A young girl with difficulties in school Decision Tree case study
A young girl with difficulties in school Decision Tree case study
BACKGROUND
In psychopharmacology you met Katie, an 8-year-old Caucasian female, who was brought to your office by her mother (age 47) and father (age 49). You worked through the case by recommending possible ADHD medications. As you progress in your PMHNP program, the cases will involve more information for you to sort through.
For this case, you see Katie and her parents again. The parents have reported that the medication given to Katie does not seem to be helping. This has prompted you to reconsider the diagnosis of ADHD. You will consider other differential diagnoses and determine what information you need to accurately assess the DSM-5 criteria to make the diagnosis of ADHD or another disorder with similar diagnostic features. A young girl with difficulties in school Decision Tree case study.
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When parents bring their child to your office, they may have read symptoms on the internet or they may have been told by the school “your child has ADHD”. Your diagnosis will either confirm or refute that diagnosis.
Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine a differential diagnosis and to begin medication, if indicated. The PMHNP makes this diagnostic decision based on interviews and observations of the child, her parents, and the assessment of the parents and teacher.
To start, consider what assessment tools you might need to evaluate Katie.
- Child Behavior Check List
- Conners’ Teacher Rating Scale
The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised” (Available at: https://www.ncbi.nlm.nih.gov/projects/gap/cgi-bin/GetPdf.cgi?id=phd000099.1 ). This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, makes careless mistakes in her schoolwork, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. She has difficulty interacting with peers in the classroom and likes to play by herself at recess.
When interviewing Katie’s parents, you ask about pre- and post-natal history and you note that Katie is the first born with parents who were close to 40 years old when she was born. She had a low 5 minute Apgar score. The parents say that she met normal developmental milestones and possibly had some difficulty with sleep during the pre-school years. They notice that Katie has difficulty socializing with peers, she is quiet at home and spends a lot of time watching TV.
SUBJECTIVE
You observe Katie in the office and she is not able to sit still during the interview. She is constantly interrupting both you and her parents. Katie reports that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds some subjects boring or too difficult, and sometimes hard because she feels “lost”. She admits that her mind does wander during class. “Sometimes” Katie reports “I will just be thinking about something else and not looking at the teacher or other students in the class.” A young girl with difficulties in school Decision Tree case study.
Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. She offers no other concerns at this time.
Katie’s parents appear somewhat anxious about their daughter’s problems. You notice the mother is fidgeting with her rings and watch while you are talking. The father is tapping his foot. Other than that, they seem attentive and straight forward in the interview process.
MENTAL STATUS EXAM
The client is an 8-year-old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is neutral. Katie says that she doesn’t hear any ‘voices’ in her head but does admit to having an imaginary friend, ‘Audrey’. No reports of delusional or paranoid thought processes. Attention and concentration are somewhat limited based on Katie’s short answers to your questions. A young girl with difficulties in school Decision Tree case study.
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHAT IS YOUR DIAGNOSIS FOR KATIE?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.
314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- You have selected Autism Spectrum Disorder along with co-occurring Social Anxiety Disorder. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. Be sure to include standardized assessment instruments that you would administer
Based on your diagnosis and the parents’ concerns, you decided to begin Risperal 0.5 mg po BIDRESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Upon her return to the clinic in 4 weeks, Katie’s parents feel that Katie is calmer, but no changes in her school performance have been noted. Additionally, her parents have noticed that she seems more “tired” than usual, and report that she seems to ‘space out’ more often. They further report that she has been falling asleep during her usual television shows. A young girl with difficulties in school Decision Tree case study.
Augment current dose of Risperdal with Cognitive-Behavioral Therapy and Video Modeling/self-modeling therapyGuidance to Student
The information provided in the scenario is not suggestive of the diagnostic criteria for autism spectrum disorder (ASD) or co-occurring social anxiety disorder. Even if it were, Risperdal is not routinely used to treat autism-spectrum disorder- in fact, there are no FDA approved drugs for treatment of this disorder. Antipsychotics are only used to treat violent or self-injurious behaviors in ASD, and in those cases, used off-label. Antipsychotics did slow Katie down, but also gave her a other side effects, and did nothing to treat the primary presenting problems of inattention. A young girl with difficulties in school Decision Tree case study.While CBT has evidence of efficacy in both autism spectrum disorder and social anxiety disorder, and while video modeling and video-self modeling therapy has some evidence for efficacy in ASD, these therapies will not, in and of themselves, help Katie as she does not have ASD with co-occurring social anxiety disorder.
315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in MathematicsRESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- You have selected 315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics. Based on this choice, outline the remainder of the diagnostic evaluation that you will conduct on this child and their parents. A young girl with difficulties in school Decision Tree case study. Be sure to include standardized assessment instruments that you would administer.
Decision Point TwoRESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Katie’s parents feel that Katie is no different. She has had no changes in school performance, but has been having trouble falling asleep at night
- Additionally, Katie has reported having “scary dreams” to her parents and has been feeling “stomach sick”
Decision Point ThreeReconsider Diagnosis
Guidance to Student
The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it Katie did meet the diagnostic criteria for this condition, donepezil is not FDA approved for treatment of this disorder, instead, is FDA approved for treatment of Alzheimer’s disease. Although used off-label in memory disorders in other conditions, there is nothing to suggest that it would be effective in consideration of Katie’s presenting symptoms. It is also noted that Katie is demonstrating side effects to this medication, and increasing the dose would not be appropriate.Augmentation with Trazodone to address the side effects of this medication is not appropriate.
At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.
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