Age: 14 years NAME A.L Gender: Male Ethnicity: white Background: A.L is a 14-year-old adolescent from a working-class family residing in an urban neighborhood.
Age: 14 years
NAME A.L
Gender: Male
Ethnicity: white
Background: A.L is a 14-year-old adolescent from a working-class family residing in an urban neighborhood. He lives with his mother and two younger siblings. A.L is currently attending a public middle school.
Presenting Concerns:
A.L’s mother has sought assistance at a mental health clinic due to concerns about her son’s behavior and academic performance. The primary concerns include:
Academic Struggles: A.L has experienced consistent academic difficulties throughout his school years. He has trouble staying focused during class, completing assignments, and following instructions from teachers. His grades have been below grade level, despite having average to above-average intelligence.
Inattention and Forgetfulness: A.L often appears forgetful and is easily distracted. He frequently loses or forgets school materials, assignments, and personal items. He has difficulty organizing tasks and managing his time effectively.
Impulsivity: A.L has displayed impulsive behavior in both school and home settings. He often acts without thinking through the consequences, leading to disruptions in the classroom and conflicts with peers.
Difficulty with Sustained Effort: A.L struggles to maintain focus on tasks that are not inherently interesting to him. This impacts his ability to complete assignments and chores at home.
Hyperactivity: While not hyperactive to the extent of some individuals with ADHD, A.L tends to fidget and is restless when seated. He finds it challenging to sit still for extended periods.
Emotional and Behavioral Issues: A.L’s difficulties with attention and impulse control have led to emotional and behavioral challenges. He has become frustrated and demotivated by his academic struggles, which affect his self-esteem and mood. There have been occasional outbursts of anger or frustration.
Family History:
There is no known family history of ADHD, although A.L’s mother reports that she had difficulties with inattention and impulsivity during her childhood. The family structure is stable, with two working parents and a supportive extended family.
School History:
A.L has had an Individualized Education Plan (IEP) since elementary school, which provides accommodations for his ADHD. He receives additional support from a resource teacher and special education services.
Medical History:
A.L’s medical history is unremarkable. He has no known physical health issues or medication allergies. He has not been previously diagnosed or treated for any mental health conditions.
Assessment and Diagnosis:
A.L’s presentation aligns with the criteria for Attention-Deficit/Hyperactivity Disorder (ADHD) as described in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). To confirm the diagnosis, a comprehensive assessment is conducted, including clinical interviews with A.L and his mother, teacher reports, and standardized ADHD rating scales. This evaluation helps to rule out other potential contributing factors and comorbid conditions.
Treatment Plan:
Upon diagnosis of ADHD, a multi-modal treatment plan is developed involving:
Medication Management: Considering the severity of A.L.’s symptoms and his significant academic challenges, medication is prescribed in consultation with a pediatric psychiatrist. Stimulant medications, such as methylphenidate, is effective in managing the symptoms of ADHD.
A.L will start methylphenidate
Behavioral Interventions: A behavioral intervention plan is established to address A.L.’s impulsivity, inattention, and academic challenges. This may involve implementing strategies like time management and organizational skills, reinforcement of positive behaviors, and coping skills to manage impulsivity.
Educational Support: A.L.’s existing IEP is reviewed and modified to accommodate the new treatment plan and to provide further academic support and accommodations.
Family Counseling: A.L.’s family is included in the treatment plan to provide them with guidance on managing ADHD-related behaviors, setting clear expectations, and offering emotional support to A.L.
Regular Follow-Up: Periodic assessments are scheduled to monitor A.L’s progress, Top of Form
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