A 12-Year-Old Boy With Falling Grades and Forgetful Behavior

Stephen Soreff, MD; Foad Afshar, PsyD, EdM

Disclosures

June 25, 2019

Physical Examination and Workup

During the initial interview, in addition to the history taken from both parents, a mental status examination is conducted via a clinical interview with the patient. The examination reveals relatively high anxiety, orientation x 3, coherent thoughts, and an affect that is contextually congruent. Michael shows a good sense of humor and typical mastery of oral expression, with complex sentence structure and age-appropriate vocabulary. Michael’s short- and long-term memory are intact as well. No hallucinations, delusions, or violent behavior are reported. He does not report thoughts of self-harm, although he does note that he feels "stupid" and not part of groups sometimes. He has no history of head injuries or any significant medical conditions. No routine laboratory or physical examination findings appear abnormal. Test results also indicate that Michael does not have any hearing or sight problems.

Growing up, Michael reached all developmental milestones within normal limits; indeed, Michael is reported to have talked and walked early (and often). In addition, his parents describe him as an “active and outdoors kind of kid.” No history of any major family crises or emotional traumas is reported. The boy’s early school history is significant for reports of classroom disruption and Michael’s need to move about; however, at that time, Michael was able to meet academic demands without having to do his homework. Michael has no family history of mental illness; however, his father states that he himself often starts too many tasks and sometimes does not complete them.

During the diagnostic session, Michael becomes visibly fidgety, his speech becomes more stammered, his ears become red, and he turns blotchy red when asked to read a third-grade ̶ level text passage and do basic arithmetic. He later explains that when he has to do tasks like this, he becomes nauseous and feels “hot.” Michael also reports that he often gets headaches as soon as he begins to do tasks that require extended attention over time, especially “if they are boring.” He has no difficulty memorizing dialogue from plays (he is involved in theater), nor does he have trouble reading musical notes during band rehearsal.

He admits to feeling “stupid” in school and taking his frustrations out on kids whom he considers to be smart by sabotaging their learning through disruptive behaviors.

In a comprehensive psychoeducational evaluation by school personnel (including completion of Conners’ Rating Scales by Michael’s parents and teachers), which was carried out prior to the consultation, his teachers indicated that Michael was unable to focus on tasks; abandoned tasks that he had already started, moving on to new ones; and daydreamed often.

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