Case #13: the 8-year-old girl who was naughty | NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology | Walden University

   

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Volume 1, Case #13: The 8-year-old girl who was naughty

The client is an 8-year-old girl who has been brought to her primary care provider (PCP) by her mother with complaints of fever and sore throat. She attends public school where her teacher has reported the client is disobedient, and fights with other children by getting into verbal altercations with other girls. Her mother reports that she is still angry and resentful of her little sister, who was born six years ago. She has little contact with her father, who lives in a city nearby. At the end of the appointment, her mother is given both the parent and teacher version on the Conners Attention Deficit Hyperactivity Disorder (ADHD) rating scale and is to bring them with to the follow-up appointment. 

Additional Questions

My first question would be: How do you feel about your mother? Father? Sister? Parent’s ADHD symptoms can negatively affect parenting, family relationships, and the entire environment of the house (Gray, 2020). Since the client’s mother has undiagnosed and untreated ADHD and often reports disorganization and feeling overwhelmed, these could easily translate to feelings of anger or frustration for the client, and hence defiant, argumentative behavior at home.

My second question would be: Are you struggling with any subjects in school? What are they? Do you ask for help? Children with ADHD have a slower response time and require more time to respond to stimuli (Wells, Day, Harmon, Groves, & Kofler, 2019). This could lead to feelings of frustration and anger, especially if there are subjects that the client is already struggling with understanding. These emotions could translate into negative behaviors both at school and at home. If the client is struggling with some subjects, she could also be getting bullied, which could also lead to feelings of anger. This could be especially true if she has told her teacher or mother and she feels nothing has been done to resolve the problem.

Additional People to Interview

I would like to speak with her teacher. Even though she completed the form, I would like to get her opinion on other aspects of the child’s behavior in school. Her teacher most likely has interacted with the client’s mother or grandmother so it would be nice to see if she sees any similarities in the mother’s behavior and the client’s.

I would also like to speak with the client’s father. Despite her not having much contact with him, it would be good to know if her behavior is consistent when she is with him compared with her mother. A parent’s emotions can affect the child’s, whether negative or positive (Musser, Lugo, Ward, Tenenbaum, Morris, Brimohan, & Martinez, 2018). By questioning the client’s father and learning how her behavior is with him, it might help determine if her mother is playing a large role in her behavior; whether she is aware of it or not. However, this could yield no potentially useful information since the client has little contact with him.

Her maternal grandmother would be another person I would want to talk with. Since she often helps with after-school supervision and babysits, I would also like to know if the client’s behavior continues when her mother is not around. As mentioned previously, the client’s emotions are influenced by the parent’s. Since her maternal grandmother often watches her, it would be helpful to know if her behavior differs than that with her mother. Since her mother has undiagnosed and untreated ADHD, this may be a catalyst for the client’s negative behavior, especially the behavior toward her mother.

Finally, her sister would be good to try and interview though this might be difficult since she is six. Since it has been reported by the client’s mother that the client is angry and resentful of her younger sister, I would like to get the sister’s opinion on how their relationship is and how the client acts toward her.

Physical Exams and Diagnostic Tests

Two subjective items that should be recorded are the client’s height and weight. This information could be necessary for medication dosing, and for monitoring for weight loss which can be a side effect of stimulant medication.

Differential Diagnoses

1. Attention-deficit disorder, predominantly inattentive presentation, moderate. The client meets diagnostic criteria for the inattention portion of ADHD diagnosis, but only has one of the diagnostic criteria of the hyperactivity and impulsivity portion (American Psychiatric Association [APA], 2013). I think this is the most likely diagnosis because, based on the client’s history, her behaviors at school are indicative of attention-deficit disorder (ADD) and are also not reported by her mother to occur at home; the only reports the mother is making is that the client seems aggressive toward her, mostly.

2. Intermittent explosive disorder. The client’s mother has frequently reported that the client has temper tantrums, verbal arguments, and physical aggression toward both her younger sister and peers. The diagnosis of intermittent explosive disorder is also made in addition to ADHD (APA, 2013). 

3. Conduct disorder, childhood-onset type, with limited prosocial emotions, moderate. This diagnosis covers both the behaviors the client is exhibiting as well as the lack of remorse or guilt she also exhibits after hurting someone (APA, 2013).

Pharmacologic Agents

One medication that could be used is atomoxetine (strattera). It has been shown to improve response inhibition in children and general symptoms of ADHD and is the only non-stimulant medication available to treat ADHD (Griffiths, et al., 2018). Dosing in children is based on weight. If the client weighs more than 70 kg, she would be started on 40 mg/day with a possible increase at day three (Prescriber’s Digital Reference [PDR], 2020a). If she weighs less than or equal to 70 kg, dosing would be 0.5 mg/kg/day with a potential increase after at least day three (PDR, 2020a).

A second medication that could be beneficial is clonidine (catapres). While normally used to treat hypertension, clonidine can be a useful augmenting agent for individuals with conduct disorder, oppositional defiant disorder, sleep problems, and other disorders co occurring with ADHD (Kutuk, Guler, Tufan, Sungur, Topal, & Kutuk, 2018). Dosing is also based on weight, with different doses for individuals weighing 27 to 40.5 kg, 40.5 to 45 kg, and greater than 45 kg (PDR, 2020b). 

Checkpoints

Three weeks later (week 3), the client and her mother return to her PCP’s office. Neither of the forms given to her at the initial appointment were completed; her mother reports having been too busy to complete her’s and forgetting to give the teacher her’s. The client’s mother reports that the addition of her second daughter attending school has made it extremely difficult to keep the client organized and focused on school. The pediatrician is going to send the client’s teacher the form to complete and when it is mailed back, the mother will be contacted for a follow-up appointment.

An additional three weeks later (week 6), the client’s mother comes to a follow-up appointment on her own. The response from the client’s teacher regarding the ADHD rating scale indicates that the client has significant problems with talking excessively, sustaining attention, being organized, being distracted, being forgetful, following instructions, and making careless errors except when it comes to her homework. The teacher also indicated that the client is more argumentative and disobedient than the other children in her class. When comparing the mother’s responses with the teacher’s, the ratings are similar; however, there is an inconsistency between the client’s ability to listen. The client’s mother also reports that the client argues with her a lot and will sometimes have milder forms of temper tantrums similar to those she had when she was five. The pediatrician diagnoses that client with ADHD, mostly inattentive type, comorbid with symptoms of oppositional defiant disorder (ODD). However, the client exhibits inattention but not hyperactivity, and her ODD symptoms appear to be willful and on purpose. The mother is uncomfortable with these diagnoses and requests different options rather than medications; cognitive behavioral therapy (CBT) and parent training are suggested.

Four weeks later (week 10), the client and her mother return to the clinic. The mother has looked into CBT and has learned that the closest specialist is a one-hour drive away, and thus not an option. The client’s mother has reconsidered medication for her daughter, given the lack of non-pharmacological options. The client is started on d-methylphenidate XR (focalin).

Within two and four weeks after this appointment (weeks 12 and 14), the dose of focalin has been titrated to 20 mg/day and there has been some improvement in her classroom behavior, according to her teacher. Unfortunately, the client has developed problems with initial insomnia which is most likely due to the initiation of focalin as she did not have this problem beforehand. Her mother is also continuing to report defiant behavior while at home. She was advised to give the medication another month to see if the client’s behavior improves. She was also educated on appropriate sleep hygiene for the client.

The next follow-up appointment four weeks later (week 18) reveals that the mother’s disorganization and overwhelmed feeling create a barrier to regular schedules and consistent bedtimes; both the insomnia and defiant behavior continue. There also was an incident at school where the client shoved a classmate, which caused her to cut her knee deep enough where it required sutures. The client was not sorry or remorseful. Different medication options were discussed with the client’s mother; she decided on the methylphenidate (ritalin) patch patch because it is the most convenient way to resolve the client’s insomnia.

Two weeks later (week 20), the 20 mg methylphenidate patch addresses the classroom issues and does not cause insomnia if worn for eight hours or less; however, on the days when it is not removed prior to 3 p.m., the insomnia returns. The client remains argumentative at home and has recently scratched her sister’s face, which she finds funny. The client’s PCP feels that little progress has been made, despite a trial of two different stimulants; at this time, the client and her mother are referred to a psychiatrist.

At the initial psychiatric appointment, it appears that the client needs more stimulant during the day and less at night as well as a therapeutic focus on the oppositional symptoms. It was also discussed with the mother switching back to oral medication rather than the patch. The client was started on lisdexamfetamine (vyvanse) 30 mg once daily in the morning.

The first and second follow-up appointments (weeks 4 and 8) yield partial efficacy but no insomnia after starting the vyvanse. Rather than increasing the client’s dose of vyvanse, dextroamphetamine was added at 7am. After numerous adjustments, the dose was settled on 10 mg with a second 5 mg dose after school as needed. This regimen also does not cause insomnia, her ADHD is better, but the oppositional symptoms continue. Guanfacine XR (intuniv) 1 mg/day was added to her medication regimen. 

The final follow-up appointments from weeks 12 to 20 reveal no report of side effects from the client. The guanfacine has been increased to 2 mg/day, and the daily dextroamphetamine was decreased to 5 mg daily in the morning. The oppositional symptoms improved over two months. The mother was encouraged to speak with her other daughter’s teacher and complete the screening form for her. She was also asked to make appointments for herself because she has undiagnosed and untreated ADHD.

Lessons Learned

Diagnosing children with a psychiatric disorder can be more difficult than adults. They often do not exhibit the range of emotions that adolescents and adults do, many manifest as irritability or anger. For younger children, it is not as easy to directly interview them to help determine a root cause of their issue; it is necessary to phrase questions appropriate for a child, and make inferences. It is also important to consider the testimony of their parents, siblings, educators, or other close individuals.

References

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Gray, L. (2020). Do parent ADHD symptoms influence sleep and sleep habits of children with ADHD? A pilot study. Pediatric Nursing, 46(1), 18-39.

Griffiths, K.R., Leikauf, J.E., Tsang, T.W., Clarke, S., Hermens, D.F., Efron, D., …, & Kohn, M.R. (2018). Response inhibition and emotional cognition improved by atomoxetine in children and adolescents with ADHD: The ACTION randomized control trial. Journal of Psychiatric Research, 102, 57-64. Doi: 10.1016/j.jpsychires.2018.03.009

Kutuk, M.O., Guler, G., Tufan, A.E., Sungur, M.A., Topal, Z., & Kutuk, O. (2018). Evaluating clonidine response in children and adolescents with attention-deficit/hyperactivity disorder. AIMS Medical Science, 5(4), 348-356. Doi: 10.3934/medsci.2018.4.348

Musser, E.D., Lugo, Y., Ward, A.R., Tenenbaum, R.B., Morris, S., Brimohan, N., & Martinez, J. (2018). Parent emotion expression and autonomic-linked emotion dysregulation in childhood ADHD. Journal of Psychopathology & Behavioral Assessment, 40(4), 593-605. Doi: 10.1007/s10862-018-9685-3

Prescriber’s Digital Reference (PDR). (2020a). Atomoxetine – Drug summary. Retrieved from https://www.pdr.net/drug-summary/Strattera-atomoxetine-294.933#topPage

Prescriber’s Digital Reference (PDR). (2020b). Clonidine – Drug summary. Retrieved from https://www.pdr.net/drug-summary/Catapres-TTS-clonidine-2349.327

Wells, E.L., Day, T.N., Harmon, S.L., Groves, N.B., & Kofler, M.J. (2019). Are emotion recognition abilities intact in pediatric ADHD? Emotion, 19(7), 1192-1205. Doi: 10.1037/emo0000520

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