Respond to at least two of your colleagues who were assigned to a different case than you. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
NOTE: Positive Comment
Case #13 the 8-year-old girl who was naughty
This case study will examine an 8-year-old girl who initially presents to the pediatrician’s office with complaints of a fever and sore throat. After further examination, the client is diagnosed with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). According to Ghosh, Ray, & Basu (2017), characteristics of ODD include persistent anger or irritable mood, argumentativeness, defiance, and vindictiveness for at least 6 months. ADHD is characterized by a pattern of inattention, hyperactivity, and impulsivity that interferes with daily functioning or development (American Psychiatric Association, 2013).
3 Additional Assessment Questions for the Client:
1. I would ask the client and her mother how often her daughter displays symptoms that are congruent with ODD and? According to the authors Ghosh, Ray, & Basu (2017), the occurrence of ODD symptoms must be disproportionate to the child’s developmental stage and age.
2. I would ask the client if she had trouble learning in class when she was younger. The onset of ADHD symptoms usually occurs before a child reaches age 12, and in some children, these symptoms are noticeable at age 3 (Sibley, Rohde, & Swanson, 2017).
3. A final question that I would ask the client is if she interrupts her classmates when they are speaking. Children suffering from ADHD feel the need to be constantly active and struggle with controlling impulsive behaviors (American Psychiatric Association, 2013).
Feedback From the Client’s Loved Ones
The first person in this client’s life that I would like to further interview is the client’s mother. According to Stahl (2019), the client’s mother is 26 years old and is a single parent of two children, ages 8 and 6. I would want to ask the client’s mother more about her daughter’s academic performance in earlier grades. Identifying the precise onset of the client’s ADHD symptoms will assist the provider in creating the most appropriate treatment for the client (Stahl, 2014). I would also like to interview the client’s teacher in order to gain another perspective on the client’s behavior in the classroom. The client’s teacher did use an ADHD rating scale, but scales of that nature are very broad and do not elaborate on the child’s specific classroom behaviors. A third person that I would interview is the client’s 6-year-old sister. According to Stahl (2019), the client began displaying signs of anger and resentfulness when her sister was born. I would ask the client’s sister if she felt safe at home and if she and her sister fought often, in order to determine if the home environment is safe for both children.
Physical Exams and Diagnostic Tests
The physical assessment of the client is essential for developing an appropriate diagnosis and treatment plan. Visual assessment of the client’s behaviors during the physical assessment will be extremely useful to the provider. The provider would also want to obtain and review the client’s report cards along with any behavior reports, and attendance records from the client’s school (Adesman, 2011). The healthcare provider should also review the client’s pediatric health records to see if her symptoms are congruent with a learning disability, auditory processing disorder, signs of language delay, spacial orientation confusion, and complete a more thorough family history involving learning disabilities (Adesman, 2011). A complete blood count should be down to rule out physical illness as a causetive factor for the client’s ODD symptoms. The client is currently suffering from a fever and sore throat, which could be an indicator of PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections). Since the client does have a current sore throat, a rapid strep test should be ordered. If the client does test positive for strep, it could explain the client’s symptomologies impulsivity, temper tantrums, and aggressiveness.
Autism Spectrum Disorder: there are deficits in social-emotional reciprocity, ranging from an abnormal social approach and failure to communicate in a standard back-and-forth conversation (American Psychiatric Association, 2013). There is also a reduced sharing of interests, emotions, or affect, along with a failure of the patient to initiate or respond during social interactions (American Psychiatric Association, 2013). The client’s history does not show any indication of impaired communication.
Conduct Disorder: characterized by behavior that violates either the rights of others or major societal norms, the symptoms must be present for at least 3 months with one symptom having been present in the past 6 months. The symptoms of conduct disorder must cause significant impairment in social, academic or occupational functioning (American Psychiatric Association, 2013). Per the client’s medical record, her symptoms fit the time frame for conduct disorder, however, her behavior is not this severe in nature.
ADHD with Co-occurring ODD: The authors Ghosh, Ray, & Basu (2017), describe the characteristics of ODD as persistent anger or irritable mood, argumentativeness, defiance, and vindictiveness for at least 6 months. ADHD is characterized by a pattern of inattention, hyperactivity, and impulsivity that interferes with daily functioning or development (American Psychiatric Association, 2013). The client’s behavior is congruent with ADHD with co-occurring ODD.
Pharmacological Agents for ADHD/ODD Therapy:
Risperdal is the first pharmacological agent that I would choose for this client. This medication is not listed on the suggested medication list of the case study, however, the medication list does list “other” as a possible choice. According to Stahl (2014), Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to 16 years of age. Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. The second medication that was chosen for this client is Vyvanse. Vyvanse increases norepinephrine and dopamine actions by blocking their reuptake and creating an environment that allows their release (Stahl, 2013). Vyvanse also causes an enhancement of dopamine and norepinephrine in specific areas of the brain that may improve attention, concentration, executive dysfunction, and wakefulness (Stahl, 2013). According to Stahl (2014), it is thought that the increased dopamine action caused by Vyvanse, may help with hyperactivity. I would initially start this client on Vyvanse due to its efficacy in treating symptoms of ADHD. If the child’s academic performance and classroom behavior improve, perhaps ODD symptoms will improve.
According to Stahl (2019), the closest child psychotherapist is an hour away, therefore the client did not receive therapy. I would refer the client and her mother to case management in order to connect the client with resources that are closer to her home. I would also ask the client’s school what type of resources are available in terms of psychotherapy.
Through this case study I have learned that co-occurring childhood disorders can be difficult to treat. Pediatric clients can respond differently to medication dosages than adults, so careful dose titration is essential. Pediatric clients also rely on their parents or caregivers to provide them with their prescribed medications and transportation to medical appointments. It is essential that the healthcare provider conveys how important treatment regime compliance is to both the client and their caregiver.
Adesman, A. R. (2011). The Diagnosis and Management of Attention-Deficit/Hyperactivity Disorder in
Pediatric Patients. Primary care companion to the Journal of clinical psychiatry, 3(2), 66-77.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author. Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: current insight. Psychology
research and behavior management, 10, 353-367. https://doi.org/10.2147/PRBM.S120582
Sibley, M. H., Rohde, L. A., & Swanson, J. M. (2017). Late-Onset ADHD Reconsidered with
Comprehensive Repeated Assessments between Ages 10 and 25. American journal of psychiatry,
175(2), 140-149. https://doi.org/10.1176/appi.ajp.2017.17030298
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (fourth ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Stahl Online. (2019). Volume 1 case #5: The sleepy woman with anxiety. (PDF file).