by Katherine T. Klykylo, MHSA, ACSW, and William M. Klykylo, MD

Ms. Klykylo is with the Psychiatric Emergency Services, a joint program of the University of Michigan Department of Psychiatry and the Washtenaw County Health Organization (WCHO) in Ann Arbor, Michigan; and Dr. Klykylo is the Professor and Director, Division of Child and Adolescent Psychiatry, Wright State University School of Medicine in Dayton, Ohio.

Psychiatry (Edgemont) 2008;5(8):43–47

Series Editor: Paulette M. Gillig, MD, PhD, Professor of Psychiatry, Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio.

Abstract
ADHD, often misdiagnosed or unrecognized, can lead to serious personal and family disruption. Younger patients with ADHD frequently present to hospital emergency departments with crises involving behavioral dyscontrol, legal, school or family conflict, and substance abuse. An emergency room visit provides an excellent opportunity to use such crises as catalysts to effect lasting change in these patients and their families. The efficacy of a biopsychosocial model is demonstrated in a case involving a 15-year-old boy presenting to the emergency department with legal, psychological, educational, and family problems. Multiple teaching points are highlighted throughout the case.

Key Words

ADHD, substance abuse, adolescent psychiatry, emergency psychiatry, educational problems, legal problems, families, biopsychosocial approach

Introduction
This case epitomizes the need for early and multimodal intervention in the treatment of attention deficit hyperactivity disorder (ADHD).[1,2] Despite the increased public awareness of this disorder and the plethora of pharmacologic agents for its treatment, it remains a major cause of personal misfortune and social cost.[3,4] The treatment of ADHD requires an approach that is truly biopsychosocial. The case presented in this article also demonstrates the opportunity for focal psychotherapy in a crisis or emergency setting that can lead to lasting change.

Case example
Mr. S, a 15-year-old Caucasian boy, was brought to the emergency room late on a Saturday night by law enforcement personnel. His mother, father, and a 12-year-old brother, who could not be left at home alone, arrived at the hospital shortly thereafter. A psychiatrist and social worker were paged to evaluate Mr. S.

Earlier that evening, a passerby had noticed Mr. S and a group of boys and girls turning into a shopping mall parking lot with Mr. S hanging onto the top of the car. The police were called and found the boys and girls sitting in the car in the parking lot. The smell of marijuana was evident. There was a physical altercation when Mr. S and another boy tried to get away. During the struggle, Mr. S stated he should “just kill himself.” All were taken into custody, with Mr. S brought to the emergency room because of his statement about suicide. The police told the staff at the hospital that they had been called before about disturbances involving Mr. S, including the offense of minor in possession of cigarettes.

When interviewed alone initially by the social worker, Mr. S was angry and withdrawn, with one leg hung over the arm of the chair. He was a well-groomed, attractive boy, but his hair hung over his face, obscuring his features. He swore at the social worker, refusing to talk and stated that he did not need to be in the emergency room. He was told that his talking might hasten his leaving the emergency room. He was also told that verbal abuse was not acceptable, and in turn, by eliminating his use of verbal abuse, he would be treated with respect.

Mr. S calmed down somewhat and agreed to discuss what had happened earlier in the evening. Mr. S’s parents were also interviewed. This was not the first time they had been involved with the police regarding Mr. S. They were frustrated and angry, but were also scared to learn that Mr. S had talked about suicide.

Mr. S described the situation that had occurred that evening. He and his friends had been driving around, and “on a dare” he had agreed to hang onto the ski rack of the car. As soon as the car started moving, he said he was scared, but did not shout for the car to stop because he did not want his friends to think he was “weak” and he wanted to impress one of the girls in the car.

At the time, he did not remember thinking at all about the potential danger involved in what he had done. He did remember saying he should “just kill himself,” but he denied really wanting to kill himself. He just said it was because he was angry and upset. He had never made a suicide attempt, nor even entertained the thought of doing it or how he would do it. He admitted he sometimes wished he were dead because he kept “f****g up.”

Practice Point: The Risks of Untreated ADHD
ADHD, if untreated, is highly correlated with substance abuse in adolescents.[5,6] It should be considered in the differential diagnosis of these patients. Tobacco abuse is commonly seen in children and adolescents with ADHD, in excess of the general population.[7] Mr. S’s situation also demonstrates a sequence of impulsivity, self-defeating behavior, and dysphoria or depression that marks the lives of many of these youths.[8]

The intervention in the case of Mr. S demonstrates the need for simultaneous respect and structure of the patient. Mr. S’s unhappiness over his current situation was acknowledged and validated. At the same time, he was told clearly what the rules were in such a situation.[9] Like many youths with ADHD, he needed and may have tacitly welcomed the imposition of external structure and control, lest he succumbed to his own fearsome impulses.

Risk-taking behavior and poor social judgment are frequently seen in patients with ADHD. These are an obvious consequence of impulsivity, a cardinal sign of ADHD. However, they can also be related to self-esteem issues.[10] These youths frequently enter adolescence with a heritage of failure and social rejection, leaving them especially vulnerable to the peer pressure of early and mid-adolescence.

Parents may often exhibit what appears to be denial or unawareness of children’s affective status. Clinicians must be on guard against belittling or underestimating parents in this situation. Often what is in fact happening is an isolation of affect in an effort to preserve their own emotional well being and maintain the homeostasis of the family. This can often be seen in the context of chronic parental anger over a challenging, obnoxious, or disappointing child.[11]

In the case of Mr. S, the clinician was able to induce Mr. S to identify his feelings by using a firm but respectful approach and recognizing that this situation may have embodied a focal crisis for the patient. This may have represented the beginning of a focal conflict intervention, which as part of a multimodal treatment can lead to improvement.[12] The clinician ruled out symptoms of major depressive disorder in Mr. S, which avoided premature and unwarranted employment of an antidepressant. The possibility of substance abuse was noted.

Case example, continued

His parents described Mr. S as an active, happy baby. His verbal and particularly his physical milestones had been reached very early, and the parents remembered having to lay down mattresses around his crib because Mr. S kept managing to climb over the railing and fall out of his crib. They finally purchased a bed for him. One of his first words was “climb.” They had advised their pediatrician of his unusually high level of physical activity, and she had suggested that they keep her apprised of his developmental progress. Unfortunately, when their insurance plan changed, they were forced to seek a new primary care provider (PCP), and this matter was not pursued.

When induced to share his feelings in the emergency room, Mr. S said he hated his life. His mood was angry and depressed. He denied any problems sleeping, except that he liked to stay up late and get up late, which made his already poor school performance even worse, since he was late a lot. His appetite was good, as was his energy.

School was an incredible burden to Mr. S. He disliked most of his classes, and since grade school he had never gotten more than Cs or an occasional B. It was hard to pay attention to what the teachers were saying, and he often got into trouble for provoking other students in class or making comments under his breath when the teacher was talking. Sitting still in most classes made him “crazy,” and he often found himself thinking about “lots of other things.” Mr. S was in danger of being put in the “slow” class, and some of his friends were making fun of him because of this.

Mr. S expressed that he felt his parents preferred his younger brother to him because his brother made good grades and did not cause them trouble. Mr. S was now spending a lot of time in his room playing video games because that was the only thing that made him feel “ok.”

Mr. S always had friends, but also had difficulties with them because he would be “hyper” around them, and not conform to rules of games or play. Mr. S’s parents mentioned that a number of Mr. S’s former friends, including a girlfriend, had begun avoiding him because of his school problems and problems with the police. His parents worried about his new peer group, who were the “troublemakers” and were known to use drugs. Mr. S’s parents were worried that he was using marijuana and other drugs, too.

Mr. S admitted to smoking marijuana with his friends that night and one other time, and he said that it helped his thoughts slow down. He said he felt like a loser.

Practice point: Recognizing the symptoms of ADHD
Such an early history of attention issues and hyperactivity should be a red flag to PCPs. PCPs provide the bulk of psychiatric care for these patients. Their roles include not only early identification, but early preparation, education, and reassurance of parents. Unfortunately, in the case of Mr. S, this opportunity was lost.[13,14]

Mr. S described the cardinal symptoms of ADHD and their consequences in a traditional academic setting.[1] Mr. S exhibited inattention, distractibility, impulsivity, and hyperactivity. Some students may learn to suppress their physical hyperkinesis to some degree, but may do so at the cost of “feeling crazy,” not unlike a patient with akathisia.

Assigning a student with ADHD to the “slow” class, unfortunately, is not an infrequent response of some school systems, especially if a child with ADHD has not been diagnosed. The student’s condition may be attributed by the school to cognitive impairment or to delinquency, and these may in turn lead to the system tacitly “giving up.” In this case example, such a placement would be associated with social opprobrium and rejection.

This is a typical history. Children with ADHD are valued by peers for their energy and vivacity, but over time they may “wear out” their companions. As they grow older, their social skills deficits may become more apparent and consequential.[15] They may benefit from social skills training, although the preferred modality and effectiveness is controversial. Often patients with ADHD are well served by having multiple social groups: different sets of friends for different aspects of their lives, such as school, neighborhood, and extracurricular activities.

Self-medication is common among these patients, most especially for relief of anxiety. It may lead to the elevated rate of substance abuse seen in adults with this condition, especially if it is untreated.[13]

Case example, continued
Mr. S liked and excelled in art class, particularly sculpture. He was an accomplished gymnast, but he was dropped from the team because of his failing grades. Being dropped from gymnastics considerably upset Mr. S because it was one of the few things he liked, but he didn’t talk much about it with his parents.

Practice point: Recognizing strengths in individuals with ADHD
Individual sports can address a number of problems, such as concentration, self esteem, and depression. It is frequently a destructive mistake to drop patients with ADHD from these activities. But without a diagnosis, this is a common occurrence.[21]

Case example, continued

A conference with Mr. S’s school had been held a few months earlier regarding Mr. S’s learning and behavioral problems. It was recommended that Mr. S get special tutoring, which had just started, and that he see a physician for a medication evaluation. After an office visit with a practitioner who had never before met Mr. S, he was started on a stimulant. But the stimulant had not helped after a few weeks, and his parents took him off of it because it also interfered with his sleep and appetite.

Practice point: Utilizing school interventions properly for the patient with ADHD

A parent who believes that a child has a handicapping condition that is interfering with educational progress can request a multifactorial evaluation (MFE) through the school. The school is then obligated under federal law (the Individuals with Disabilities Education Act [IDEA]) to provide this evaluation and, if indicated, to collaborate with the parents to develop an Individual Educational Plan (IEP) for the child. The special tutoring arranged for Mr. S, while well-intentioned, may have been too nonspecific for his particular needs. Often, parents are unaware of their rights in the school system, and the counsel and support of a physician can be of incalculable value.[17]

The abrupt initiation of medication without a complete evaluation, as well as proper education and preparation of the family, is often unsuccessful. Even if medication might be indicated, the family and patient may not have come to terms with what is going on emotionally or educationally. Without proper education and preparation, they are likely to focus on adverse effects of medication and drop out of treatment rather than work with the psychiatrist to reach an appropriate regimen.[18] An ADHD parents group is helpful, both to educate parents about their child’s condition and to help them come to terms with their feelings about their child’s difficulties. Both of these points illustrate the need for continuity of care for this chronic condition.

Case example, continued
Mr. S’s father mentioned that he had had some of the same problems in school when he was younger, but he had “grown out of them.” Presenting as initially frustrated and angry, Mr. S’s parents were tearful when they talked about their once happy boy who was now withdrawn and talking about killing himself. They had tried “tough love,” obtained extra help in school, and had taken him to a doctor, but little was working.

The clinician acknowledged their sadness, and then went on to ask the father more about his childhood. He revealed that he had “given up” on school by the fifth grade, being regarded as stupid and lazy by his teachers. His parents, who were now deceased, had hoped he would go to college, but were forced to give up their aspirations for him. He himself developed an interest in electronics, and became skilled as a radio technician. He had little social life in high school: “They all thought I was a loser.” As a senior in a science class, he proved to be far ahead of his most successful classmates when they studied electricity; he remembered the class valedictorian asking him, “How did you get to be so smart?” He did not go on to college but specialized in electronics in the service and found steady employment thereafter as a mobile technician. Throughout this discussion, Mr. S showed rapt attention.

Practice point: Recognizing family history of ADHD

Unconscious recollection of his own trauma led the father to repress and deny an identification with his son and suppress his recognition of Mr. S’s sadness. His response of anger and frustration resulted in part from an unconscious identification with the aggressor, in this case the school system. His social isolation and immersion in electronics was an adaptation that proved eventually to be productive for him. However, this constellation of defenses interfered with early identification and remediation of Mr. S’s condition. The clinician very skillfully addressed this by asking the father what his experience was like as a child and adolescent. The mention of the problems the father experienced growing up was a red flag to the clinician about the son’s condition, and addressing it in this time of crisis proved to be therapeutic.[11]

The clinician explained to the family that it was very likely Mr. S had ADHD, and that his problems were not due to laziness or delinquency. His father replied that a neighbor had once suggested this, but that he disagreed at the time and paid no attention. The clinician, sensing that the father might be feeling responsible for his son’s difficulties, immediately mentioned to the parents that often many parents receive unsolicited advice from others on a regular basis, and the matter seemed to pass. The clinician went on to suggest that the entire family should have an opportunity to discuss these matters further with an experienced practitioner, and provided a referral.

The process of education for the patient with ADHD and his or her family begins with the initial contact. The issue of parental guilt and responsibility is often a chronic issue. However, a direct reassurance of “innocence” may presuppose feelings that are not present or are not ready to be addressed. By indirectly acknowledging the possibility of these things with generalization, the clinician in the case of Mr. S allowed for further work in the future.

Epilogue
The family was provided a referral to a medical home clinic, since they did not have a PCP for Mr. S and needed multiple services. At the clinic, they were connected with a therapist who saw Mr. S and his parents separately and together. A consultant child and adolescent psychiatrist completed his evaluation and began treatment with a slow-release stimulant preparation. Mr. S did not exhibit adverse effects from this medication and was better able to concentrate and complete his school work.[19,20] The psychiatrist and the pediatrician worked with the parents to assure that Mr. S received an MFE through the school system, and an educational prescription suited to his needs was developed. Mr. S’s progress was reported to the juvenile court, and his charges were dropped. At last report, Mr. S had completed his junior year of high school and planned to go on to technical studies after graduation.

References
1. Rube DM, Reddy DP. Attention deficit hyperactivity disorder. In: Klykylo WM, Kay J (eds). Clinical Child Psychiatry, Second Edition. London: John Wiley & Sons, 2005:75–90.
2. ADHD: a guide for families. http://www.aacap.org/cs/adhd_a_guide_for_families/getting_treatment. Accessed June 2008.
3. Wilens TE, Biederman J, Spencer TJ. Attention deficit hyperactivity disorder accross the lifespan. Ann Re Med. 2002;53:113–131.
4. Currie J. Stabile M. Child mental health and human capital accumulation: the case of ADHD. J Health Econ. 2006;25(6):1094–1118.
5. Biederman J, Wilens T, Mick E, et al. Pharmacotherapy of attention-deficit/hyperactivity disorder reduces risk for substance use sisorder. Pediatrics 1999;104(2):e20.
6. Wilens TE, Faraone SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? a meta-analytic review of the literature Pediatrics. 2003;111(1):179–185.
7. Lambert NM, Hartsough CS. Prospective study of tobacco smoking and substance dependencies among samples of ADHD and non-ADHD participants. J Learn Disabil. 1998;31(6):533–544.
8. Harpin VA. The effect of ADHD on the life of an individual, their family, and community from preschool to adult life. Arch Dis Childhood. 2005;90(Suppl I):i2–i7.
9. Uribe VM. Short-term psychotherapy for adolescents: management of initial resistances. J Am Acad Psychoanal. 1988;16:107–116.
10. Bussing R, Zima BT, Perwein AR. Self-esteem in special education children with ADHD: relationship to disorder characteristics and medication use. J Am Acad Child Adolesc Psychiatry. 2000;39(10):1260–1269.
11. Sorensen PB. Changing positions: helping parents look through the child’s eyes. J Child Psychother. 2005;31(2):153–168.
12. Bentovim A. Towards creating a focal hypothesis for brief focal family therapy. J Fam Ther. 1979;1(2):125.
13. Jensen PS, Hinshaw SP, Swanson JM, et al. Findings from the NIMH Multimodal Treatment Study of ADHD (MTA): implications and applications for primary care providers. J Dev Behav Pediatr. 2001;22(1):60–73.
14. Power TJ, Mautone JA, Manz PH, et al. Managing attention-deficit/hyperactivity disorder in primary care: a systematic analysis of roles and challenges. Pediatrics. 2008;121(1):e65–72.
15. de Boo GM, Prins PJ. Social incompetence in children with ADHD: possible moderators and mediators in social-skills training. Clin Psychol Rev. 2007;27(1):78–97. Epub 2006 Jun 30.
16. Wilens TE, Upadhyaya HP. Impact of substance use disorder on ADHD and its treatment. J Clin Psychiatry. 2007;68(8):e20.
17. Feldis, D. Educational assessment and school consultation. In: Klykylo WM, Kay J (eds). Clinical Child Psychiatry, Second Edition. London: John Wiley & Sons, 2005:65–74.
18. Leslie LK, Plemmons D, Monn AR, Palinkas LA. Investigating ADHD treatment trajectories: listening to families’ stories about medication use. J Dev Behav Pediatr. 2007;28(3):179–188.
20. Barbaresi WJ, Katusic SK, Colligan RC, et al. Modifiers of long-term school outcomes for children with attention-deficit/hyperactivity disorder: does treatment with stimulant medication make a difference? Results from a population-based study. Dev Behav Pediatr. 2007;28(4):274–287.
21. Dykens EM, Rosner BA, Butterbaugh G. Exercise and sports in children and adolescents with developmental disabilities. Child Adolesc Psychiatr Clin N Am. 1998;7(4):757–777.