A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay
BACKGROUND
In psychopharmacology you met Katie, an 8-year-old Caucasian female, who was brought to your office by her mother (age 47) and father (age 49). You worked through the case by recommending possible ADHD medications. As you progress in your PMHNP program, the cases will involve more information for you to sort through.
For this case, you see Katie and her parents again. The parents have reported that the medication given to Katie does not seem to be helping. This has prompted you to reconsider the diagnosis of ADHD. You will consider other differential diagnoses and determine what information you need to accurately assess the DSM-5 criteria to make the diagnosis of ADHD or another disorder with similar diagnostic features.
When parents bring their child to your office, they may have read symptoms on the internet or they may have been told by the school “your child has ADHD”. Your diagnosis will either confirm or refute that diagnosis. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.
Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine a differential diagnosis and to begin medication, if indicated. The PMHNP makes this diagnostic decision based on interviews and observations of the child, her parents, and the assessment of the parents and teacher.
To start, consider what assessment tools you might need to evaluate Katie.
- Child Behavior Check List
- Conners’ Teacher Rating Scale
The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised” (Available at: https://www.ncbi.nlm.nih.gov/projects/gap/cgi-bin/GetPdf.cgi?id=phd000099.1 ). This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, makes careless mistakes in her schoolwork, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. She has difficulty interacting with peers in the classroom and likes to play by herself at recess. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.
When interviewing Katie’s parents, you ask about pre- and post-natal history and you note that Katie is the first born with parents who were close to 40 years old when she was born. She had a low 5 minute Apgar score. The parents say that she met normal developmental milestones and possibly had some difficulty with sleep during the pre-school years. They notice that Katie has difficulty socializing with peers, she is quiet at home and spends a lot of time watching TV.
SUBJECTIVE
You observe Katie in the office and she is not able to sit still during the interview. She is constantly interrupting both you and her parents. Katie reports that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds some subjects boring or too difficult, and sometimes hard because she feels “lost”. She admits that her mind does wander during class. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay. “Sometimes” Katie reports “I will just be thinking about something else and not looking at the teacher or other students in the class.”
Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. She offers no other concerns at this time.
Katie’s parents appear somewhat anxious about their daughter’s problems. You notice the mother is fidgeting with her rings and watch while you are talking. The father is tapping his foot. Other than that, they seem attentive and straight forward in the interview process.
MENTAL STATUS EXAM
The client is an 8-year-old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is neutral. Katie says that she doesn’t hear any ‘voices’ in her head but does admit to having an imaginary friend, ‘Audrey’. No reports of delusional or paranoid thought processes. Attention and concentration are somewhat limited based on Katie’s short answers to your questions.
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHAT IS YOUR DIAGNOSIS FOR KATIE?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- You have selected Autism Spectrum Disorder along with co-occurring Social Anxiety Disorder. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.
Based on your diagnosis and the parents’ concerns, you decided to begin Risperal 0.5 mg po BIDRESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Upon her return to the clinic in 4 weeks, Katie’s parents feel that Katie is calmer, but no changes in her school performance have been noted. Additionally, her parents have noticed that she seems more “tired” than usual, and report that she seems to ‘space out’ more often. They further report that she has been falling asleep during her usual television shows.
Increase Risperdal to 1 mg po BIDGuidance to Student
The information provided in the scenario is not suggestive of the diagnostic criteria for autism spectrum disorder (ASD) or co-occurring social anxiety disorder. Even if it were, Risperdal is not routinely used to treat autism-spectrum disorder- in fact, there are no FDA approved drugs for treatment of this disorder. Antipsychotics are only used to treat violent or self-injurious behaviors in ASD, and in those cases, used off-label. Antipsychotics did slow Katie down, but also gave her a other side effects, and did nothing to treat the primary presenting problems of inattention.While CBT has evidence of efficacy in both autism spectrum disorder and social anxiety disorder, and while video modeling and video-self modeling therapy has some evidence for efficacy in ASD, these therapies will not, in and of themselves, help Katie as she does not have ASD with co-occurring social anxiety disorder.
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Based on your diagnosis and the parents’ concerns, you decided to begin Risperal 0.5 mg po BID
Based on your diagnosis and the parents’ concerns, you decided to begin Celexa 20 mg po dailyRESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.
- Katie’s parents feel that Katie is no calmer, and that there have been no changes in her school performance. Her parents are also concerned that Katie has been asking them “odd” questions such as “where do you go when you die?” and “when you die, do you get to see your pets that have died?” Her parents indicated that she had never had such questions before.
Increase Celexa to 40 mg PO dailyGuidance to Student
The information provided in the scenario is not suggestive of the diagnostic criteria for autism spectrum disorder (ASD) or co-occurring social anxiety disorder. Even if it were, Celexa is not routinely used to treat autism-spectrum disorder- in fact, there are no FDA approved drugs for treatment of this disorder. Antidepressants may be considered if the child has co-occurring depression and/or anxiety disorder, but only after careful consideration of risk/benefits associated with antidepressant therapy in a child. The Celexa did nothing to alter Katie’s behavior, and in fact, Katie developed what appeared to be some morbid thoughts, possibly suggesting a fascination with death. While there is insufficient information to suggest that she was entertaining suicidal ideation, her parents clearly indicated that she was not having these thoughts before the antidepressant therapy was initiated.While CBT has some evidence for efficacy in ASD and social anxiety disorder, it will not help Katie as she does not have either of these diagnoses. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.
Based on your diagnosis and the parents’ concerns, you decided to begin Celexa 20 mg po dailyRESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- You have selected Autism Spectrum Disorder along with co-occurring Social Anxiety Disorder. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer
Based on your diagnosis and the parents’ concerns, you decided to begin Celexa 20 mg po dailyRESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s parents feel that Katie is no calmer, and that there have been no changes in her school performance. Her parents are also concerned that Katie has been asking them “odd” questions such as “where do you go when you die?” and “when you die, do you get to see your pets that have died?” Her parents indicated that she had never had such questions before.
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Increase Celexa to 40 mg PO dailyThe information provided in the scenario is not suggestive of the diagnostic criteria for autism spectrum disorder (ASD) or co-occurring social anxiety disorder. Even if it were, Celexa is not routinely used to treat autism-spectrum disorder- in fact, there are no FDA approved drugs for treatment of this disorder. Antidepressants may be considered if the child has co-occurring depression and/or anxiety disorder, but only after careful consideration of risk/benefits associated with antidepressant therapy in a child. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay. The Celexa did nothing to alter Katie’s behavior, and in fact, Katie developed what appeared to be some morbid thoughts, possibly suggesting a fascination with death. While there is insufficient information to suggest that she was entertaining suicidal ideation, her parents clearly indicated that she was not having these thoughts before the antidepressant therapy was initiated. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.While CBT has some evidence for efficacy in ASD and social anxiety disorder, it will not help Katie as she does not have either of these diagnoses.
Augment with CBT
Reconsider Diagnosis
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- You have selected 315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.
Begin Donepezil 10 mg po dailyRESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s parents feel that Katie is no different. She has had no changes in school performance, but has been having trouble falling asleep at night
- Additionally, Katie has reported having “scary dreams” to her parents and has been feeling “stomach sick”
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Explain that the side effects will abate with time and increase to 15 mg orally daily. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.Augment with Trazodone 50 mg po at HS.Reconsider DiagnosisRESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- You selected Attention deficit hyperactivity disorder, predominantly inattentive presentation. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer
Begin Wellbutrin 75 mg orally dailyRESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s parent report that the teacher has indicated that Katie seems to be paying more attention during class. They have also noticed that Katie is able to attend more closely to her homework. However, her parents are somewhat concerned that Katie has been asking them “odd” questions such as “where do you go when you die?” and “when you die, do you get to see your pets that have died?” Her parents indicated that she had never had such questions before. A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay.
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Assure the parents that the questions Katie are asking are age-appropriate and increase dose of Wellbutrin to 150 mg dailyImplement psychodynamic therapyChange drug to Concerta 18 mg orally daily in the morning A young girl with difficulties in school – Child Abuse Case study – Katie ADHD Essay