Week 9: (ADHD)
Subjective: CC (chief complaint): ‘his hyperactivity has increased, and he is unable to focus after midday”, reported by the mom.ff
HPI: J.S is a 6 years old Caucasian who presented with his mum for medication management. The patient was started on Ritalin 5mg in the morning about 4 weeks ago. The mum reported that the medication is effective up until midday. The patient loses concentration afterward and becomes very hyperactive.
Past psychiatric history- Patients have a history of ADHD. ADHD was properly diagnosed about 4 weeks ago. No prior psychiatric illness or hospitalization.
Medication trials and current medications- Ritalin 5mg in the morning for ADHD
Psychotherapy or previous psychiatric diagnosis- No history of previous psychotherapy or prior psychiatric hospitalization. During this visit, the patient and the mother were educated on a healthy living lifestyle. Helping the child to organize his life and also limiting distraction
Pertinent substance use- The patient denies any substance use or history of substance use. The mother denies substance use during pregnancy.
Family psychiatric/substance use. The patient lives with both parents in their home in the suburbs. The patient was born at 40 weeks gestational age via SVD. No history of sexual abuse. No known substance abuse in the family. No known family psychiatry history.
Social History- The patient lives with both parents. The patient has two older siblings, male and female (18 and 12, respectively). They all live together with their parents. The patient has a fair relationship with his siblings. He sometimes gets into an argument with them. He is very active with a good appetite. He is in grade 1 and attends the IEP program.
Allergies- No known allergies
Medical History: No medical history.
Current Medications: Ritalin 5mg in the morning and Ritalin 2.5mg at 1 pm
Reproductive Hx: ROS:
Vitals: BP 111/72, P- 66, T-96.8, R- 16, Spo2-98% in room air
GENERAL: No fever, chills, weakness, or fatigue and no weight loss
● · HEENT: Head is Normocephalic and traumatic, Eye- pupils are equal, no discharges, No double, blurred vision. Ear, Nose, and Throat -No hearing loss, No congestion, no sore throat, and no sneezing
● · SKIN: Skin is warm, No rash or itching
● · CARDIOVASCULAR: No chest pain, No chest pressure, and no edema, No palpitation
● · RESPIRATORY: No respiratory distress.
● · GASTROINTESTINAL: No distension noted, No anorexia and vomiting
● · GENITOURINARY: No burning on urination
● · NEUROLOGICAL: The patient is alert and oriented, no dizziness, numbness, or tingling sensation of the extremities
● · MUSCULOSKELETAL: No muscle pain, No back pain, nobody stiffness, no edema noted
● · HEMATOLOGIC: The patient is not frail and no bleeding
● · LYMPHATICS: No enlarged lymph nodes.
● · ENDOCRINOLOGIC: No reports of polydipsia. No report of sweating or heat intolerance.
Diagnostic results: School history and the teacher’s report was used to evaluate the patient for the diagnosis.
Mental Status Examination
He is a 6year-old Caucasian male who looks older than his stated age. He is alert and orientated to time, place, person, and situation. The patient was very jumpy and very hyperactive. He was inattentive and was unable to respond to most questions. He is neatly groomed and clean, dressed appropriately. The mother reported that he was not medicated that morning. Per the mother’s report, the patient is calm and focused till midday. The patient does not seem to focus or stay in his seat. The mother reported he is getting to be more independent. The mother reported that IEP is progressing, and she thinks he is where they want him to be. The patient was unabated, and there is no evidence of any abnormal motor activity. His speech is clear, coherent, normal in volume and tone. The patient sometimes blurts during the assessment making requests. Patients are easily distracted with short attention spans. Lack of organization was also noted there is no evidence of looseness of association or flight of ideas. His mood is euthymic and hyperactive. He denies any auditory or visual hallucinations. There is no evidence of any delusional thinking. He denies any current suicidal or homicidal ideation. Cognitively, he is alert and oriented. His recent and remote memory is intact. His concentration is poor. His insight is good.
According to DSM-5, the patient showed signs and symptoms of Attention-deficit/ hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct disorder. ADHD is a mental disorder that mostly affects children (Danielson et al., 2018). The disorder is characterized by inattention, excess movement, and impulsivity, which are among the patient-reported significant symptoms. The oppositional defiant disorder is a behavior disorder that mainly occurs during the childhood of an individual. Some of its signs and symptoms as provided by DSM-5 include being uncooperative, defiant, and authoritative, and mostly hostile towards peers. On the other hand, conduct disorder is a condition that occurs in children and is normally characterized by violent and disruptive behavior. Other symptoms of the disorder include fighting, bullying, and deceitful behavior.
According to my assessment and using the rules of DSM-5 for diagnosis, the main diagnosis for the client’s condition is Attention-Deficit/Hyperactivity Disorder (ADHD) because all the symptoms characterize the condition that the patient is experiencing and also the chief complaint confirms the condition (Madsen et al., 2018). The pertinent positives from the patient’s case include being jumpy and hyperactive and short attention span, while pertinent negatives include looking older than the stated age, being alert and oriented. If I were to assess the patient again, I would ensure I observe his attention after midday to determine the change in his level of attention.
The patient reported symptoms of ADHD, and from the interaction I had with the patient during the assessment, the diagnosis and assessment impression both confirms the disorder. From the patient’s case, I have learned to pay more attention to the small changes that the patient might show during the assessment because they play a significant contribution to the patient’s diagnosis (Danielson et al., 2018). Also, it is important to identify and evaluate all the possible diagnoses before concluding. Ethically, it is critical to acquire information that applies to the patient’s health and get consent from the client’s parent before collecting relevant information.
I plan to conduct cognitive-behavioral therapy, which according to Gould et al. (2018), has been approved to be successful in treating ADHD. Conducting therapy will ensure reinforcement of the desired behavior on the client. Including frequent therapy sessions with the client will ensure that he manages the daily challenges, improves on time management, and reduces the conditions.
The pharmacologic treatment I would recommend to the patient is Ritalin (Pakdaman et al.., 2018). The medication works better for the treatment of hyperactivity and increases the dopamine level in the children’s brain, which controls the movement of an individual. Some of the alternative medications that I would administer to the patient include intake of supplements containing Omega-3s and an elimination diet (Holton et al., 2019). There should be a follow-up on the patient. One of the follow-up parameters vital for this case is hyperactivity which will indicate the effectiveness of the medication. Some of the health promotion activities that will be beneficial to the patient include parent training, exercise, and memory training. Regarding patient education strategy, I would recommend a self-help strategies where the child will use posters and charts with the mother’s help.
Danielson, M. L., Bitsko, R. H., Ghandour, R. M., Holbrook, J. R., Kogan, M. D., & Blumberg, S. J. (2018). Prevalence of parent-reported ADHD diagnosis and associated treatment among US children and adolescents, 2016. Journal of Clinical Child & Adolescent Psychology, 47(2), 199-212.
Gould, K. L., Porter, M., Lyneham, H. J., & Hudson, J. L. (2018). Cognitive-behavioral therapy for children with anxiety and comorbid attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 57(7), 481-490.
Holton, K. F., Johnstone, J. M., Brandley, E. T., & Nigg, J. T. (2019). Evaluation of dietary intake in children and college students with and without attention-deficit/hyperactivity disorder. Nutritional neuroscience, 22(9), 664-677.
Madsen, K. B., Ravn, M. H., Arnfred, J., Olsen, J., Rask, C. U., & Obel, C. (2018). Characteristics of undiagnosed children with parent-reported ADHD behaviour. European child & adolescent psychiatry, 27(2), 149-158.
Pakdaman, F., Irani, F., Tajikzadeh, F., & Jabalkandi, S. A. (2018). The efficacy of Ritalin in ADHD children under neurofeedback training. Neurological Sciences, 39(12), 2071-2078.
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