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CPAN Case of the Month – June 2025

Each month, PCPs call CPAN with a wide variety of mental health questions. Find out how CPAN helped a PCP during this consultation.

Psychiatrist: Catherine Karni, MD  

Consult: An 11-year-old male with ADHD and Anxiety on 1mg of Intuniv continues to worsen, and the family has concerns about psychotropic medication.  

First, there was a diagnosis of ADHD at age 7, but the parents decided against medical management. Next, the young person had DRESS syndrome after an antibiotic course, which worsened anxiety and further made the parents hesitant to try medical management. The patient’s anxiety has worsened to the point where he is refusing to attend school, complains of abdominal pain and and is fearful about storms, flying, and playing baseball. They started Intuniv 1mg nightly most recently, but have complaints related to sedation. Additionally, the family and PCP have concerns related to autism. As the young person matures, concerns related to social skills have emerged. They are in a charter school without any accommodations, and grades have dropped from A/B to Cs.  

Educational points for the PCP:  

This is clearly a complicated situation with multiple diagnoses being discussed. Deciding what is the next best recommendation to provide the parents should start with a thorough evaluation to clarify the diagnosis and prioritize. Given the ongoing concerns related to medications, any changes to medications should follow the prioritization process and go slowly.  

A direct one-time patient consultation may help the PCP and families get a quick sense of the order of next steps.  

If the PCP or family declines, then the following is a suggested order. The CPAN team will provide recommendations for referral options.  

  1. Referral for psychotherapy with a focus on anxiety. The team will attempt to locate therapists who are experienced ain ssessing and working with youth who have ASD in case psychological testing supports that assessment, Psychotherapy is the first-line treatment of choice for all childhood anxiety disorders.  
  1. Psychological assessment for ASD is best provided through a school process. Families can do outside assessments, but schools may refuse to accept results, so it is best to attempt testing first within their primary school district. Schools are required by law to respond within a defined time period with a parent/guardian request in writing an assessment for diagnosis and development of an IEP.  
  1. ADHD treatment is effective and relatively quick in action. Given that a psychological assessment at age 7 confirmed the diagnosis, the PCP should work with parents about trying a stimulant medication. A short acting methylphenidate can alleviate concerns related to side effects, and dose adjustments can occur every few days to either positive effect or side-effect/lack of efficacy. First, have a wash out period of the Intuniv and only work with one medication at a time to establish efficacy or lack thereof. This is recommended best practice and likely will help encourage trust with the family, given their concerns and history related to medications.