Daisy is an 8-year-old girl with ADHD-Combined Presentation, well controlled on methylphenidate ER 36 mg for two years. Her mother brings her in because the school has called four times this month about explosive outbursts: throwing materials, screaming at a teacher, and shoving a classmate. Each episode was triggered by minor frustrations such as being told to wait her turn. Between outbursts, her mother describes Daisy as persistently irritable, angry, and difficult to be around. When the clinician asks what Daisy looks like on a good day, her mother says, "I can't remember the last one." This pattern has been present for over 14 months across home, school, and aftercare. Daisy has no history of discrete manic or hypomanic episodes.

Joaquin is a 13-year-old boy referred for suspected ADHD. Over the past 18 months, his grades have dropped from As to Cs. He cannot complete homework, loses track of classroom instructions, and appears "spacey" during tests. A previous provider started atomoxetine 40 mg with minimal improvement and is considering switching to a stimulant. During the intake, Joaquin's mother mentions that he has started erasing and rewriting the same sentences repeatedly, sometimes five or six times, and asks whether homework answers are "right" despite clear evidence they are correct. His checking provides only seconds of relief before the urge returns. His mother confirms the concentration problems developed only after the checking behaviors started.

Noor is a 7-year-old boy in kinship foster care with a documented history of physical abuse and neglect. His caregiver reports severe hyperactivity, difficulty following instructions, exaggerated startle to unexpected sounds, and nightly nightmares. He was diagnosed with ADHD at age 5, and a previous provider prescribed methylphenidate, which was discontinued after two weeks because the caregiver reported worsening nightmares and startle responses. His therapist has attempted trauma-focused CBT (TF-CBT) but reports that Noor cannot sustain attention through the narrative exposure components, dissociates during emotional content, and cannot retain session-to-session material. His hyperactivity and impulsivity were documented before the abuse began.

Hugo is a 10-year-old boy with ADHD-Combined Presentation on methylphenidate ER 27 mg for eight months. His inattention at school has improved. His mother reports he takes over an hour to fall asleep most nights, wakes frequently, and complains of uncomfortable leg sensations that he describes as "creepy-crawlies" that only improve when he walks around. His mother attributes the insomnia to his ADHD medication. When asked, she says the sleep problems existed before starting methylphenidate but have worsened slightly since.

Simone is an 11-year-old girl with ADHD-Predominantly Inattentive Presentation on atomoxetine 40 mg for one year. She was diagnosed with OCD six months ago after developing contamination fears and handwashing rituals. Her psychiatrist started fluoxetine 20 mg for OCD three months ago. At today's visit, Simone's mother reports that her pulse rate has increased, she has become more irritable, and she "isn't herself." The OCD symptoms have improved moderately on fluoxetine.