Jade is an 8-year-old girl diagnosed with ADHD, Predominantly Inattentive Presentation, six months ago. She was started on methylphenidate ER 36 mg (taken daily, including weekends) with moderate improvement in classroom attention. At today's visit, her mother reports that Jade has become increasingly worried: she asks repeatedly whether she did her homework correctly, gets stomachaches before school, and cannot fall asleep because she worries about the next day. Her mother asks whether the medication is "causing the anxiety." Jade's teacher notes that her anxiety fluctuates with her academic performance and is minimal during school breaks. There is no family history of anxiety disorders.

Ezra is a 6-year-old boy diagnosed with ADHD-Combined Presentation. Methylphenidate ER 18 mg has helped his attention at school, but at home he is increasingly defiant: he refuses to follow household rules, deliberately annoys his younger sister, argues with every request, and blames others when things go wrong. His teacher describes him as "stubborn and willful" but not particularly irritable or tearful. He has no history of cruelty to animals, fire-setting, or property destruction. His mother asks whether he needs a separate medication for the defiance.

Vivian is a 16-year-old girl with ADHD-Combined Presentation on stable lisdexamfetamine 50 mg for two years. Over the past two months, she has become withdrawn, stopped attending her art club, sleeps 12 hours per day, and told her mother "I don't see the point of anything anymore." She denies active suicidal ideation but endorses passive death wishes: "I wouldn't care if I didn't wake up." Her mother reports Vivian was recently rejected from two college programs and failed a major exam.

Gavin is a 9-year-old boy with ADHD-Combined Presentation on methylphenidate ER 36 mg for one year. His attention and impulsivity have improved, and his parents are satisfied with the medication. However, he reads at a first-grade level, cannot do grade-level math, and his written expression is severely impaired. His teacher says: "He sits still and pays attention now, but he still can't do the work." Testing reveals average IQ with specific deficits in phonological processing and math reasoning. Separately, his occupational therapist has noted new sensory sensitivities since the medication was optimized: he covers his ears in noisy environments and refuses certain clothing textures. His teacher also mentions that now that he sits still, she notices he rarely initiates conversation with peers and tends to play alone at recess.

Malik is a 17-year-old boy with ADHD-Combined Presentation, a persistent motor tic disorder (shoulder shrugging, eye blinking), and cannabis use disorder in early remission (3 months abstinent). He previously took methylphenidate ER but stopped at 15 when cannabis use escalated. He is failing 11th grade, cannot sustain attention in his intensive outpatient program group sessions, and his tics have worsened over the past month (shoulder shrugging now occurs roughly every 30 seconds and eye blinking is noticeable to peers, though Malik reports they are not painful or functionally limiting). His addiction counselor urgently requests ADHD treatment to support his recovery.

Cleo is a 14-year-old girl with a 3-year history of ADHD-Combined Presentation treated with mixed amphetamine salts XR 20 mg. Over the past 10 days, she has become unusually energetic, sleeping only 3-4 hours per night without fatigue, talking rapidly about plans to start three businesses, and spending $400 of her savings on supplies for projects she abandons within hours. Her mother describes the change as "a completely different kid." She has a maternal uncle with bipolar I disorder.