A 15-year-old girl presents to your clinic in distress. The patient fidgets and has a hard time remaining seated during the consultation. Her speech is pressured and she states that she is having increasing difficulty remembering to complete school work and chores at home since she began high school about 2 months ago. The patient is accompanied by her parents, who report that she is currently failing three classes and has recently begun having emotional outbursts (crying and hyperventilating) at school and demanding to be picked up early. On at least three occasions, the patient became so upset that she vomited. Since grammar school, her teachers have described her as a kind student, but excessive absenteeism and missing assignments have continually undermined her academic success. A pattern of inattentiveness and distractibility, disorganization, and impulsivity has been noted by several of her middle-school teachers. The patient has difficulty making friends and working collaboratively with her peers. During the interview, the patient declares that she hates school and says she feels "like a loser," and she believes that her parents hate her. She has a difficult time sleeping at night and waking up on time to catch her bus. The patient also says she "dreads" presentations or having to collaborate with other students, who think she is "weird and bossy."

The patient underwent neuropsychological testing 5 years earlier but the results were inconclusive. A trial using a psychostimulant did not result in an observable treatment effect and was discontinued after 2 weeks.