History of Present Illness
Timothy is a 7-year-old boy referred by the Special Needs Ministry director at a local church. He had been involved in several physical altercations with another boy during a regular evening activity at church, and has an individualized education plan - IEP) at school for issues with speech and articulation, social interactions, disruptive behavior, and difficulty remaining in-task. Another psychologist (a friend of Timothy's parents) suspected attention deficit-hyperactivity disorder (ADHD) and referred the family to a highly regarded research psychologist at a nearby teaching hospital for a formal evaluation. The parents contacted our office for an earlier appointment because his behavior at home and in school has become intolerable.
Timothy's mother forwarded an e-mail message from his classroom teacher, who described him as follows:
"Timothy has been talking out incessantly during lessons, put also shouting out, singing, humming, burping, pretend sneezing, and disrupting every lesson I've tried to teach this week. He =epeatedly kicks his shoes off, once hitting me in the shin with his shoe. My usual nonverbal prompts to him were useless this week. He will keep getting louder and louder until he finishes speaking. Even though he sits right in front of me, he deliberately broke 3 pencils and scribbled all over his paper to avoid writing. After we kept him in from recess to finish his work, he threw a fit, saying there was too much to write. As the week progressed, he fell further and further behind in terms of his work completion. When I asked him why he wasn't writing with the rest of the class, he said he was distracted even though the room was quiet. The other kids are starting to speak up when Timothy is mean or will not stop talking. This is not what we want for him socially."
Timothy's mother notes that he needs constant reminders to complete chores and has a very hard time remembering multi-step instructions. Homework completion is a major ordeal, consuming much of the family's energy in the evening and leaving Timothy's parents frustrated and exhausted. He'll frequently wet himself because he becomes so wrapped up in a play activity that he gets to the bathroom too late. He will hug and squeeze other children until they cry, and he is no longer being invited to birthday parties by other boys in his class. His family avoids taking long car trips to visit his grandparents because of Timothy's loud complaints whenever he becomes bored.
His family recently became involved in a local church (important to both parents) because no previous church they had attended was equipped to manage Timothy's behavior during worship or children's activities. He has taken swimming and martial arts lessons, but has been unable to participate in team sports because of his distractibility and poor impulse control.
Timothy was seen at age 5 by a psychologist who diagnosed a nonverbal learning disorder and sensory integration disorder. She also raised concerns about possible obsessive-compulsive disorder, but didn't find enough evidence to support a diagnosis. following that assessment, he was referred to an occupational therapist to address his sensory issues.
Timothy was hospitalized at 8 months of age with respiratory syncytial virus (RSV). He experienced recurrent inner ear infections and was identified with hearing loss at age 2. He underwent a number of surgeries to place tubes in his ears, initially at 27 months of age, with the tubes replaced at age 4.
Timothy had a complete speech and hearing evaluation last year and his hearing was found to be within normal limits. A screening vision examination performed as part of his most recent multifactored evaluation was normal.
Substance Use History
Timothy has never tried alcohol, tobacco products, or =llicit substances. A maternal uncle was convicted twice of driving =nder the influence. Timothy's maternal grandfather reportedly =drank a lot" during his 20s and 30s.
Medications and Allergies
None currently. A rash developed following treatment with a amoxicillin.
Family Psychiatric History
Timothy's father reports that he engaged in frequent 'attention-seeking behavior' during his school years, and described himself as an 'underachiever' in school. A paternal cousin was diagnosed with ADHD and obsessive-compulsive disorder. Timothy's mother was treated with psychotherapy for depressed mood following the birth of Timothy's little sister. Timothy's maternal grandfather was briefly hospitalized with an episode subsequently diagnosed as a panic attack.
Timothy was the product of an uncomplicated, full-term pregnancy. He had mild jaundice, which resolved within a week of birth. His gross motor skills developed normally, but he continues to have significant issues with fine motor skills, and wears loafers to school because he struggles with tying laces. He was always active as a child. Onset of speech was delayed, and Timothy has received speech therapy both privately and through his local school system since age 3.
Timothy has received services through the public schools since age 3. He has an IEP, and currently receives speech and language therapy for issues with articulation and social language. Social language skills are practiced during a weekly 'lunch bunch' social skills group. He also practices maintaining appropriate personal space in this group. He receives occupational therapy for weaknesses in fine motor skills contributing to problems with handwriting.
Timothy lives with his father (Edward), mother (Sarah), and 3-year-old sister Skylar in an upper middle class suburb of a major city. His father works as a vice-president of sales and marketing for a local manufacturing company; his mother works as a grade teacher in a neighboring community.
Timothy's parents were seeking treatment because "neither Edward nor I feel like we have a good handle on what's going on with him." Sarah tends to react angrily to Timothy's behaviors, while Edward often finds excuses to travel or work late, to avoid dealing with Timothy. Both parents report they argue with each other and second-guess one another's parenting strategies in front of Timothy. Timothy tries to be affectionate to his little sister, but as often overly aggressive with her to the point that she cries.
Timothy's parents have become socially isolated. They express frustration at rarely being able to go out together or with friends, because their pool of teenage babysitters struggle trying to supervise Timothy and his sister. A local college student is present in the home daily when Timothy gets off the school bus until his mother arrives home, but she is unavailable on evenings and weekends because of her school and work schedule. Timothy's parents have lived in their current home for 5 years, and neither parent has extended family in the area.
Timothy is at the 95th percentile in both height and weight. His blood pressure is 104/70 mm Hg; pulse is 76 beats per minute; heart rate and rhythm regular, without murmurs or rubs. Lungs are clear to auscultation. The remainder of the physical examination is normal.
Following a comprehensive psychiatric evaluation lasting several hours that included an extended interview with Timothy Malone), his parents (without Timothy), and review of his IEP, multifactored evaluation, and previous treatment records, Timothy's initial DSM-IV diagnosis was:
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