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.