Brian, a 9 yr old who presents with his mother to the psychiatric nurse practitioner’s office for an initial evaluation, seems of normal height and weight.His mother explains that they came in at the father’s insistence that Brian be evaluated for ADHD. He has never been to a mental health office before, and has never taken medication for mood, behavior or ADHD.Brian’s parents have been divorced for 1½ yrs, and have shared custody of him and his 7 yr old sister Emily.The shared custody agreement is on file in Brian’s chart.The children spend alternating weeks with their father and stepmother, and with their mother.
Brian’s mother describes his behavior as normally active for a boy his age.He’s always had a lot of energy.He makes A’s, B’s and C’s in school, and his current 4th grade teacher has expressed concern about his hyperactivity and inattention; last year’s teacher never mentioned it.He seems to be having a little more trouble this year keeping up with assignments.Mom reports that she sits with Brian while he does homework to help him stay on task.She reports that Brian met all developmental milestones, has no medical problems, and has never repeated a grade.He has been sent to the principal’s office 3 times this year for excessive talking in class.He does require several reminders at night to go to bed and to stay in bed.He likes to “do one more thing”.His room has always been messy, as has his sister’s.Mom denies that he has any unusual behavior problems.He enjoys all sports but is not on any teams.He can play a video game for over 2 hours at a time, but doesn’t seem to watch TV for more than 15-20 minutes without wanting to do something else.He quarrels with his younger sister, but Mom doesn’t think this is out of the ordinary for siblings.When asked why Dad believes Brian may have ADHD, Mom reports that Dad complains of Brian not listening, not following instructions and not being able to sit at the table and complete his homework.Mom attributes the increased difficulty in school this year and any behavior problems at Dad’s house to difficulty adapting to the divorce, and to his new step-mother of 4 months.Mom reports that Brian has complained of the step-mother being too harsh, and not feeling comfortable during his weeks with Dad.
Brian has been fidgeting through most of this discussion, but has remained in his seat next to Mom.He rarely interjects any comments.When asked directly about the situation, he mumbles some answers, making little eye contact.He becomes more interactive describing his favorite video game, and listing the friends he plays basketball with at both houses.There is a basketball hoop in both driveways.He is reluctant to discuss conditions at Dad’s house, or his relationship with his father or step-mother.He seems to have an appropriate vocabulary for his age.
When the nurse practitioner later calls Dad for more information, he is quite vocal about Brian’s difficulties at his house.Brian doesn’t seem to listen, he forgets to follow through with tasks, even within a span of 3 minutes.Brian’s step-mother does supervise homework, and is frustrated that one math work sheet can take over an hour because Brian loses focus and starts doing other things.He cannot seem to resist arguing with his sister, and has to be reminded repeatedly not to talk back or argue with the adults.Emily is much easier to handle and seems to enjoy spending time with their step-mother.He reports that they use time out and restriction of privileges for punishment of bad behavior, and these seem to work, but Brian seems to soon impulsively repeat the offending behaviors again without seeming to have learned anything.Dad has talked with Brian’s teacher and she reports frequent talking in class, blurting out answers when it’s not his turn, and difficulty staying in his seat.She has arranged the room so Brian is directly in front of her desk, but he is still easily distracted.Dad suspects that Mom helps Brian so much that she doesn’t even notice that he has more difficulty than other boys his age.Dad would like to get Brian into a community basketball league, but he’s not sure he could concentrate and follow instructions.The step-mother wants him to be more caught up in school and better behaved at home before he joins a team.
Include:
Any differential diagnoses
Your diagnosis and reasoning
Any additional questions you would have asked
Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
Any labs and why they may be indicated
Screener scales or diagnostic tools that may be beneficial
Additional resources to give (Therapy modalities, support groups, activities, etc.)
Expert Solution Preview
Introduction: In this case, a 9-year-old boy named Brian is being evaluated for ADHD at the insistence of his father. Brian exhibits symptoms of hyperactivity, inattention, and impulsivity, as well as behavioral problems at school and at home. His parents are divorced, and he spends alternating weeks with each parent. This case requires a differential diagnosis, a diagnosis and reasoning, additional questions to ask, medication recommendations, possible labs, screener scales or diagnostic tools, and additional resources to provide.
1. Any differential diagnoses:
Some potential differential diagnoses for Brian’s symptoms could include anxiety disorders, oppositional defiant disorder (ODD), learning disorders, and adjustment disorders related to the divorce.
2. Your diagnosis and reasoning:
Based on Brian’s symptoms, including hyperactivity, impulsivity, inattention, and behavioral problems at school and home, I would diagnose him with Attention-Deficit/Hyperactivity Disorder (ADHD). Brian meets the criteria for a diagnosis of ADHD as per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
3. Any additional questions you would have asked:
I would want to gather more information about Brian’s family history, including any history of ADHD or other psychiatric conditions. I would also want to inquire about Brian’s sleep patterns, as well as his eating habits and physical activity levels. To better understand Brian’s behavior, I would inquire about any changes in his routine or environment over the past year.
4. Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent:
For medication treatment of ADHD, stimulant medications such as methylphenidate (Ritalin) or dextroamphetamine (Adderall) are the first-line treatment. These medications increase the levels of dopamine and norepinephrine in the brain, leading to improved focus and decreased hyperactivity and impulsivity. Common side effects of stimulants include loss of appetite, difficulty sleeping, and irritability. I would recommend starting with a low dose and titrating up as necessary, and closely monitoring for any side effects or changes in behavior.
5. Any labs and why they may be indicated:
No labs are indicated for the diagnosis of ADHD. However, I might consider a basic metabolic panel or thyroid function tests to rule out any underlying medical conditions that could be contributing to Brian’s symptoms, such as hypothyroidism.
6. Screener scales or diagnostic tools that may be beneficial:
Diagnostic tools that may be beneficial in this case include the ADHD Rating Scale-5, the Vanderbilt ADHD Diagnostic Parent Rating Scale, and the Conners 3 ADHD Index. These tools can help to assess the presence and severity of ADHD symptoms.
7. Additional resources to give (Therapy modalities, support groups, activities, etc.):
Additional resources that may be helpful for Brian and his family include behavioral therapy, parent training, and support groups for parents of children with ADHD. Brainspot.com has a list of therapists who are trained in ADHD. Strategies such as positive reinforcement, consistent routines, and accommodations in the classroom or at home can also benefit children with ADHD.
