CHALLENGING CASE: FAMILY RELATIONSHIPS AND ISSUES ADHD, Divorce, and Parental Disagreement About the Diagnosis and Treatment*

CASE Steven Davis, the divorced father of Sara Davis, aged 7 years, called Dr. Francis, Sara’s pediatrician, with a sense of distress and urgency as he asked for “another opinion” about his daughter’s attentiondeficit hyperactivity disorder (ADHD). Mr. Davis asked if he could first speak to the doctor without Sara present. Dr. Francis agreed, and at a first meeting Mr. Davis explained that his ex-wife, now remarried as Carol Henry, unilaterally took Sara for an evaluation by a psychologist associated with a large tertiary care university medical center. According to Mr. Davis, he was never contacted by the psychologist, nor did he know of the evaluation at the time. The psychologist determined that Sara had ADHD and recommended stimulant medication as part of the treatment plan. Mr. Davis, who had joint legal and physical custody of Sara and her older brother, did not experience any behavior problems with Sara on the 3.5 days per week she spent with him. He acknowledged she required immediate response and firm discipline, but she generally behaved quite well at his home. He believed her mother’s environment was more chaotic, with looser and inconsistent standards of discipline. He was aware of some behavior problems at school, but believed they were minor and were managed effectively by Sara’s teacher. He was not willing to permit his daughter to take methylphenidate, but he also feared that Sara’s mother had a secret agenda. He believed that Sara’s mother and stepfather intended to soon leave the state and wished to take both children with them. He believed that his opposition to the use of medication would be used as grounds for the judge to award physical custody of the children to the mother and allow them to leave the state together. The pediatrician asked Mr. Davis if the children’s mother had been informed about his desire for another opinion. Mr. Davis said that he had asked his ex-wife if she would join him for this visit with the pediatrician. Mrs. Henry refused, declaring that Sara had received an excellent evaluation from an expert at the university and that another evaluation was unnecessary and would stress Sara needlessly. Dr. Francis telephoned Mrs. Henry to see whether she could directly engage the mother. Mrs. Henry initially agreed to an office visit and then canceled the appointment. Dr. Francis then received a letter (copied to Mr. Davis) from Mrs. Henry’s attorney suggesting that any further evaluation should wait until the psychologist’s written report of the evaluation is received. Two weeks later, Dr. Francis received the evaluation. The psychologist had performed a complete psychometric assessment that indicated the absence of any learning problems. There were minimal signs of impulsivity in the office setting. The evaluator had relied on a history obtained only from the mother that was supplemented by a standardized behavioral questionnaire from both the mother and teacher which indicated clinical levels of impulsivity, inattention, and oppositional behavior in both the home and school settings. The teacher wrote that Sara’s performance could be very inconsistent, ranging from quite competent to out of control. The psychologist was aware of Sara’s living in two separate households and acknowledged the possibility of the parents’ very different parenting styles. The psychologist’s diagnosis was ADHD (combined type) and oppositional defiant disorder. He recommended a behavioral program for home and school, counseling for Sara and her parents (not clear whether that included the biological father), and stimulant medication. After reading the report, Dr. Francis made two more calls to Mrs. Henry and left messages that she would like to meet with the mother. The calls were not returned.