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. 

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      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.  

Differential Diagnoses

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. 

   

CheckPoints: 

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.

Lessons Learned: 

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. 

    
           https://doi.org/10.4088/pcc.v03n0204 

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). 

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