Psychiatric Diagnostic Evaluation Disorder: Attention-Deficit/Hyperactivity Disorder

Psychiatric Diagnostic Evaluation Disorder: Attention-Deficit/Hyperactivity Disorder

Identifying Information

LJ is an 8-year-old English-speaking Caucasian male in Grade 3 and a resident of West Virginia State. He has Medicaid insurance; the patient is a practicing Catholic.


The following discussion is based on the case of LJ, an 8-year-old Caucasian boy in Grade 3. His mother brings him to the clinic after he has been exhibiting symptoms of inattention, hyperactivity, and impulsivity at home and school for nearly a year. To vividly picture his behavior at school, his class teacher narrates over a phone call about his inability to maintain focus, interruption of classmates, and decline in performance.

He is usually ‘on the go’ at home, and his upheaval behavior has caused his siblings and father to distance themselves from him. The mother’s frenzy was heightened after witnessing a friend’s child with similar characteristics being diagnosed with a mental condition-ADHD, prompting her visit to the clinic.

On MSE, the patient moves up and down, is overly talkative, has a flight of ideas, and is preoccupied with thoughts of playing. Physical examination reveals no concerning findings. After a complete assessment, he is diagnosed with ADHD using the DSM-5 criteria and started on Ritalin 5mg PO BD, with the dosage increased by 5mg weekly and not exceeding 60mg/day. The mother and teacher are given suggestions for behavioral interventions to use at home and school. He is then referred to a psychiatrist for cognitive behavioral therapy (CBT).


Over the last century, the diagnosis of Attention-Deficit Hyperactivity Disorder has been fraught with controversy. However, over the last 30 years, a consensus on its diagnosis has emerged, thanks to the Diagnostic and Statistical Manual of Mental Disorders (DSM), particularly the fifth edition (DSM-5).

Furthermore, research on the neurochemical and physiological mechanisms of ADHD has been conducted, resulting in a better understanding of the disorder and the development of appropriate pharmacological and psychotherapeutic interventions.

According to the DSM-5, the disease is diagnosed in childhood, specifically before the age of 12. It impacts children’s ability to function, as evidenced by inattention, hyperactivity, and impulsivity (APA, 2013). These symptoms have a high potential for causing dysfunction in social, occupational, and academic settings, highlighting the importance of managing the disorder to prevent and reduce levels of dysfunction.

The cause of this disease has been attributed to several environmental, genetic, and biological factors, and in some cases, the factors all contribute to the disease’s etiology. According to the APA (2013), the disorder affects 5% of children and 2.5% of adults, while Magnus et al. (2022) report that the inattentive subtype is present in 18.3% of total patients, while the hyperactive/impulsive and combined types are present in 8.3% and 70%, respectively.

The significant morbidity associated with ADHD in terms of social, occupational, and academic dysfunction is the reason I believe the topic is important. Furthermore, I have a cousin who is socially disabled due to the disease. This has piqued my interest in the subject, as I believe that learning more about it will broaden my knowledge and increase my ability to solve my cousin’s problems.

Case Presentation

LJ is an 8-year-old Caucasian male patient who lives in West Virginia State, is in Grade 3, and lives with his parents. He visits a community primary care clinic in the company of her mother, the chief informant, who is concerned that her son may have a mental disorder. The patient and his family are Catholic and have Medicaid insurance, and his referral was prompted by the mother’s friend, who had a child with similar symptoms diagnosed with ADHD.

The mother contacts LJ’s class teacher, who describes his range of inattentive and hyperactive behaviors at school, as well as his alleged decline in performance. On the other hand, the mother describes the range of inattentive, hyperactive, and impulsive symptoms he exhibits at home, which has lasted nearly a year.

The mother claims that his brother has had issues at school with pot use and that, at one point, the mother thought he could have influenced LJ. His past medical issues include gastroenteritis five months ago and a distal phalangeal fracture of the right little finger caused by his “on the go” behavior. Because of his upheaval behaviors, his social relationships with his peers, siblings, and parents have deteriorated.

His family has changed residence three times in the state due to his father’s transfers, and his mother once believed that his behaviors were the result of adjusting to a new environment. Because both parents work, the family is adequately supported in terms of school, food, and other basic needs.

Source and Reliability: LJ’S mother and class teacher narrate his history of presenting illness with consistency

Chief Complaint

“I have received several reports from the school regarding my son’s careless mistakes and inability to pay attention in the classroom. He is also very forgetful in doing his chores at home,” The mother reports.

History of Presenting Illness

LJ, an 8-year-old Caucasian male patient, visits our clinic in the company of her mother, the chief informant. The mother reports that she has received three phone calls from school in the last four weeks regarding his son’s behavior. She called the teacher and put the call over the loudspeaker since the class teacher was in a better position to account for LJ’s behavior.

The class teacher claims that LJ makes careless mistakes in schoolwork and that when given assignments, he overlooks instructions and does not complete them. Furthermore, the class teacher reports that most of their classes are 45 minutes long, but LJ has never made it through even 15 minutes of class without needing to use the restroom. Even during periods of personal study in the classroom, he struggles to stay focused and frequently interrupts other students by butting into conversations and games and begins using their books and pens without asking permission.

When given assignments, the teacher reports that he begins well but quickly loses focus and is easily distracted by any event occurring through the windows or movements of people along the corridors. As the teacher narrates, his desk is usually disorganized, and he frequently loses his exercise books, usually three times a week, necessitating the mother’s purchase of new exercise books and pens.

The teacher goes on to say that during a class session, when students ask questions, he does not wait his turn and blurts out answers before the questions are even completed. LJ’s school performance has recently declined, and he does not get along with his friends or classmates.

After the class teacher hung up the phone, the mother recounts that LJ was assigned the task of emptying the dustbin into the main dumpster, which is located next to their home’s gate, but he forgets to do so daily. While at home, he frequently runs around and climbs the house’s pillars, and he recently suffered a distal phalangeal fracture of the right little finger when he fell from the house’s pillars.

Because of his running around and climbing in inappropriate situations, his father even stopped taking LJ to work with him. The mother reports that LJ’s older siblings frequently avoid or punish him because of his unsettling behaviors. After hearing and seeing how her friend’s child, who was diagnosed with ADHD, behaved, the mother was convinced that LJ would be suffering from the same condition, prompting her decision to bring him to the clinic. She has tolerated LJ’s behavior for almost a year, but this time she feels his excessive excitement and frequent upheaval require attention.

Current Medication: Zipsor: 25 mg PO QID PRN

Past Psychiatric History: No past psychiatric illness. This is his first time visiting a psychiatric clinic.

Past psychiatric medication: Nil

Substance Use: The mother claims that LJ once reported that his older brother hides pot in his room. The mother, however, is unsure whether LJ has ever used pot.  LJ denies any substance use.

Medical History: A month ago, he sustained a distal phalangeal fracture of the right little finger, which was splinted, and he recovered except for some mild pain, which he manages with Zipsor PRN.  The mother reports that he was treated for gastroenteritis five months ago, which was severe enough to require a three-day hospital stay.

Allergies: No known food or drug allergies.

Family History:

Both parents are still alive. The father is a 44 years old Caucasian public health officer. He is hypertensive, well controlled on Losartan/Hydrochlorothiazide 12.5 mg PO 12 hourly. He used to be a binge alcohol drinker before being diagnosed with HTN three years ago, but he now limits himself to two bottles of beer in one sitting if he wants to drink. The mother is 39 years old and works as a software developer for her own IT company. She has no morbidity.

He has two siblings. His 20-year-old brother is a college student studying electro engineering. The brother was suspended in senior high school for allegations of pot abuse. He had two run-ins with his previous principal for bringing pot to school. Due to his behavior, his parents enrolled him as a day student for close monitoring.

His high school-aged sister has allergic rhinitis, which she manages symptomatically with antihistamines and, on occasion, nasal corticosteroid spray.

Developmental & Social: The mother reports LJ had normal developmental milestones. He has two childhood friends with whom he has grown up. They no longer play with him as frequently as they did when he was younger. His bond with his siblings has deteriorated. Because of his behavior, his father has distanced himself from him.

Mental State Exam

Appearance and behavior: A young Caucasian boy, well-dressed, wearing a long-sleeved shirt with one sleeve at wrist length but the contralateral side folded up.

Motor Activity: He is moving up and down around the examination room. He is handed a chair to sit in but has not spent a single minute fully sited. He is fidgeting and telling his mother that they should go home.

Speech: He is excessively talkative. Speaks loudly, but when asked a question, blurts out the answer before it is finished. Interrupts the mother frequently while she is answering a question. He engages in desultory conversation, jumping from one topic to the next.

Mood: subjective “I feel excited.” Objective Mood-euphoric

Affect: Appropriate and congruent with mood

Though content: preoccupied with thoughts of playing

Thought process: Flight of ideas

Perceptual disturbances: No abnormality

Cognition: Conscious, oriented to time, person, and place

Abstract reasoning: When he was given a word game on board to find the word ‘good,’ which was conspicuous, he quickly read it out.

Concentration: Poor concentration. The task was to subtract five from 100 in descending order. He stopped at 85 and switched to playing.

Impulsivity: Makes a lot of noise and is disruptive. Interrupts the mother and blurts out responses to the mother.

Insight: Poor.

Judgment: Inappropriate

Threat to others: No evidence of a possible threat to self and others

Motivation: Have difficulty initiating and maintaining tasks, especially those that require sustained mental effort, such as school work. He does, however, enjoy cartoons, as his mother claims that this is the only activity in which he can stay focused for an extended period.

Physical Exam Findings

General appearance: The patient is alert and oriented in time, place, and person. He is not in obvious respiratory distress. He is well nourished. He has no pallor, jaundice, lymphadenopathy, cyanosis, or edema.

Vital signs are as follows: BP122/81 mmHg; RR 22 breaths/minute; HR 78 beats/minute; Temp 98.6 F; SPO2 100% on room air.

Head: Normocephalic. No masses, tenderness, or lacerations.

Eyes: No pathology in the periorbital areas. The extraocular movements are normal and symmetrical. No conjunctival injection. The pupils are bilaterally and equally reactive to light.

Ears: No swelling, hemorrhage, or discharge. The tympanic membranes are grey and intact. No hearing on tuning fork tests

Nose:  No deformities. The nasal mucosa is pink and moist. There is no swelling, discharge, or

Throat: Oral mucosa is moist, good oral hygiene, no halitosis, dentition is complete, normal gingiva. Uvula and soft palate are pink, no evident pathologies.

Chest/Lungs:  On inspection, no deformities on the chest wall. It is symmetrical and moves with respiration. Equal expansion. No masses seen. On palpation, no masses, tenderness or crepitus. Chest expansion is bilaterally symmetrical. Normal tactile fremitus. On percussion note is resonant. On auscultation, there is bilateral, clear, and equal air entry. Vesicular breath sounds present.

Cardiovascular: Pulse 78 beats/minute, regular. The capillary refill is less than two seconds. There is no pallor or cyanosis. The precordium is normoactive. Apex beat at 5th intercostal space. S1 and S2 sounds were heard. No added sounds

Abdomen: Inspection: the abdomen is symmetrical, has normal fullness, and moves with respiration. No scars or caput medusa. Auscultation: Bowel sounds present. Palpation: skin warm to touch. No masses or crepitus. The liver span is 10 cm. No tenderness. Percussion: tympanic.

Musculoskeletal: Normal gait, No joint swelling, normal range of motion across all joints, no joint tenderness. Muscle bulk is normal in all muscle groups.

Neurological: GCS is 15/15. Normal balance and proprioception.  Normal sensation. Motor: Muscle bulk normal, normal tone, and deep tendon reflexes, power is 5/5 in all muscle groups. No peripheral neuropathy.

Genital/Rectal: Genitalia: Normal external genitalia. Rectal: the anal region is clean and dry. No masses or tenderness. The rectal mucosa is smooth.

Diagnostic Tests:

There is no single test to diagnose ADHD. The diagnosis is exclusively based on the DSM 5 criteria, and rules out other potential diagnoses. However, as baseline tests, the following would be essential.

Complete blood count: This will be done to determine the hemoglobin level and the white blood cell count and correct any deficits before initiating treatment

Urea and electrolytes (UECs). UECs help to determine the baseline function of the kidney, which is the major excretory pathway for most drugs.

Monitoring height and weight: Stimulant medications (Methylphenidate and Amphetamine) and Atomoxetine decreases a patient’s appetite, so monitoring height and weight for a medication-related reduction in growth rate are essential (Mattingly et al., 2021)

Electrocardiograms: Imipramine has studies indicating its efficacy in the treatment of ADHD. If Imipramine is to be used, electrocardiograms should be followed because of QT prolongation (Aronow & Shamliyan, 2020).

Electroencephalogram: As a group compared with peers, children with ADHD display increased slow wave electroencephalograms (APA, 2013). However, this finding is not diagnostic

MRI: As a group compared with peers, children with ADHD have reduced total brain volume (APA, 2013). This finding is not diagnostic

Note: In uncommon cases, there may be a known genetic cause (Fragile S syndrome, 22q11 deletion syndrome), but the ADHD presentation should still be diagnosed (APA, 2013)

Case Formulation/Diagnostic Formulation

LJ, an 8-year-old grade 3 Caucasian student from West Virginia, presents with a nearly one-year history of inattention, hyperactivity, and impulsivity. Careless mistakes at school manifest his hyperactivity, difficulty focusing, failure to follow instructions, difficulty organizing tasks, losing things, and being forgetful. His hyperactivity is manifested by fidgeting, frequently leaving his seat at school, excessive and inappropriate running and climbing, excessive talking, and difficulty playing quietly.

His impulsiveness is demonstrated by blurting out answers before a question is finished, frequently interrupting others, and having difficulty waiting his turn to answer questions in class. His symptoms are linked to altered relationships with his friends and parents and poor academic performance. He does not have a family history of mental disorders.

His eldest brother had several run-ins with his previous school’s principal over allegations of pot use. He receives adequate financial (school fees) and other basic needs support from his parents, except that the father distances himself a bit due to his upheaval behaviors.

Diagnosis: Attention-Deficit/Hyperactivity Disorder. According to the DSM5, a diagnosis of ADHD requires the fulfillment of five criteria. In criteria A, there is a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as defined by (1) and/or (2)

  1. Inattention: Making careless mistakes, having difficulty focusing one’s attention, often seeming not to listen, often failing to follow directions, having difficulty in organizing tasks, avoiding tasks requiring sustained mental effort, often losing things, and often becoming distracted by other stimuli and being forgetful (APA, 2013)

What are the symptoms of LJ inattention? His teacher reports that he is careless with his schoolwork, that he cannot maintain a 45-minute concentration during class sessions (requests to use the restroom every 15 minutes, interrupts other students during periods of personal study, uses their books and pens without asking permission, loses focus when doing assignments and attention is drawn to events through the window or movements through the corridors, that his desk is disorganized, that he loses his exercise books and pens weekly necessitating his mother to buy new ones, and he forgets to accomplish his chores at home-emptying the dustbin.

  1. Hyperactivity and impulsivity: Hyperactivity symptoms include fidgeting or squirming, often leaving one’s seat, running or climbing excessively and inappropriately, difficulty playing quietly, often being “on the go,” and talking excessively, while the impulsivity symptoms include often blurting out an answer before a question is completed, difficulty waiting for one’s turn and often interrupting others (APA, 2013).

What are the signs of LJ’s hyperactivity? His class teacher reports that he leaves his seat every 15 minutes during a class session, his mother reports that he climbs and runs around unnecessarily, and he is fidgeting and talking excessively on MSE.

Criteria B requires that the symptoms appear before the age of 12 (LJ is 8 years old); Criteria C requires that the symptoms appear in two or more settings (home, school, work, etc.); Criteria D requires that the symptoms are associated with significant dysfunction in social, academic, or occupational areas—this is evidenced by LJ’s poor academic performance—and Criteria E requires that the symptoms cannot be attributed to another mental disorder (APA, 2013)

Differential Diagnoses:

Oppositional Defiant Disorder (ODD). Individuals with ODD may resist work or school tasks that require self-application because they resist conforming to others’ demands. These people may defy instructions in the same way that LJ does not follow instructions and does not complete assignments. However, ODD manifests as argumentative behaviors and vindictiveness, which are conspicuously absent in LJ.

Autism Spectrum Disorder: Individuals with autism spectrum disorder exhibit inattention, social dysfunction, and difficulty to manage behavior. However, children with autism spectrum behavior exhibit deficits in social communication and interaction, with restricted, repetitive patterns of behaviors, interests, and activities (APA, 2013), which lack in LJ.

Specific Learning Disorder: These individuals may be inattentive because of frustration, limited ability, or lack of interest. However, they are not impaired outside the classroom, which is conspicuously present in ADHD.

Intermittent Explosive Disorder: These individuals have high levels of impulsivity, just like ADHD patients. They show aggression towards others, which is not the case with ADHD. However, they do not have problems with inattention (APA, 2013).

Treatment Plan

Ritalin (Methylphenidate): start with 5mg PO twice a day (before breakfast and lunch), typically 30-45 minutes before the meals (Haverkampf, 2019). Increase dosage gradually, increment of 5mg weekly. Do not exceed 60 mg/day.

Indicated Diagnostic/Lab Work

  1. Screen for the presence of heart disease: ECG. Rationale-the drug raises blood pressure and heart rate and may worsen an underlying heart disease (Haverkampf, 2019).
  2. Monthly monitoring of height and weight as long as the patient is on the drug. Rationale-The drug suppresses appetite (Haverkampf, 2019).

Evidence-Based Non-Pharmacological Interventions

Environmental Manipulation (Staff et al., 2021)

  1. Increase the play opportunities. Allow the children to go and play outside
  2. Reduce the opportunity for disruptive behavior: Teachers should place the child in front of the class for close monitoring.
  3. Reduce the time for sustained attention to 5-10 minutes.
  4. Reduce the availability of items or activities that cause excessive excitement at home, such as toys or parties.

Formal behavior modification programs, such as ignoring the child, may make him realize that no one is interested in his upheaval behavior, and he may thus quit (Staff et al., 2021)

Patient and Family Education

The mother must maintain regular contact with the child’s teacher. The mother should maintain a consistent daily routine for homework, meals, and outdoor activities. Any schedule changes should be made in advance, rather than at the last minute. The mother should also limit distractions in the child’s environment.

Concerning the drug, it may cause decreased appetite, initial insomnia, headaches, irritability, and dysphoria. If these symptoms worsen, reduce the dosage or, if necessary, return to the clinic for possible drug discontinuation. In terms of storage, keep the medication between 20°C and 25°C (Haverkampf, 2019).


Referral to a psychiatrist for the pharmacotherapeutic and psychotherapeutic management of the patient

The indications for referral to or consultation with a specialist (child neurologist, developmental-behavioral pediatrician, child psychiatrist, psychopharmacologist, clinical child psychologist) may include

  1. Coexisting psychiatric condition
  2. Coexisting neurologic or medical condition
  3. Lack of response to a controlled trial of a stimulant therapy

Psychotherapy Treatment Plan

Counseling and supportive psychotherapy: The parents are taught to accept the child as being different. Support the child in school and at home in doing assignments and reminding them of their schedule

Play therapy: Allows children to express themselves in a language all of their own. Allow the child to act out fanciful scenarios, through which he will express a variety of emotions

Cognitive behavior therapy: Improves organizational and planning skills, and cognitive functions

Outcome and Follow Up

70% to 80% of children with ADHD respond to stimulant medications (Grazioli et al., 2021). Symptoms such as inattention, hyperactivity, and impulsivity are expected to improve. A monthly follow-up for side effects, side effects, and medication refills is recommended.


This case demonstrates the importance of early ADHD diagnosis and aggressive management to avoid significant morbidity. ADHD, as quintessentially demonstrated by the case, represents a constellation of symptoms that include inattention, hyperactivity, and impulsivity. These symptoms must have occurred in two or more settings, just as LJ’s symptoms occurred at school and home, and must have occurred before age 12.

The treatments discussed are among the evidence-based strategies for managing ADHD patients. The first-line treatment is pharmacotherapy, with or without behavioral and psychological interventions, and stimulant medications (Methylphenidate and Dextro-Amphetamine) are considered first). My choice of Methylphenidate (Ritalin), is evidence-based and supported by several studies as the drug of choice in ADHD, with a high response rate.

Behavioral interventions at home, such as maintaining a daily schedule, reducing exposure to items that cause excessive excitement, and providing adequate time for play, are among the non-pharmacological interventions that are effective when dealing with ADHD patients. Furthermore, because the child’s two most essential environments are school and home, school-based interventions such as classroom modifications—putting him in front of the classroom and sitting near the teacher—help to closely monitor the patients and improve their productivity.

Additionally, training them on social skills will improve his relationship with his peers, which could be done separately or as part of the CBT sessions. Even as the patients’ treatment continues, it is essential to note that combination therapy (the use of medication and psychotherapy and/or behavioral interventions) is recommended, as this may result in a lower dosage of medication being used to achieve greater improvement in ADHD symptoms.

Learning Points

  1. I learned about the DSM-5 diagnostic criteria for ADHD and how to formulate a case scenario using the criteria
  2. I explored the specific pharmacotherapeutic and psychotherapeutic modes of treatment appropriate for ADHD
  3. I have also learned about the various evidence-based non-pharmacological and non-psychotherapeutic interventions that can be used to manage patients with ADHD at home and school.

Strengths and Deficits of Write-Up

The strength of this write-up is that it allowed me to analyze a patient case scenario and justify the diagnosis using DSM-5 criteria. It also enabled me to formulate a case that could be a real-life situation simply by applying the DSM5 diagnostic criteria. Furthermore, I am capable of ruling out differential diagnoses and explaining why. The main weakness is that the activity is solely focused on a patient, denying us the opportunity to extend the assessment to the patient’s family and determine any circumstances that may have predisposed or precipitated the patient’s illness.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association.

Aronow, W. S., & Shamliyan, T. A. (2020). Effects of antidepressants on QT interval in people with mental disorders. Archives of Medical Science: AMS16(4), 727–741.

Grazioli, S., Rosi, E., Mauri, M., Crippa, A., Tizzoni, F., Tarabelloni, A., Villa, F. M., Chiapasco, F., Reimers, M., Gatti, E., Bertella, S., Molteni, M., & Nobile, M. (2021). Patterns of response to methylphenidate administration in children with ADHD: A personalized medicine approach through clustering analysis. Children (Basel, Switzerland)8(11).

Haverkampf, C. J. (2019). Christian Jonathan Haverkampf Methylphenidate (RITALIN®) IN The Treatment Of ADHD.

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2022). Attention Deficit Hyperactivity Disorder. In StatPearls [Internet]. StatPearls Publishing.

Mattingly, G. W., Wilson, J., Ugarte, L., & Glaser, P. (2021). Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions. CNS Spectrums26(3), 202–221.

Staff, A. I., van den Hoofdakker, B. J., van der Oord, S., Hornstra, R., Hoekstra, P. J., Twisk, J. W. R., Oosterlaan, J., & Luman, M. (2021). Effectiveness of specific techniques in behavioral teacher training for childhood ADHD: A randomized controlled microtrial. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 5350(6), 763–779.

Psychiatric Diagnostic Evaluation Disorder: Attention-Deficit/Hyperactivity Disorder Instructions








Upon your assessment make a Diagnosis based on DSM-5 and Treatment Plan: Definitive diagnosis, Differential diagnosis: and other Include neurobiology of disorder(s). (Include genetics, neurotransmitters, neuroanatomical changes, current theories of causation, cultural factors);
Rationale for each part of management plan (labs; meds: why this med, what is neurochemistry action of med, side effects to monitor, expected benefits, contraindications; counseling-goals, rationale for this type of therapy, expected benefits, teaching, referrals, follow-up).