Decision Tree: A Young Girl with Difficulties in School
Decision Tree: A Young Girl with Difficulties in School
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder seen in children. ADHD makes children unable to pay attention, control impulsive behaviors or become overly active (Doernberg & Hollander, 2016). It occurs in three forms which include predominantly inattentive presentation, predominantly hyperactive-impulsive presentation or a combined presentation. The purpose of this paper is to review a case study of a young girl with difficulties in school. The paper will follow a decision tree to execute a differential diagnosis and offer treatment to the client. The paper will also summarize with ethical issues that will guide communication and treatment plan.
Case Study
The case presents an 8-year-old Caucasian female named Katie. Her parents brought her to the clinic after being on ADHD medication without reprieve. The patient requires a new diagnosis. The parents believe that their child had ADHD after reading through the internet. As a clinician, the duty at hand is to confirm or refute the parents’ diagnosis. To make the diagnosis, interviews, and observations of the child, her parents and assessment of parents and teacher will be followed. For instance, Conner’s Teacher Rating Scale-Revised report from the teacher indicates that Katie’s attention is poor, she is easily distracted, makes careless mistakes in her schoolwork, she forgets things already learned and has poor arithmetic, reading and spelling skills (Laureate Media, 2020). She pays attention to things of interest and has poor interaction with peers. From the parents’ report, they state that she has difficulty socializing with peers, quiet at home and watches TV most of the time. An observation of the patient shows that she cannot sit still and she interrupts conversations. The patient states that school is OK and admits that her mind wanders during class. The parents appear anxious. The mental exam shows a neutral affect and euthymic mood. The patient denies voices in the head but admits having an imaginary friend ‘Audrey’. She has limited concentration since she provides short answers to questions.
Decision One
314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation
Reason for Selecting the Decision
Katie fulfills the DSM-5 criteria for ADHD predominantly inattentive presentation. According to DSM-5, a child should present with six or more symptoms of inattention for at least six months to a point they are inappropriate for developmental level. Katie has seven out of eight symptoms required for inattention. Her attention is class is poor, she has trouble keeping attention on tasks, does not follow through on instructions, has trouble organizing activities, avoids things requiring mental effort, loses things needed for tasks and is easily distracted and forgetful (Rigler et al., 2016). Katie only has one hyperactivity symptom, which is an inability to sit still and one impulsivity symptom, which is interrupting others.
Presence of 299.00 Autism Spectrum Disorder (ASD), mild and co-occurring; 300.23 Social Anxiety Disorder is refuted because although Katie has difficulty settling down, impulsivity, social awkwardness and ability to focus on things that interest her, she lacks other symptoms of ASD. Her communication is not impaired, she does not portray a restricted repertoire of activities and interest and she does not have poor social interaction (Doernberg & Hollander, 2016). Additionally, she has no reported social phobia that would point towards social anxiety disorders. The presence of 315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics is also refuted. Although Katie has inattention, as well as poor arithmetic, spelling and reading skills, her inattention is not caused by frustration, lack of interest or lack of ability during academic work (Friedman et al., 2019). Additionally, her inattention appears in a non-academic setting unlike most patients with specific learning disorders.
Expected Results
The clinician expects to make the right diagnosis to help in coming up with an intervention that resolves Katie’s symptoms and dissipates the concern displayed by her parents. An accurate diagnosis will aid in reviewing treatment options and help in planning a course of appropriate medical and psychosocial interventions.
Differences between the Results
Although the DSM-5 indicated that the patient has ADHD, predominantly inattentive presentation, the clinician decided to administer child behavior checklists to assess Katie’s emotional and behavioral problems. The CBCL offered information on mood and behaviors, social competence and academic functioning (Hong & Comer, 2019). The parents and the teacher filled the checklists and the scores confirmed the diagnosis made. The clinician initiated the treatment plan.
Decision-Two
Begin Adderall XR 10mg orally daily
Reason for Selecting the Above Option
Adderall XR is a stimulant medication and the first-line treatment for ADHD symptoms. It enhances arousal in the prefrontal cortex
and works by blocking dopamine and norepinephrine transporters, dampening monoamine oxidase action and enhancing the release of dopamine into the synaptic space (Brown, Samuel & Patel, 2018). Research shows it improves symptoms for 70-80% of people with ADHD. It improves focus and reduces impulsivity and hyperactive behaviors. The XR is a long-acting medication that reduces the need for in-school dosing, enhances compliance and offers more after school treatment effects.
Wellbutrin 75 mg is avoided because it is an antidepressant and less effective than stimulants when managing ADHD. Additionally, it is not FDA approved for ADHD and it is used as an ‘off-label’ medicine (Brown et al., 2018). It also has a high risk of inducing suicidal ideation. Strattera 25mg is a second-line treatment for ADHD and has a slow response compared to Adderall. It also has a risk for suicidal ideation as well as adverse events like sedation and decreased appetite which may result in compliance issues (Brown et al., 2018).
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Expected Results
The clinician expects that the patient’s symptoms will improve with minimal side effects. The Conner’s Teacher Rating Scale-Revised report should indicate better concentration, less distraction, fewer mistakes, better memory and improved arithmetic, reading and spelling skills.
Differences between the Results
After four weeks the parents appeared happy and they reported that Katie was paying more attention at school. The only problem was that Katie maintained concentration in the morning classes while she daydreamed in the afternoon (Laureate Media, 2020). Her appetite had also decreased.
Decision Three
Add a small dose of immediate-release Adderall in the afternoon.
Reason for Selecting the Option
The main aim of the treatment was to arrest ADHD symptoms and dispel Katie’s parents’ concerns. The initial dosage offered a therapeutic response although it did not sustain attention for the whole day. Therefore, a small dose of immediate-release Adderall in the Afternoon will help sustain attention for the entire day and even into the early evening to help Katie tackle her homework (Laureate Media, 2020). The decreased appetite can be linked to weight loss which is a common side effect of stimulant medication. Assuring Katie’s parents about weight loss does not tackle their concern on the return of symptoms in the afternoon. Lastly, adding family therapy to the current medication does not handle the inattentive symptoms in the afternoon although it may increase knowledge on the disease, challenges faced and ways of managing the symptoms.
Expected Results
The clinician expects sustained concentration throughout the day and into the early evening.
Difference between Expected and Actual Results
The patient appeared as expected.
Ethical Considerations
In terms of ethics, when handling ADHD in children, it is essential to make an accurate diagnosis. The child should be thoroughly evaluated and information gathered from multiple sources (Zuddas, Banaschewski, Coghill & Stein, 2018). Informed consent is also essential to ensure that the client understands the risk and benefits of medication taken as well as alternative interventions available. Autonomy should also be maintained by allowing the child to participate in the decision-making process. For Katie, her objective and subjective report were taken, the Conner’s Teacher Rating Scale-Revised report adopted and the CBCL used to guide diagnosis. After diagnosis, the parents were informed of the available interventions and they consented to the selected medication. Katie’s opinions were taken into consideration as well.
Assignment: Practicum: Decision Tree
For this Assignment, you examine the client case study in this week’s Learning Resources. Consider how you might assess and treat pediatric clients presenting with symptoms noted in the case.
Note: This Assignment is the first of three assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.
Learning Objectives
Students will:
Evaluate clients for treatment of mental health disorders
Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders
The Assignment:
Examine Case 1. You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.
At each Decision Point, stop to complete the following:
Decision #1: Differential Diagnosis
Which Decision did you select?
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
Decision #2: Treatment Plan for Psychotherapy
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
Decision #3: Treatment Plan for Psychopharmacology
Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients and their families.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.