshold ADHD
symptoms responded positively to six weeks of atomoxetine treatment in
adults demonstrating atypical manifestations or insufficient symptoms of
ADHD (ADHD-Not Otherwise Specified) (27). Between the onset and
discontinuation of methylphenidate treatment, which lasted about 27
months, there was only a small reduction in total SCT scores reported by
the parents and the teacher. It was observed that he continued to
exhibit significant SCT symptomatology and scored above threshold
values. On the flip side, there have been higher rates of improvements
in the signs of moderate attention deficit symptoms of the case. An
up-to-date study suggested there were improvements in the scores of
SCT-Total and SCT-Daydreams both at home and at school after the use of
methylphenidate, and SCT-Sluggish scores were found to have improvements
only at school. The study also claimed that the presence of SCT symptoms
in children with ADHD had negative effects on methylphenidate treatment
in the school area (28). Another study points out that
SCT-sluggish/sleepy appearance symptoms do not respond to
methylphenidate, whereas SCT-daydreaming symptoms are not associated
with methylphenidate nonresponse (7). Similar to this study, our case
had no significant improvement in the signs of slow movement,
absent-mindedness, and sleepy appearance, especially when medicated with
methylphenidate. However, contrary to what was noted in these two
studies, there was no significant improvement in daydreaming symptoms
despite methylphenidate treatment.
Since it was determined that the case did not benefit enough from
methylphenidate in terms of SCT, the medication was switched to
atomoxetine. Using atomoxetine for 7 months, he was found to have higher
acceleration and higher rates of decline in SCT scores based on parents
and teachers. Wietecha’s study is the first study in the literature
showing improvement in SCT with medication. In this double-blind
placebo-controlled study, three groups diagnosed with ”ADHD+Dyslexia”,
”ADHD only” and ”Dyslexia only” were initiated atomoxetine and 16 weeks
of treatment were administered. Significant reductions in both ADHD and
SCT symptoms were detected in all three groups. A positive correlation
was determined between ADHD and SCT symptoms in terms of improvements in
these symptoms with atomoxetine treatment (5). In line with this study,
SCT symptoms of our case have shown improvement with atomoxetine.
Our case report has some strengths and limitations. This is the first
study in the literature investigating the differential diagnosis and
treatment process of a patient with SCT. So far, it has been observed
that either methylphenidate or atomoxetine is used for SCT treatment in
clinical trials, but there is no publication in the literature where
both drugs are involved and compared. From this point of view, our case
report provides the first data in this field by simultaneously observing
and comparing the effects of methylphenidate and atomoxetine together on
SCT symptoms on a case-by-case basis. In addition, the absence of other
comorbidities including threshold ADHD made the results of this case in
the course of treatment clearer and more valuable. The study might help
clinicians to better analyze and develop more appropriate treatment
strategies regarding SCT. Furthermore, in order to confirm SCT
diagnosis, both the parents and the teacher were asked to fill the
scales related to SCT periodically, and these scales have been
supportive of the clinician’s psychiatric examination. In this way,
information related to SCT symptoms of the case could be obtained from
multiple informants. These scales also monitored the pharmacotherapy
process, making it easier to find out the results of treatment
effectiveness.
As for the limitations; the results cannot be generalized for all cases
with SCT since the findings are valid for one case alone. The findings
should be replicated and clinical trials with a higher number of cases
are needed.
In conclusion, both methylphenidate and atomoxetine, which are commonly
used for ADHD, were used for sufficient time in a case, who did not have
any other comorbidity as well as subthreshold ADHD symptoms and whose
SCT symptoms were severely observed. Both drugs have improved the signs
of moderate attention deficits. Although there were no high response
rates to SCT in both drugs, SCT symptoms have decreased much more and
faster in the use of atomoxetine compared to methylphenidate. These
results should be replicated, and randomized controlled trials are
needed with more patients.
Conflict of Interest: ESE is on the advisory board for Sanofi
Turkey. AT declares that there is no conflict of interest.
Data Availability Statement: We have not shared the data from
this study yet.
Author Contributions: A.T. contributed to the processes of
investigation, validation, formal analysis, original draft preparation,
review and editing. E.S.E. contributed to the processes of
conceptualization, methodology, investigation, validation, review &
editing and supervision.