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discussion week 9 main post
The client, Tonja, is a 13-year-old female who was brought to therapy by her parents at the request of her school. According to her teachers, Tonja is unable to focus and requires near constant redirection in the classroom. She displays pressured speech, impulsivity, and an inability to focus. Tonja has been homeschooled by her mother, and entered public school this year. Tonja’s parents state she has been extremely active and has had difficulty focusing since the age of four. The client’s parents report she has been assigned detention several times and received poor grades on her first report card this year. Tonja discusses difficulty with homework. She feels she annoys others and wishes she could be invisible. She enjoys playing video games, but her parents want her to complete her homework and spend time with the family before playing.
Tonja exhibits symptoms consistent with the criteria for attention-deficit/hyperactivity disorder (ADHD) in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013). She displays inattention as well as hyperactivity and impulsivity. She has trouble remaining attentive in the classroom and when doing homework. She frequently fails to finish her assignments in the classroom and at home. Tonja’s father states she spends hours at the kitchen table attempting to get her homework done, she spreads everything out haphazardly on the table, but then cannot find anything. Tonja’s mother reports frequent trips back to the school to pick up worksheets or books that the client forgot to bring home. Tonja states she hates homework and often thinks about playing video games when she is trying to study. During the therapy session, Tonja constantly fidgets, has difficulty remaining seated, talks excessively, does not wait for an answer to her questions, and starts grabbing toys off the shelf without asking for permission. Tonja states she hates to have to sit in the classroom and always feels like she needs to move.
Tonja would benefit from a combination of psychotherapeutic and pharmacological interventions. The American Academy of Child and Adolescent Psychiatry considers behavioral therapy to be the first-line treatment for children and adolescents with mild ADHD and states behavioral therapy should be used in conjunction with medications for moderate to severe ADHD (Pliska, 2007). Recent studies have shown that behavioral therapy amplifies the effects of medication in adolescents with ADHD (Sibley, Kuriyan, Evans, Waxmonsky, & Smith, 2014). Tonja’s teachers should be provided with behavioral classroom approaches, the parents should be given behavioral parent training, and Tonja needs behavioral therapy sessions (Delaney, Desocio, & Carbray, 2014). She should be prescribed lisdexamfetamine 30 mg orally every morning. Randomized controlled trials found lisdexamfetamine is superior to methylphenidates in the treatment of ADHD and have less side effects than amphetamines (Soutullo et al., 2013; Stuhec, Munda, Svab, & Locatelli, 2015).
The stimulant, lisdexamfetamine, should provide Tonja with an increased ability to focus and a decrease in hyperactivity and impulsivity immediately. Behavior therapy will take several weeks to a few months to help reduce her disruptive behaviors. The goal of behavior therapy will be to strengthen her positive behaviors and to eliminate her negative behaviors.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Delaney, K. R., Desocio, J., & Carbray, J. A. (2014). Psychotherapy with children. In K. Wheeler (Ed.), Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (pp. 597-624). New York, NY: Springer Publishing Company.
National Institute of Mental Health. (n.d.). Any disorder among children. Retrieved from https://www.nimh.nih.gov/health/statistics/prevalence/any-disorder-among-children.shtml
Plizka, S. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 46(7), 894-921. doi:10.1097/chi.0b013e318054e724
Sibley, M. H., Kuriyan, A. B., Evans, S. W., Waxmonsky, J. G., & Smith, B. H. (2014). Pharmacological and psychosocial treatments for adolescents with ADHD: An updated systematic review of the literature. Clinical Psychology Review, 34(3), 218-232. doi:10.1016/j.cpr.2014.02.001
Soutullo, C., Banaschewski, T., Lecendreux, M., Johnson, M., Zuddas, A., Anderson, C., … Coghill, D. R. (2013). A post hoc comparison of the effects of lisdexamfetamine dimesylate and ssmotic-release oral system methylphenidate on symptoms of attention-deficit hyperactivity disorder in children and adolescents. CNS Drugs, 27(9), 743–751. doi:10.1007/s40263-013-0086-6
Stuhec, M., Munda, B., Svab, V., & Locatelli, I. (2015). Comparative efficacy and acceptability of atomoxetine, lisdexamfetamine, bupropion and methylphenidate in treatment of attention deficit hyperactivity disorder in children and adolescents: A meta-analysis with focus on bupropion. Journal of Affective Disorders, 178, 149-159. doi:10.1016/j.jad.2015.03.006
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