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Volume 1, Case #13
Ernesto Hernandez: Main Post
Volume 1, Case #13: The 8-year-old girl who was naughty
The case study that selected this week is on an 8-year-old girl who is having symptoms of attention deficit hyperactivity disorder (ADHD) with oppositional defiant disorder (ODD). ADHD is characterized as being a disorder that includes a combination of inattention and/or hyperactivity (Tenenbaum at al., 2019). According to Burke and Loeber (2017), ODD is characterized by chronic problems with noncompliance and defiance, antagonism, and irritability, typically having an onset early in childhood. She is reportedly negative and defiant at home, and she has similar reports from her teacher at school. Her teacher also reported that the client is disobedient. The client has reportedly had temper tantrums since the age of 5 but that they have decreased over the past three years. She is reportedly angry and resentful since her little sister was born six years ago. Her symptoms appear to be negatively affecting her academic performance, and she is getting into verbal arguments with other girls at school. The purpose of this discussion will be to review the assigned case study and develop a treatment plan for this client. I will provide rationales for each decision and support my information with evidence-based literature.
If the client was in my office, I would ask the following three questions:
1. Do you have a hard time paying attention or memorizing things when learning things or doing classwork?
Rationale: ADHD often manifests as limited attention span, distractibility, forgetfulness, or procrastination (Lawson, Nissley-Tsiopinis, Nahmias, McConaughy, & Eiraldi, 2017). Asking this question would provide me information about the client’s ability to pay attention, memorize, and concentrate. This would also be a good leading questions where I could branch off and then ask about day dreaming and other school-related topics that would provide me with more information about factors that may be affecting her academic performance.
2. Are you being bullied at school?
Rationale: Many children react differently to being bullied at school. Some children that are bullied may become aggressive towards their peers and unreasonable (Healy & Sanders, 2018). I would like to ask this question to rule out the possibility that something else may be contributing to the defiant behavior. I want to be sure that the behavior is not a result of another underlying problem. If the child is being bullied, they can have mood swings and difficulty concentrating at school.
3. How is your home life? Do you feel safe in your home?
Rationale: Children who are neglected, abused, or in an unhealthy home environment may displace their anger towards their peers or teachers at school (Casillas, Fauchier, Derkash, & Garrido, 2016). I would like to ask this question to ensure that the client’s behavior is not related to something being experience at home. Whenever possible, it is important to determine if there is an underlying problem that may be contributing to the behavior being displayed. If this is the case, the underlying problem must be addressed. This question would be asked without the parents in the room.
Additional Questions for People in Client’s Life
To obtain further information, I would like to ask additional questions to the client’s parents, siblings, caregivers, and teachers.
1. When did the defiant behavior start at home and school?
Rationale: It is important to ask when the behavior started, to rule out the possibility of there having been triggering events or stressors that may be contributing to the main problems (Leopold, Christopher, Olson, Petrill, & Willcutt, 2019).
2. Do you feel like there may be something contributing to your child’s behavior?
Rationale: Sometimes young clients will not explain what they are going through and be guarded with providers. Sometimes parents know if something happened to the child at home that may be affecting their current behavior. This question is important to ask to determine if there is something affecting the behavior or if it is related more to ADHD (Leopold, Christopher, Olson, Petrill, & Willcutt, 2019).
3. When did you notice that your child was struggling academically?
Rationale: It is important to identify when the child’s symptoms first began to interfere with his/her ability to excel academically because the practitioner could focus on this time period and ask about any trauma or factors that may have affected the client’s ability to concentrate in school (Leopold, Christopher, Olson, Petrill, & Willcutt, 2019).
Physical Exams and Diagnostic Tests
1. Comprehensive head-to-toe assessment: since the client is having complaints of a sore throat and fever, it is important to perform a physical head-to-toe assessment. According to McDonald and Eckhardt (2017), a physical examination is an opportunity to ask about and assess for suspected physical or sexual abuse. These are other factors that could potentially affect the client’s behavior.
2. Rapid Streptococcal Antigen Detection Test: this test could be performed to rule out group A streptococcal pharyngitis in children (Finkelstein et al., 2017). Since the client is having complaints of a sore throat, this test could be ordered to determine treatment.
3. Vision and hearing tests: vision and hearing tests should be ordered to rule out other possible conditions that may be interfering with the client’s ability to concentrate, pay attention, and poor academic performance (Hall et al., 2016).
4. Neurological exam: a neurological exam would test the following functions: eyelid strength, peripheral vision, visual function, tongue and lip movements, ability to identify tastes and smells, and sensations in the neck, head, and face (Sweeney et al., 2018). This exam could be done to rule out developmental or neurological factors.
5. Connors’ Continuance Performance Test (CPT): This is a neuropsychological task that been effective in differentiating ADHD from normal groups (MacQueen et al., 2018). This test would be important to conduct because it evaluates attention-related problems and treatment for participants aged eight years and older (MacQueen et al., 2018). This tool could also be used to aid in diagnosing clients with ADHD.
6. The Gordon Diagnostic Systems (GDS): This test is an assessment device that aids in the diagnosis of ADHD. The GDS consists of eleven tests that aid in assessing ADHD (Mayes, Frye, Breaux, & Calhoun, 2018).
1. ADHD: The client is reportedly is having difficulty with paying attention and is displaying defiant behavior. She is also having difficulty functioning at home, and she is struggling academically. These problems are associated with ADHD. ADHD includes a combination of inattention and/or hyperactivity (Tenenbaum at al., 2019). Since there do not appear to be other factors that may be contributing to these symptoms, a diagnosis of ADHD is my top diagnosis for this client.
2. Oppositional Defiant Disorder: This disorder is a behavioral or defiance disorder that is defined by chronic aggression, frequent outbursts, and a tendency to ignore requests and purposely irritate others (Burke & Loeber, 2017). The client in this case study displays impulsive behavior, and she is disobedient and argumentative.
3. Conduct Disorder: This is a highly impairing psychiatric disorder that usually emerges in childhood or adolescence and is characterized by severe antisocial and aggressive behavior (Fairchild et al., 2019). I am considering this diagnosis because the client is disobedient and argumentative. The client displays impulsive behavior. These are symptoms that are consistent with conduct disorder.
Top diagnosis: ADHD, inattentive type with comorbid ODD
The client has difficulty following commands and paying attention at school. She is also disobedient and argumentative. She is forgetful, easily distracted, and disorganized. The data presented in the case study supports this diagnosis.
1. Intuniv (Guanfacine) extended release 1mg orally at bedtime: Intuniv (guanfacine) is a norepinephrine receptor antagonist that is approved by the FDA to treat children ages 6-17 with ADHD (Childress, Hoo-Cardiel, & Lang, 2020). According to Childress, Hoo-Cardiel, and Lang (2020), Intuniv has central actions on postsynaptic alpha 2A receptors in the prefrontal cortex. The prefrontal cortex is believed to play a role in modulation of working memory, attention, impulse, control, and planning (Stahl, 2013). When considering the mechanism of action for ADHD, Intuniv is a nonstimulant that centrally acts on alpha 2A agonist receptors, increasing attention and memory. The dosing of 1mg orally at bedtime is appropriate for the treatment of ADHD. Pharmacokinetic properties differ for immediate and extended release formulations (Stahl, 2013). Guanfacine is metabolized by CYP450 3A4 (Stahl, 2013).
2. Ritalin (methylphenidate) chewable tablets 10mg orally in the morning: Ritalin (methylphenidate) is a stimulant that is approved by The Food and Drug Administration (FDA) for use in both children and adults for the treatment of ADHD (Pakdaman, Irani, Tajikzadeh and Jabalkandi, 2018). When considering the mechanism of action, Ritalin is believed to increase norepinephrine and dopamine actions by blocking their reuptake (Stahl, 2013). It also enhances dopamine and norepinephrine actions in the dorsolateral prefrontal cortex, improving attention, concentration, executive function, and wakefulness (Pakdaman, Irani, Tajikzadeh, & Jabalkandi, 2018).The dose of 10mg orally in the morning is appropriate for this client’s age (Sthal, 2013).
When considering pharmacokinetics and pharmacodynamics, the average half-life of Ritalin in children is 2.5 hours (1.5-5 hours) (Stahl, 2013). First-pass metabolism is not extensive with transdermal dosing, resulting in higher exposure to methylphenidate and lower exposure to metabolites as compared to oral dosing (Stahl, 2013). Ritalin is a short-acting stimulant that is absorbed well from the gastrointestinal tract and easily passes to the brain (Pakdaman, Irani, Tajikzadeh, & Jabalkandi, 2018). It blocks dopamine and norepinephrine reuptake by neurons, increasing the availability of the neurotransmitters (Stahl, 2013).
3. Wellbutrin (bupropion) XL 150mg orally daily: Wellbutrin is a norepinephrine dopamine reuptake inhibitor that is not approved by The Food and Drug Administration (FDA) to treat ADHD (Stahl, 2013). Wellbutrin is an antidepressant that is given off-label to manage ADHD symptoms. When considering the mechanism of action, Wellbutrin blocks norepinephrine and dopamine reuptake pumps, boosting the neurotransmitters norepinephrine/noradrenaline and dopamine (Goodman, 2017). According to Stahl (2013), the dosing of 150mg orally daily for Wellbutrin is safe for this client. When considering pharmacokinetics, Wellbutrin inhibits CYP450 2D6, and it has a parent half-life of about 10-14 hours (Stahl, 2013). The metabolite half-life is 10-27 hours, and food does not affect its absorption (Stahl, 2013).
I selected Ritalin and Guanfacine because they are both FDA approved, and Guanfacine is given off-label to treat ODD. Research also supports that a stimulant alone may not be effective in treating behavior seen in ADHD with ODD. According to Stahl (2013), ADHD with ODD comorbidly can be a difficult combination of behaviors to treat in children but combining stimulants with alpha 2A selective agonist actions may be useful in some clients with this combination of symptoms not adequately responsive to stimulants alone. One is a stimulant and the other is a nonstimulant. Some parents are often opposed to having their child on a stimulant. As future practitioners, it is important to be educated on FDA approved medications and on medication that may be given off-label for ADHD. I would select Ritalin and Guanfacine over Wellbutrin because Ritalin and Guanfacine are approved by the FDA, and they have a lot of evidence-based research that supports their effectiveness for the treatment of ADHD symptoms and ODD (Stahl, 2013). The medications and dosages are appropriate for the client’s age.
Based on the data provided in the case study, I would start the client both on Ritalin and Guanfacine. I would first begin with Guanfacine because it appears that the client’s mother is opposed to having her child start on a stimulant. Guanfacine is FDA approved for the treatment of ADHD and it is given off-label to treat ODD (Stahl, 2013). Starting both medications at the same time because it would be hard for the practitioner to determine which medication is doing what therapeutic or adverse effects. If possible, I would continue to encourage the mother to have the client participate in cognitive behavioral therapy (CBT). CBT is a short-term, goal-oriented form of psychotherapy that aims to change negative patterns of thinking and change the way a client feels about herself, her abilities, and her future (Maric, van Steensel, & Bögels, 2018).
In this case study, I learned about treating an 8-year-old client diagnosed with ADHD, inattentive type with comorbid ODD. I learned that high doses of stimulants can reduce inattention but that they can cause insomnia and do not adequately treat oppositional symptoms (Stahl, 2013). It is for this reason that it is recommended to start a client on both a stimulant and an alpha 2A selective noradrenergic agonist (guanfacine XR) to improve symptoms of ADHD and ODD (Stahl, 2013). I also learned about different aids that can be used to aid in diagnosing ADHS such as CPT and GDS. I will also consider ruling out other factors that may make the client appear like they have ADHD. For example, I would want to rule out a potential problem at home or school such as bullying or abuse. I would also want to rule out potential neurological, vision, or hearing problems. I learned that there are a lot of factors to consider when diagnosing and treating ADHD.
Treating clients with comorbid disorders can be challenging. It is important for practitioners to be up to date on evidence-literature being conducted on treating comorbid disorders. Sometimes clients will not respond to monotherapy, and other treatment options must be explored. There are a lot of factors that must be considered before diagnosing a client with ADHD. The practitioner must also work with the client and parents to determine the best therapeutic approach as treatment options warrant ethical and legal considerations. It is important to educate both clients and their parents on the risks and benefits of treatment. As future practitioners, we must have a strong understanding of the different psychiatric disorders and treatment options available. By having this understanding, we can ensure that we are providing the best care and doing all we can to provide optimum care.
Burke, J. D., & Loeber, R. (2017). Evidence based interventions for oppositional defiant disorder in children and adolescents. Handbook of evidence-based interventions for children and adolescents, 181.
Casillas, K. L., Fauchier, A., Derkash, B. T., & Garrido, E. F. (2016). Implementation of evidence-based home visiting programs aimed at reducing child maltreatment: A meta-analytic review. Child abuse & neglect, 53, 64-80.
Childress, A., Hoo-Cardiel, A., & Lang, P. (2020). Evaluation of the current data on guanfacine extended release for the treatment of ADHD in children and adolescents. Expert Opinion on Pharmacotherapy, 21(4), 417-426.
Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., … & De Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 1-25.
Finkelstein, S. N., Horowitz, G. L., Diamond, D. V., Bartels, P., Joseph, J., Hartman, L., … & Slack, W. V. (2017). Rapid Streptococcal Antigen Detection Test Performed by Parents of Children with Sore Throat. Journal of Participatory Medicine, 9.
Goodman, D. W. (2017). ADHD across the lifespan. Mental Disorders in Primary Care: A Guide to their Evaluation and Management, 99.
Hall, C. L., Valentine, A. Z., Groom, M. J., Walker, G. M., Sayal, K., Daley, D., & Hollis, C. (2016). The clinical utility of the continuous performance test and objective measures of activity for diagnosing and monitoring ADHD in children: a systematic review. European child & adolescent psychiatry, 25(7), 677-699.
Healy, K. L., & Sanders, M. R. (2018). Mechanisms through which supportive relationships with parents and peers mitigate victimization, depression and internalizing problems in children bullied by peers. Child Psychiatry & Human Development, 49(5), 800-813.
Lawson, G. M., Nissley-Tsiopinis, J., Nahmias, A., McConaughy, S. H., & Eiraldi, R. (2017). Do Parent and Teacher Report of ADHD Symptoms in Children Differ by SES and Racial Status? Journal of Psychopathology and Behavioral Assessment, 39(3), 426-440.
Leopold, D. R., Christopher, M. E., Olson, R. K., Petrill, S. A., & Willcutt, E. G. (2019). Invariance of ADHD symptoms across sex and age: A latent analysis of ADHD and impairment ratings from early childhood into adolescence. Journal of abnormal child psychology, 47(1), 21-34.
MacQueen, D. A., Minassian, A., Henry, B. L., Geyer, M. A., Young, J. W., & Perry, W. (2018). Amphetamine modestly improves Conners’ continuous performance test performance in healthy adults. Journal of the International Neuropsychological Society, 24(3), 283-293.
Maric, M., van Steensel, F. J., & Bögels, S. M. (2018). Parental involvement in CBT for anxiety-disordered youth revisited: family CBT outperforms child CBT in the long term for children with comorbid ADHD symptoms. Journal of attention disorders, 22(5), 506-514.
Mayes, S. D., Frye, S. S., Breaux, R. P., & Calhoun, S. L. (2018). Diagnostic, demographic, and neurocognitive correlates of dysgraphia in students with ADHD, autism, learning disabilities, and neurotypical development. Journal of Developmental and Physical Disabilities, 30(4), 489-507.
McDonald, K., & Eckhardt, A. L. (2017). Evidence-based practice in action: ensuring quality of pediatric assessment frequency. Journal of pediatric nursing, 35, 134-138.
Pakdaman, F., Irani, F., Tajikzadeh, F., & Jabalkandi, S. A. (2018). The efficacy of Ritalin in ADHD children under neurofeedback training. Neurological Sciences, 39(12), 2071-2078.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Sweeney, K. L., Ryan, M., Schneider, H., Ferenc, L., Denckla, M. B., & Mahone, E. M. (2018). Developmental trajectory of motor deficits in preschool children with ADHD. Developmental neuropsychology, 43(5), 419-429.
Tenenbaum, R. B., Musser, E. D., Morris, S., Ward, A. R., Raiker, J. S., Coles, E. K., & Pelham, W. E. (2019). Response inhibition, response execution, and emotion regulation among children with attention-deficit/hyperactivity disorder. Journal of abnormal child psychology, 47(4), 589-603.
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