Case Studies

Case 7 - A 12-year-old boy with behaviour problems

As a psychiatric junior doctor, you see Andrew, a 12-year-old boy who has been brought to clinic by his parents. They have become increasingly concerned about his behaviour, which has deteriorated over the last year since he moved to senior school. They asked his GP for help after Andrew was warned by the police for attempting to set fire to an abandoned car on the local recreation ground with his friends. At a recent parents’ evening, his form teacher also expressed concern that he seemed to be having difficulty concentrating, and is over-talkative in class, which distracts the other students. She commented that he seems to have developed a tic, which involves Andrew blinking his eyes, which his mother says dates back a few years. He is bullied at school.

His parents adopted Andrew when he was five years old, and have been told that his birth mother had alcohol and opiate dependence and mental health problems. There is no information on the biological father. As a young child Andrew was overactive and clumsy. When you see Andrew, he avoids making eye contact and is very reluctant to engage. He admits to feeling annoyed and sad. He says he hates life.

• a. Give at least four possible diagnoses.

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  Correct answer:

  Attention deficit hyperactivity disorder; conduct disorder; Tourette’s syndrome; depression.

After a full investigation, you diagnose him with ADHD.

• b. How could you treat this?

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  Correct answer:

  Stimulants (e.g. methylphenidate); atomoxetine; behavioural therapy; parent training in behavioural methods (e.g. Webster–Stratton parenting programme).

You see Andrew in clinic with his mother a few months later. His ADHD is slightly improved with treatment, but he feels very sad and is sleeping poorly. You diagnose him with depression.

• c. How would you treat this?

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  Correct answer:

  Psychological therapies (e.g. CBT) are the main treatment. Anti¬depressants are not generally recommended for children under 18, although they are prescribed for severe or resistant cases by specialists.

• d. His mother remains concerned about the tic he has developed. What further information would help you clarify the diagnosis.

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  Correct answer:

  If the motor tic described has been present, together with one or more vocal tics, for at least a year, this would fulfil the diagnostic criteria for Tourette's disorder.