Identify people in the patient’s life, you would need to speak to or get feedback from to further assess the patient’s situation..
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Case 1: 8-year-old girl who was naughty
Child maltreatment (physical, emotional and sexually) has consistently been found to be associated with attention-deficit/hyperactivity disorder (ADHD) (Stern, Agnew-Blais, Danese, Fisher, Jaffee, Matthews, & Arseneault, 2018). Three questions that I would ask the eight-year-old: Tell me about a time when you have experienced any trauma? Have anyone inappropriately touched you? Have you had any physical abuse? Has anyone ever did anything that made you feel harmful? Did your dad ever live in the home? Have you ever experience any family violence in the home? Rationale: The American Academy of Child and Adolescent Psychiatry (AACAP) also advises the clinician to have a degree of suspicion of possible abuse in cases of young children presenting with ADHD-like symptoms (Vaughn & Kratochvil, 2006). Could you explain to you and your father’s relationship? Understanding the family dynamics and the exposure in the home. (Did mom and dad have a history of yelling, fussing, and fighting in the home? Have you ever been suspended from school? Have you been in detention at school? Rationale: Evaluate the degree of her behaviors at school.
Identify people in the patient’s life, you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Medical, social, and family histories should be reviewed for medical, contextual or environmental, and genetic risk factors (Felt, Christner & Kochhar, 2014). Ideally, the father, if he is available: Questions would be to gain insight into the family dynamics. Does anyone in your family have a mental health diagnosis? Can you explain your history in school? (Did you have academic trouble?) Rationale: Assess the possibility of genetics and to make sure of the appropriate diagnosis for the patient. Explain the relationship between you and her mom? Was there any physical or domestic violence in the home? Rationale: Gathering more information about the home environment would help identify childhood exposure.
Mother would be a second person: Can you explain your childhood when you were adopted? Did you experience family violence? How was your relationship with your daughter’s father? Do you have trouble keeping tasks? Does anyone in your family have a history of mental illness? Rationale: The pathogenesis of ADHD is assumed to be multifactorial, influenced by genetic and environmental factors (Starck, Grunwald, & Schlarb, 2016).
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that the initial assessment consists of a thorough developmental, medical, psychiatric, and family history of the child, as well as a systematic assessment for DSM-IV symptoms. Standardized rating scales, such as the Conners’ Rating Scales for parents and teachers, or the ADHD-IV Rating Scale, may be utilized to document baseline symptom severity (Vaughan & Kratochvil, 2006). Lab work: To rule out any co-morbid conditions that can be the cause of the disease process. Hearing and eyesight tests, a blood test for lead levels (kids living in low poverty areas are more susceptible to lead exposure). A thyroid assessment to rule out possible disorder and CT/MRI to rule out brain abnormalities. The diagnostic test administered is not based on an isolated assessment. For example, ACE assessment, which is a trauma assessment for mom and daughter to rule out trauma history). Bipolar assessment because with the medication in the scenario, her focus and attention improved, but her aggression continue to have highs and lows. Strength and Difficulties questionnaire (behavior screening for emotion, conduct, hyperactivity, peer problems, and pro-social behavior). School reports of psychoeducational or other standardized testing, grades, behavior reports, and any individualized educational plans (IEPs) should be reviewed in the course of the diagnostic evaluation (Vaughn & Kratochvil, 2006).
List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
Three differential diagnosis: Oppositional Defiant Disorder which is classified as: Disruptive, Impulse-Control, and Conduct Disorders: According to the Diagnostic and Statistical Manual of Mental Disorders, for a patient to be classified as having oppositional defiant disorder A pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least six months as evidenced by at least four symptoms of the following categories, and exhibited during interaction with at least one individual who is not a sibling ((American Psychiatric Association, 2013). The patient presented with anger and resentful, aggression, refusing to comply with school rules and loss of temper. The teacher also complains of the patient being more argumentative and disobedient than the other children in her class, which is a classified symptom.
2. Intermittent explosive disorder
3. Posttraumatic stress disorder
V61.8 Sibling relational problem
Pharmacologic agents and their dosing
There are different classifications of medications that can be initiated for the treatment of ADHD. Effective management of ADHD is necessary for children and adolescents and may include non-pharmacologic treatments, pharmacologic therapy including use of stimulant and non-stimulant medications, or a combination of the different treatment modalities which is considered safe and effective (Brown, Samuel, & Patel, 2018). The two pharmacologic medications for the patient would be a stimulant and a drug that can be used as monotherapy or combined with the medication to minimal side effects. Ritalin LA 20mg is the first drug of choice for ADHD. Stimulants are considered to be the first drug of choice in the treatment of ADHD. Short-acting start working in about 30 to 45 minutes and generally wear off in 3 to 6 hours as compared to long-acting that work in phases and last longer. As it relates to the above scenario, the patient would require medication to last the duration of the school day.
Atomoxetine is a non-stimulant therapy that works by increasing the amount of norepinephrine in the brain. This drug is not a controlled substance making it less likely to cause abuse and dependency. The weight of the individual doses this medication. For children less than 70kg the initial dose is 0.5mg/kg/ per day and increases to a target dose of 1.2mg/kg per day after seven days (Stahl, 2017).
Medication is effective for treating ADHD symptoms, and studies suggest that earlier identification and treatment may improve longer-term educational, work, and social outcomes (Currie, Stabile, & Jones, 2014).
Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations
The lesson learned from this case study: There is an abundance of information to compile when diagnosing and implementing treatment for a child with ADHD. The total dynamics of ADHD and other conditions will be vital to make an appropriate diagnosis. The inclusion of socio-economic status, environmental factors, family structure, genetics, co-morbid conditions that predispose the child will need further exploitation. To offer available community resources for psychotherapy, for example, in-house therapy due to the length of time it takes to drive as voiced by the patient’s mother would help add to the quality of care and possibly decrease stress. How would this implement this into my practice? In would be used to treat the whole person versus the symptoms.