A 13-year-old boy was diagnosed with ADHD, predominantly inattentive type, at the age of 10 by a developmental pediatrician. That diagnosis was based on observations by parents and school officials, along with a thorough medical evaluation that included a hearing test. The patient’s symptoms included difficulty sustaining attention to tasks, making careless mistakes in schoolwork, frequently losing school assignments and books, failing to complete schoolwork and chores at home, and having extreme difficulty with organization and time management. At the time of his diagnosis 3 years ago, his teacher described him as “highly distractible,” although his parents noted that he would often become hyper-focused on activities that interested him, such as building Legos. The patient had no history of delayed speech or motor development.

A therapeutic trial with a stimulant was suggested at diagnosis but the patient’s parents preferred to take a nonpharmacologic approach. Nonpharmacologic treatment is ongoing and includes family counseling (biweekly sessions) and dietary restrictions (primarily caffeine and sugar avoidance). The patient also receives interventions at school, including preferential seating, reminders to stay on task, daily check-ins with a teacher’s aide to review assignments, and weekly meetings with his guidance counselor to work on organizational skills.

Despite these interventions, the patient, now 13, has begun struggling academically, with below-average grades that do not reflect his potential. His teachers describe him as a generally pleasant student, but they report frequent tardiness, excessive assignments that are late or missing, a pattern of inattentive behavior, and social difficulties with peers. Most concerning to his parents: the patient is increasingly exhibiting emotional lability and confrontational behavior at home and in school. The parents also report delays in the patient’s maturity level compared with his siblings and peers.