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.
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: http://www.doctorrudy.com/files/teacher_add_adhd_short.pdf). 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.”
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.
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.
Decisions Made and Outcomes (Needed to formulate the paper)
MY DIAGNOSIS FOR KATIE IS :314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks. You selected Attention deficit hyperactivity disorder, predominantly inattentive presentation. 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.
Decision Point Two: Begin Adderall XR10mg orally daily.
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
RESULTS OF DECISION POINT TWO.
Client returns to clinic in four weeks. Katie’s parents seem absolutely delighted upon their return stating that Katie is paying more attention in school, but note that there is still room for improvement, particularly in the afternoon
They report that Katie’s teacher has reported that Katie is able to maintain her attention throughout the morning classes but come afternoon, she “daydreams.”
Katie’s parents are also concerned about her decrease in appetite since starting the medication
Decision Point Three: Add a small dose of immediate release Adderall in the early afternoon
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR
DECISION.
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:
1.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?
2.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?
3.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.
Sample Solution
huck Jones ‘Duck Amuck.’ Kid’s shows the whole way across the Hollywood Studios as of now took after those of Disney, with their association of altering and utilizing a quickening choke structure in their story. Be that as it may, with thesea kid’s shows being considered as a comic dream class, illustrators could try different things with the medium. Warner Bros. were a major devotee to this, making circumstances where their toon characters would converse with the gathering of people or allude to the artist or studio administrators. These toons contrasted with Disney were altogether different, the activity was frequently more rough and speedier paced, changing the circumstances routinely. Throw Jones came to past desire with his toons, broadening the cutoff points and stunning the gathering of people. One of the greats being ‘Duck Amuck’ where he utilized each bone in his body to make which is currently known as one of the gems of activity, utilizing each component to make a 7minute film simply utilizing Daffy and the inconspicuous artist. By utilizing these components he could control Daffy in any circumstance, making a hope with the group of onlookers that anything could occur straightaway. Duck Amuck, a toon subject to its own particular deconstruction. The kid’s shows traditions are continually tested, utilizing the shading, outfit, sound view and all the fundamental components need to make the toon, frequently without the familiarity with the gathering of people. Daffy’s first appearance as a musketeer, a high handed waving his sword around with such certainty soon acknowledges he has been sold out by the artist, that the foundation of the scene has vanished and he and in addition the group of onlookers is left questionable to the setting we were acquainted with. Daffy quickly drops character and addresses the camera, responding in a somewhat proficient manner as though he were a piece of any cutting edge film and eagerly pushes the illustrator to continue. A yard scene is drawn, despite the fact that not what Daffy was expecting, he proceeds on, changing to suit the scene. In any case, by and by as he’s just about changed in accordance with the scene, a cold design is shown out of sight. All through the piece there is a steady fight amongst frontal area and foundation, or more all the connection between the character and the eternity changing natural setting. The greater part of Daffy’s activities are overwhelmed by his response to the territory he involves. Pressures like these assistance the fundamental structure of account in many kid’s shows. With every one of the progressions, Daffy’s fundamental idea is for the illustrator to decide. By utilizing Daffy’s body, every condition is appeared through various famous social representations – the dungarees and the straw cap in the yard scene, the grass skirt and banjo in the Hawaiian setting. While the blank area is characterized as the unfilled setting of the toon, despite the fact that there is boundless space, Daffy’s feeling of mindfulness winds up disengaged and defenseless. To compound the situation he is then deleted from the page, where all that remaining parts is his voice. Throw Jones intensions when he made his characters where for them to be perceived in any circumstance, to exist as a body without a voice, or a voice without a body. Particularly in this scene, a customized view of Daffy as a character is known, where he can be comprehended by any of his parts. Maybe, the main component the artist can’t dispose of is Daffy’s identity. If this somehow managed to be taken, the toon would never again be a Daffy Duck picture. Despite the fact that, the components are as often as possible changing and controlled, the group of onlookers is as yet ready to perceive its a Daffy toon. Daffy is appeared as anxious to please and engage, yet is effortlessly incited and enraged by any slight change, and to finish it off has a fairly over the top conduct, particularly in the event that he doesn’t get his direction. Duck Amuck demonstrates every one of his characteristics as a character using his body and activities, utilizing the restriction of any control Daffy thought he had. As the watcher it is anything but difficult to watch an activity and overlook the exertion connected to outline the foundation landscape. it’s relatively inconsequential. Are consideration is ceaselessly on the characters and their activities. Duck Amuck advises us that there is all the more then what meets the eye, and for this situation on the screen – and just by taking out the foundation, would we be able to acknowledge and value this. Daffy is unendingly estranged, attempting to keep his picture and confidence, yet negates himself by always losing his temper. When Daffy is repainted back on the screen as a rancher with a guitar, we as the gathering of people set up music will be played or daffy will sing. Daffy humbly opens his mouth and strums the guitar, yet with the stun all over recognizes there is no solid. He holds up a little sign saying “Sound Please.” As the gathering of people we are attracted to the way that anything could happen, and Daffy would not expect it. He bombastically goes to strum the guitar, to discover it makes the sound of an assault rifle, at that point a horn and a jackass. The utilization of bungling picture and sound, is yet another comedic component utilized inside this film, making a feeling of estrangement towards Daffy, with each activity he is limited by the illustrators charge. He breaks the guitar with disappointment, and tries request to the artist, to find he has been given the voice of chicken and a couple of other diverse winged animals. After numerous endeavors he gradually loses his will, so with one final attempt he tries to talk, yet at an extraordinary volume his voice returns. Humiliated, Daffy is indeed uncovered powerless to the artist. Daffy’s characteristics are unequivocally appeared, particularly his eagerness. He worries for a view and shading, however is given a youngster like illustration foundation, and is painted in numerous hues and examples. This is trailed by a scaled down fit by Daffy. Daffy is continually tested by his general surroundings, however his responses to the occasions increment the feasible hood of the following activity made by the illustrator. In the event that he was not such a twit and self retained, the steady misfortune happening would in all likelihood be brought down. Be that as it may, plainly, the condition of the toon remains issued to the want of the illustrator. These arrangement of events just purpose included expectation from the onlookers who need to additionally witness the measure of knockbacks the character can take. Toss Jones gives Daffy all important focal point, yet in the meantime controls all aspects of him amid the liveliness, in the mean time breaking the fourth divider and featuring the development of the movements work of art. With a straightforward thought of idea of destiny, the group of onlookers can accumulate a little significance from the piece – that regardless of what life tosses at you, one ought to modify and acknowledge what nature has anticipated you, rather than discover blame. All through the entire activity, whatever Daffy’s desires are or wishes to get, he is given the direct inverse. A few times he tries to take control of the circumstance, to wind up being controlled considerably more, yet in the meantime the gathering of people can witness his outrage levels rising. An extraordinary case of this is the point at which he winds up on a little betrayed island out yonder, he requires a nearby, which the group of onlookers can barely hear. In any case, rather than getting the camera to come nearer, the casing of the screen psychologists to outline him, Daffy’s first reaction is very wry however soon detonates with disappointment. The camera rapidly zooms in to uncover only Daffy’s disturbed eyes. Daffy tries to pick up a comprehension amongst himself and the artist, yet he is soon hindered by a dark material burdening him, in the long run tearing up the ‘screen’. He at that point comes back to recommending the toon should start despite the fact that it has just been running for a few minutes. All through the piece Daffy ceaselessly tries to recapture his quality and control, yet on numerous occasions he is hindered by some sort of muffle story. Daffy is soon designated as a pilot, however this is simply to dispatch a progression of muffles, including an off screen air crash, the fall, his parachute transforming into a weight, the blast of the weight which turns into a bomb. Now Daffy is left defenseless, lost all control, however with one at last endeavor to recapture some nobility, he requests to know “Who is in charge of the greater part of this? I request that you show yourself!” The encased guest that the gathering of people is presently familiar with is split as the camera pulls away to uncover the illustrator – Bugs Bunny. The entire piece is a progression of free muffles, no significance to each other but to torment Daffy. However, with such stun and astonishment to the greatest stifler of all, that it was his most outstanding foe Bugs Bunny who was the driving force the whole time. Throw Jones awesome ability was making a comic tension, planting a joke and giving the gathering of people a chance to sit tight for the evitable result. By doing this, it made a development for chuckling, the satisfaction of a muffle. Duck Amuck shows this tremendously, for all intents and purposes each ‘rest’ point in the liveliness is the beginning of a muffle. While Daffy is consoling himself conceivably after a stifler, he is yet unconscious of the following muffle going to start. Genuine components are consolidated all through Duck Amuck, from film strips, to paint brushes, to erasers, used to control the character’s condition and appearance. In any case, these are on the whole cunningly used to demonstrate the intuitiveness between the creation and the maker. Components like these make another measurement to the story, that we as the gathering of people, to a degree can trust we are with the artist as they settles on their choices. Characters like Bugs Bunny and Daffy were insightful breaking pessimists as opposed to guiltless altruists like Mickey Mouse. Be that as it may, despite the fact that the Warner Brother characters are comparative this movement wouldn’t have worked with any other individual aside from Daffy. His loss of control and mortification is the thing that makes the piece, his unhinged ways, and his self centeredness of being not able arrange, or grappled with the higher power annihilates Daffy abandoning him dumbfounded, and at last turns out to be to a greater extent a subject characterized by a gaga. The illustrators at Warner Brother>
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