{'fraction_non_alphanumeric': 0.029671897289586305, 'fraction_numerical': 0.0019971469329529245, 'mean_word_length': 4.719412724306689, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Pharmacotherapeutic challenges in the management of attention-deficit/hyperactivity disorder and chronic tics in a school aged child.

Parents report that as early as age 3 years, A. was hyperactive, restless and fidgety, had difficulty sitting still, and had problems with focus and concentration. He was reported to be impulsive and had difficulty sleeping. At age 5 years, following an upper respiratory infection, A. developed rather abrupt onset of eye rolling. Parents reported that he seemed sick but did not have a sore throat or fever. Antibody titers were done, but definitive cultures done to confirm whether there had been an acute infection were not done. A.’s tics were treated with antibiotics and seemed to improve. A. subsequently went on to develop eye blinking, initially thought to be related to an infection, and an ophthalmologist prescribed eye drops. A.’s eye blinking persisted despite administration of the drops, and parents subsequently sought neurological consultation. The pediatric neurologist recommended EEG and MRI, but there were no EEG and MRI abnormalities and no focal neurological exam findings. A.’s eye blinking persisted for six months after the infection, and then stopped and was replaced by repetitive head and neck movements, which where followed by lateral jaw movements over a period of months. Parents report that A.’s tics are more pronounced during periods of stress, illness, and sleep deprivation. A. is well aware of the movements, but he is not embarrassed by them. Parents report that kids have made fun of him, but he has not gotten into fights, and teachers are sensitive to the potential stress the tics could cause him. When he is highly focused, parents report that A.’s eye blinking, and head/neck/jaw movements diminish. Parents report that most recently, approximately a week prior to referral, A. had begun to make a throat clearing or grunting sound. Parents report that the pediatric neurologist diagnosed ADHD, which he treated initially with Concerta 18 mg and clonidine 0.1 mg at bedtime. Response was notable for an increase in eye blinking and head and neck movements, but no improvement in ADHD symptoms. Parents report that despite treatment, A. has continued to have difficulty with restlessness, fidgetiness, and concentration. They report that he needs to be reminded to complete tasks at hand, both at home and at school. He is impulsive, and blurts out answers out of turn. They report increasing oppositional behavior over the past 6 months, as he has had difficulty following rules and refuses to do work. Mother reports that A. has continued to show poor impulse control, evidenced by losing his temper when his younger sister takes his toys. However, A. has reportedly not become physically aggressive when he is upset. In addition, parents describe A. as a ‘‘worrier;’’ he worries excessively about each family member’s well-being and about catastrophic events on the news. Although he worries, parents report that he is able to separate from parents and never had difficulty attending school. He reports anxiety about cats and spiders, which he tries to avoid. A. has no history of rituals, obsessions, or compulsions. Although he does tend to order and arrange his belongings, it is not excessive. There is no history of anxiety performing activities in front of others. There is no history of hair pulling, skin picking, or other behavioral problems. He has had no problems with excessively elevated or depressed mood.