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Objectives

Evaluate the signs and symptoms of Attention-deficit hyperactivity disorder.
Understand that ADHD often occurs with other mental and behavioral disorders.
Understand that diagnosis of ADHD requires both the presence of symptoms and impaired function.
Understand possible treatment and goals related to treatment

Subjective

Chief Complaint (CC). “He is having trouble focusing in school.” As stated by the foster father. 

History of Present Illness (HPI). JD is an 11-year-old male brought in by his foster father for an initial evaluation after having complaints from his teacher at school that the child is fidgety in class, absent-minded, talkative, forgetful, and careless. Foster father states that there is some anxiety noted as well that seems to be at school, due to the child being worried about what his peers think, but also at home stating the child seems to be a “people pleaser” which seems to be his comfort zone. He was previously neglected at a previous foster home and witnessed traumatic events occurring to his two younger brothers and to his older sister. His sister was abused the most according to the foster father, stating that she was not fed and kept in a room, and had to use the bathroom on the floor. The foster father stated that the brothers would be thrown in the room and see the sister suffering when they were in trouble as punishment. It is unknown when symptoms of anxiety and inattention first started but have been present since he was placed in this current foster home 3 months ago. Foster father states that the child asks a lot of repeat questions at home not paying close attention or keeping attention, seeming to not listen at times. He also states, and the child confirms, that it is hard to sit still and he often fidgets and it is hard to remain seated due to it being difficult to sit still for extended periods of time. Foster father confirms that the child is talkative at home like he is in school, is easily bored and changes activities frequently along with the child admitting to feelings of inner restlessness. It was stated that without supervision, getting homework completed in a timely manner is a challenge. All symptoms at home and at school are causing moderate impairment in functioning. The foster father and child state that the child is sleeping well and eating well. Child denies any thoughts or intent of hurting himself or others. 

 

Past Psychiatric History

General Statement. The patient has not had any previous treatment.

Hospitalizations. Denies

Medication trials. None.  

Psychotherapy or Previous Psychiatric Diagnosis. He has no prior history of psychiatric or psychotherapy visits or diagnosis.

Substance Current Use and History. Denies

Family Psychiatric/Substance Use History. History is unknown for both biological parents, per foster father. Child has been in foster care for most of his life. Both younger brothers have been diagnosed with ADHD. 

Psychosocial History. He is a minor under his foster father’s care, living with him and his two younger brothers. He is in school where he has struggled with dyslexia and is currently on a 504 plan. For fun he enjoys playing with his siblings. There are no previous legal issues. The child does have a history of emotional abuse. No physical abuse stated.  

Medical History. Asthma 

Current Medications. Albuterol inhaler as needed. 

Allergies. No known drug allergies.  

ROS 

GENERAL. No general physical complaints.

NEUROLOGICAL. (Information not obtained, will request information from recent pediatrician visit) 

CARDIOVASCULAR. (Information not obtained, will request information from recent pediatrician visit) 

Objective:

Vitals signs. (Information not obtained, will request information from recent pediatrician visit) 

Physical exam. (Information not obtained, will request information from recent pediatrician visit) 

Diagnostic results. Vanderbilt assessment scale done by parent and teachers shows predominantly hyperactive/impulsive. A recent visit with the pediatrician, no abnormalities were stated, chart and information will be requested for review of complete physical and any labs or tests done.  

Assessment

Mental Status Examination. The patient looks his stated age and appears to be calm, friendly, and alert with intact memory. He is cooperative during the interview but distracted at times. The patient is being seen via telehealth in his home setting and is well-groomed and dressed appropriately. There are no abnormal movements noted, however, he is fidgety and leaves his seat several times. Signs of anxiety are noted and a short attention span. He speaks with a normal rate and volume, but hesitant to answer at times. The stated mood is “fine.” He has logical and goal-directed thought processes.  No flight of ideas or looseness of associations are noted. The patient denied any thoughts or desires to harm himself. Judgment and insight appear fair. 

Reflections. With this appointment, I can see how important it is to build rapport with each client and the importance of building trust in order to be able to get information that they may hesitant at first to share with you. I can see how important it is to continue to evaluate during each consecutive session to ensure that the diagnoses are accurate and that the patient is being treated in a way that is beneficial to them. I would like to be sure that the pediatrician’s results were obtained as well to make sure there were no abnormalities.  

Treatment Plan. Treatment was initiated with guanfacine 1 mg tab in the morning. Foster parent was educated on stimulants being the first line treatment and requested the use of a non-stimulant to see if it could help prior to starting a stimulant due to the stimulant side effects of appetite loss and stimulants addictive properties. After discussing options, he agreed to trial guanfacine since a prior foster child had utilized it with good results. Behavior therapy is also recommended as part of the treatment plan. Guanfacine has been shown to be effective and well tolerated in some patients with ADHD, and in one study, 90% of the cases that were looked at showed a favorable response and medication tolerability, although only 10% of the cases had it used as a first-line treatment (Hassan et al., 2020). Although using it as a first-line treatment does not follow NICE guidelines, it is the responsibility of the provider to properly educate the patient and parent on options and consider their wants and needs when choosing a medication and treatment (Dalrymple et al., 2020).

Differential Diagnoses

The primary diagnosis is attention-deficit hyperactivity disorder, unspecified , since there are criteria for both hyperactivity and inattentiveness present, and though the assessment scales lean towards hyperactive, further assessment is needed to be sure full criteria is met. Many criteria are present and are significantly affecting the patient, but all symptoms are not clear, a diagnosis noting unspecified type can be used at this time (Mahone & Denckla, 2017). The patient does not have 6 criteria met in either the hyperactive or inattentive category as required for a diagnosis, but a mixture of the two. Both of his brothers have ADHD and it is known that family history is a risk factor with ADHD in children from 75%-90% (Faraone & Larsson, 2019). Clarifying symptoms for a proper diagnosis will be needed during future visits. 

As far as symptoms go and criteria for a diagnosis, the patient is believed to have struggled with these symptoms for more than six months but due to his recent placement this is not certain. The patient may be able to shed more light on when symptoms started once he is more comfortable and willing to discuss more. It is known that in both the home and school setting, the child does not seem to be listening when spoken to at times, needs supervision when doing homework or gets distracted and does not get it done in a timely manner, often loses things and can be forgetful, along with being easily distracted. These are five symptoms noted in the criteria for inattentive ADHD, and six are required for diagnosis. As far as hyperactive symptoms, he does fidget and squirm, tends to leave his seat, feels like he is always on the go, and it was noted that at times he talks excessively.  Further questioning can be done at subsequent visits to confirm or rule out other inattentive or hyperactive symptoms. 

My second differential would be an anxiety disorder. Either generalized anxiety since he is anxious in several situations, even at home at times, or social anxiety since worrying about what his peers may think seems to cause anxiety. It is necessary to ask more questions and dig deeper into symptoms and how the symptoms are affecting him. The child admitted to feeling restlessness and feeling anxiety several times a week. Currently, with the given information, severity is estimated to be low but should be monitored as a rule out the diagnosis as more information is shared during following visits and as he continues to be treated and reassessed.

Another differential would be PTSD. With the history of him and his siblings being neglected and abused, along with the child not opening up much since this is the first session and rapport is being built, I would not rule this out. He has anxiety that was not fully discussed and has also witnessed and been a part of events that could have been traumatic to him. There is a chance that his anxiety may be linked to this. It was not possible to get all the information needed at this time to truly rule out a PTSD diagnosis. As trust is built with the provider and more information is gathered over time, this can be diagnosed or ruled out. Time will also allow the medication to subdue some of the current symptoms and if any are remaining, the remaining symptoms may paint a better picture of what else may be going on with the child. As time goes on, and rapport is built, there may be more that comes to light about the child’s past and how it relates to his current struggles. Since this child has been in several foster homes and experienced several possible traumatic events, it is possible that some symptoms could be linked to a particular event or to several in his past which adds a level of complexity that should be considered and sorted through with time and as trust is built (Cohen & Scheeringa, 2022). 

 

References

Cohen, J. A., & Scheeringa, M. S. (2022). Post-traumatic stress disorder diagnosis in children: challenges and promises. Dialogues in clinical neuroscience.

Dalrymple, R. A., Maxwell, L. M., Russell, S., & Duthie, J. (2020). NICE guideline review: Attention deficit hyperactivity disorder: diagnosis and management (NG87). Archives of disease in childhood-education and practice, 105(5), 289-293.

Faraone, S. V., & Larsson, H. (2019). Genetics of attention deficit hyperactivity disorder. Molecular psychiatry, 24(4), 562-575.

Hassan, H. H., Chaban, H. C., & Ayyash, H. A. (2020). G619 Overview of use of guanfacine in ADHD patients in an integrated secondary care setting. Are we following nice guidelines?.

Mahone, E. M., & Denckla, M. B. (2017). Attention-deficit/hyperactivity disorder: a historical neuropsychological perspective. Journal of the International Neuropsychological Society, 23(9-10), 916-929.

 

        Discussion Questions

What questions would you ask or information would you need to confidently diagnose the patient?
What diagnosis and treatment would you choose for this patient?
What techniques do you recommend for building rapport for children with traumatic pasts who may seem hesitant to trust and share information?

      Please help me above three questions answers for me. Thank you.

 

 

 

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING

 

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