Response # 3

Discussion Assignment:

Respond to the following Case study:

Explain how you might apply knowledge gained from the Response case studies to your own practice in clinical settings.

· Share additional interview and communication techniques that could be effective with your colleague’s selected patient.

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· Suggest additional health-related risks that might be considered.

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· Validate an idea with your own experience and additional research.

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· Explain your reasoning using at least TWO different references from current evidence-based literature in APA Format.

Case Study Response

Case 1: Volume 1, Case #13: The 8-year-old girl who was naughty 

List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions

1.How are you performing in school?

     Rationale:  Children with ADHD portray academic underachievement due to inattentiveness and disruptive as well as disruptive behavior. Their general academic achievement is affected by these behaviors and the results are challenges in reading, spelling and math (Leahy, 2018).

2.How is your relationship with your family members, your teachers and your friends?

Rationale: This question is meant to elicit information regarding this patient’s social skills. Most ADHD children have problematic peer relations as well as emotional dysregulation . Therefore, it is possible that  this patient will report always being in trouble with teachers, as well as not being like by her peers due to her poor social skills ( Sjowall, D., & Thorell, L. B. 2014)

3. Do you find it hard to read and follow instructions, and do you have a hard time understanding and finishing your assignments?

Rationale: Most children with ADHD have trouble following instructions, either because they do not understand the instructions or because they do not want to. Most children are therefore academically challenged ( Parker, 2005)

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.

The patient’s parents( Mother, father), the patient’s grandparents if they are close to the child, the child’s siblings, peers, and teachers who interact with the patient.

The questions would include

1.When did you start getting concerned about her symptoms?

Rationale: This question would be asked to parents or grandparents who help take care of  the patient .  Most children generally have inattentiveness and hyperactivity. Most of them cannot adequately follow orders or concentrate on a task for a long time. However, there is that time when a parent gets concerned about these symptoms and decide to seek for professional opinion or diagnosis.

2. Is there somebody in either her father’s or mother’s side of the family that has ADHD?

This question is to the parents and grandparents who know the patient’s background. This question is meant to find out if ADHD runs in the family and if it is genetic.

3. To the mother: Were you smoking or drinking when you were pregnant with the patient?

Rationale:  Alcohol and tobacco use during pregnancy can cause a child to be born with ADHD.

4. Is the patient able to finish her homework on time?

Rationale: This question can be asked to both the parents and the teacher. This is to find out if the patient is able to complete her tasks.

5. Is the patient  able to interact and play normally with friends?

Rationale: This is a question to her teachers and her friends. Most ADHD patients do not have social skills and so they prefer to stay on their own and do not play well with their peers (CDC 2019).

6. Is the patient disruptive in class?

Rationale: This question is to the teacher. Most ADHD  patients have disruptive behavior, they talk too much, are overly active and have trouble controlling impulses.

7.What learning disabilities does the patient have?

Rationale: Most children with ADHD have problems with math, reading and spelling (Wender, 2000).

Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

As of date, there is no single laboratory test that is used to diagnose ADHD. Psychiatrists rely on continuous performance tests( CPT) for the diagnosis This is an automated scoring test whose results analysis and interpretation are also automated ( Boutros, Fraenkel,  & Feingold, 2005). 

A neurologic exam such as EEG or MRI  of the brain  would also be necessary to ensure that the patient does not have any brain injury   since one of the causes of ADHD is brain injury. A DSM5 diagnostic exam would be done to find out if the patient has all the symptoms of ADHD ( Leahy, 2018).

Head to toe physical exam would be the first thing to conduct on this patient. Since the patient comes in with fever and sore throat, it is important to first find out why she has fever and sore throat. Throat cultures will be collected to check for the organisms causing t sore throat. Also, blood cultures will need to be sent to find out if the patient has systemic infection. The other test to conduct would be the hearing and vision test. This is to make sure that these problems are not causing  all these issues (CDC2019).

List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.

Attention-Deficit and Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a  Inability to pay attention, control impulses and behaviors as well  as overactivity. Although most children will have some of these characteristics, ADHD is set apart by the  intensity, pattern and persistence of these characteristics (CDC 2019).  

Some symptoms of ADHD include extreme day dreaming,, forgetfulness, loosing or displacing things a lot, over talkativeness, making careless mistakes as well as extreme fidgeting and squirming ( CDC 2019). The causes of ADHD include alcohol and tobacco  consumption by the mother while pregnant, low birth weight, brain injury, premature delivery and exposure to pollutants such as lead ( Parker,2005).

Diagnosis of ADHD is often difficult since the symptoms resemble  characteristic behavior of some normal children and therefore, no one particular  test has been discovered and tried out to successfully diagnose  ADHD. Tests may include physical exams to rule out deficits such as hearing and vision, which could be responsible for some behaviors.

Attention-Deficit and Hyperactivity Disorder and

Oppositional Defiant Disorder  (ODD) co morbidity

Oppositional Defiant Disorder (ODD), is a condition in which a child exhibits extreme anger, irritability, temper tantrums, refuses to follow orders and directions and is easily annoyed, for a period of at least 6 months (Ehmke, 2019). According to  Wender, (2000), between 20-30% of children with ADHD also have learning disabilities, while 35% of those with ADHD have Oppositional Defiant Disorder(ODD).Children with ADHD are likely to have learning disabilities such as problems reading, spelling and math (Wender, 2000).

Developmental Delays

           Children who have developmental or intellectual  delays normally have learning, behavior, physical and language challenges in life. Developmental delay begins at infancy, but proper diagnosis is only possible after 5 years of age when IQ tests can be performed reliably . Children with developmental delays are always lagging behind in achieving age-related  milestones. When a child lags behind in more than one area of development, they are said to have global developmental delays(Stojanovic,2020).

           The cause of developmental delays is not clearly known, but premature birth,  genetic factors, infection during pregnancy are thought to be some of the causes of developmental delay. Developmental delays may also be a sign of other underlying problems such as Down’s Syndrome, autism, cerebral palsy, fetal alcohol spectrum disorders and Angelman’s Syndrome among other neurological and genetic conditions(Chung et al, 2011).

List two pharmacologic agents and their dosing that would be appropriate for the patient’s ADHD therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.

Methylphenidate (D,L) is an FDA approved central nervous system stimulant which is commonly prescribed to both children and adults for the treatment of ADHD. According to CDC (2019), children on fast acting methylphenidate have between 70-80% decrease in ADHD symptoms. Methylphenidate inhibits dopamine reuptake while at the same time it increases norepinephrine and dopamine activity, thus enhancing concentration, attention and wakefulness ( Fairman,  Peckham, & Sclar, 2020).

At this age, the patient can get the transdermal patch with a starting dose of 10mg every 9 hours, with an increase of 5mg weekly to a maximum dose of 30mg every 9 hours (Stahl,2014b). The pharmacokinetics of methylphenidate (D.L.) in children present a delay in minimum peak concentrations and second peak concentrations when compared to adults causing children to have higher concentrations of the drug, due to their smaller body size and the total volume of distribution(Rafael, 2008).

Guanfacine XR is a selective  adrenoreceptor  agonist that  works on alpha 2A agonist  sites on the prefrontal cortex of the brain It is an FDA approved  non-stimulant medication for children and adolescents with ADHD  and Oppositional Defiant Disorder symptoms ( Ngairita, 2007).

Guanfacine increases attention,, improves memory, planning and control, as well as  reduces impulsivity.  Dosage is calculated on mg/kg basis (0.05mg/kg to 0.12mg/kg) to be taken once daily. It may take days for  full benefits of Guanfacine to be realized ( Stahl,2014b).  Guanfacine  should be swallowed whole with a small amount of water or milk and high fat foods should be avoided as they cause an increase in the blood levels of guanfacine  (Guanfacine extended release (XR). (2013 ).

If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.

This case shows several weeks of ADHD treatment with little success. Although the diagnosis of ADHD  was properly diagnosed and was being treated as a solo case, the Physicians did not diagnose ODD as an accompanying diagnosis for this patient. The patient experiences increased attention while on Lisdexamfetamine and dextroamphitamine, but has no improvement on Symptoms related to ODD. To top it all, the patient has insomnia, which could be as a result of  D-methylphenidate XR stimulant in the initial stages.

Multi drug therapy  approaches should have been initiated  to help decrease ODD symptoms (Vitiello et al., 2015).  A combination therapy of guanfacine XR and lisdexamfetamine  should have been utilized as they have been  proven to be effective  for these two conditions. (Diane Christopher, 2010).

Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.

           From this case, I have learnt that an effective diagnosis leads to effective and timely treatment. In this case, there was delay in achievement of full therapeutic effects of treatment because the diagnosis was not completed on time.  I have also learnt that at times, it is necessary to try a multi-drug therapy instead of using just one drug for  the treatment of some conditions. In this case, the original belief was that Guanfacine XR alone would be sufficient in the treatment of the patient because unlike methylphenidate its efficacy in the treatment both ADHD and ODD is known.  However, after reviewing the outcome, it was decided that this patient required Multidrug therapy in order to achieve full therapeutic benefits.  From this case, it is clear that PMHNP should keep their knowledge on mental health up to date in order to be effective in diagnosing and treating mental health disorders.

            It is also clear from this case that in order for diagnosis and therapy to be effective, there should be cooperation from family members, teachers and peers. Sometimes parents tend to cover up for their children and excuse their behavior, leading to delayed diagnosis and start of therapy.

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