Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie
Examine Case 1. You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.
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At each Decision Point, stop to complete the following:
Decision #1: Differential Diagnosis
Which Decision did you select?
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources. Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie.
Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
Decision #2: Treatment Plan for Psychotherapy
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
Decision #3: Treatment Plan for Psychopharmacology
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources. Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients and their families.
Review of Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie
Introduction
Katie is a female 8 year-old Caucasian child who is brought to the clinic by her parents. She has a previous provisional diagnosis of attention deficit hyperactivity disorder or ADHD. Katie is having difficulties in school with concentration and performance. She is also not socializing well with her peers and likes to keep to herself. Her attention span is also short. Katie was born to mature parents (47 and 49 years old respectively) and had notable low wellness scores at birth. The parents bring with them the Connor’s Teacher Rating Scale form which had been filled by her teacher at school. This is helpful in assessing her condition and arriving at the correct diagnosis.
Decision Point Number 1
In using the available assessment tools and based on what the parents and the teacher had reported, the diagnosis of ADHD with predominantly inattentive presentation was made as stated above. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), inattention such as Katie’s must meet criterion A. 1 (a)-(i) for this diagnosis to be reached (APA, 2013). This was met by Katie because her Conner’s Teacher Rating Scale shows that she is easily distracted at school and has the habit of only paying attention to what she has interest in. She is also quite forgetful of what she has been taught in school, attributable too to her inattention. The hope in arriving at this diagnosis was that Katie would be started on ADHD treatment at the right time; a fact that would place her in a better position to be free of her symptoms in the shortest time possible (Wender & Tomb, 2017). However, on close assessment during the revisit session, subjective evidence showed clearly that Katie was also evidently hyperactive as she could not stay in one place during the interview with the psychiatric-mental health nurse practitioner or PMHNP. Apart from the fact that her answers were short, it was also revealed that she also wonders in thought while in class Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie. Her mental status examination was however largely unremarkable. She was oriented in all aspects and was dressed appropriately for both the time of the day and the weather. The only thing that stood out was that she had an imaginary friend by the name “Audrey.” Because of these findings, the presentation of the diagnosis had to be reviewed from predominantly inattentive to combined presentation (APA, 2013; Wender & Tomb, 2017). This is because her symptoms largely agreed also with criterion A. 2 (a)-(i) on hyperactivity and impulsivity. Moreover, she also fitted in with the rest f the criteria B, C, D, and E (APA, 2013). Thus the summary of her definitive diagnosis is ADHD with inattention, hyperactivity, and impulsivity. There wasn’t much difference in the initial decision and the revised one in terms of the results as the diagnosis itself has not changed but only the presentation. The fact that she had not started to show any significant response to treatment is to be expected because ADHD response to pharmacologic treatment typically takes weeks (Stahl, 2014; Katzung, 2018).
Decision Point Number 2
On the return visit the girl was put on wellbutrin (bupropion) 75 mg daily to be taken by mouth. This decision was taken because this s a major norepinephrine dopamine reuptake inhibitor or NDRI approved by the Food and Drug Administration (FDA) for the treatment of ADHD (Stahl, 2014; Katzung, 2018; Nursingworld.org, n.d.). The other reason for choosing wellbutrin is that it continues to work for several years later and in the process deters the recurrence of symptoms (Stahl, 2014). This long term remission is what was intended to be achieved by this choice. Wellbutrin is one of the best pharmacotherapeutic agents available for treating ADHD. However, its effects are normally not felt immediately and its full therapeutic action may be evident from up to four weeks later (Stahl, 2014). The results of this decision to start wellbutrin and what was expected are not significantly different for two reasons. First is that as stated it takes weeks for the full impact of the drug to be felt (this patient returned after four weeks). Two is that the questions that Katie is asking are not part of the known side effects of the drug (Stahl, 2014). Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie.
Case #1
A young girl with difficulties in school
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 Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie.
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.
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. Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie.
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. “Sometimes” Katie reports “I will just be thinking about something else and not looking at the teacher or other students in the class.” Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie.
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. Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie.
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.
Decision Point Number 3
As stated above, wellbutrin (bupropion) does not cause the patient to ask the type of questions that Katie is asking as a side effect (Stahl, 2014). Therefore, the decision taken in this instance is to reassure the patients that those questions she is asking are just part of her normal developmental progress given her age. They have got nothing to do with the treatment which is evidence-based. As at now, there is no evidence to suggest that the drug may cause such behavior. Therefore, because the overall response is so far promising (the teacher says the girl has started being more attentive and is doing her academic work), the dose of bupropion will be doubled to 150 mg daily. By making this decision, the hope is to augment the noted effect of the drug and ensure long-lasting remission. One consideration though is that the questions about death by Katie may persist. This would mean she is having some sort of suicidal ideation which may be caused by the wellbutrin (Stahl, 2014; Wender & Tomb, 2017). If this occurs, it would mean the results of the intervention and the expectations would be different, due to the fact that antidepressants generally may at times cause suicidal ideation. In that case, the drug would be changed from wellbutrin to concerta 18 mg mane per day. this would also be supported by psychotherapy in terms of training in social skills to improve her engagement with her peers and take her mind away from suicidal thoughts (Corey, 2017). In doing all this, the ethical principle of nonmaleficence (not causing harm) has to be remembered as continuing a drug that may result in her committing suicide will be immoral. Also the decision of the parents on treatment options has to be respected – ethical principle of autonomy (Haswell, 2019).
References
American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th ed. Arlington, VA: APA.
Corey, G. (2017). Theory and practice of counselling and psychotherapy, 10th ed. Boston, MA: Cengage Learning.
Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. Doi: 10.12968/joan.2019.8.4.177 Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie
Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. New York, NY: McGraw-Hill Education.
Nursingworld.org (n.d.). Pharmacological Principles. Retrieved 14 June 2019 from https://www.nursingworld.org/~4ae124/globalassets/catalog/sample-chapters/pmhnpsamplechapter.pdf
Stahl, S.M. (2014). Stahl’s essential psychopharmacology: Prescriber’s guide, 5th ed. New York, NY: Cambridge University Press.
Wender, P.H. & Tomb, D.A. (2017). ADHD: A guide to understanding symptoms, causes, diagnosis, treatment, and changes over time in children, adolescents, and adults, 5th ed. New York, NY: Oxford University Press. Diagnosis in Attention Deficit Hyperactivity Disorder (ADHD): The Case of 8 Year-Old Caucasian Girl Katie