ADHD Case Study Critique

ADHD Case Study Critique

CC:

“He never listens and just won’t sit still at home or school.”

 

HPI:

DB is a 7 YOWM who presents with his mother to his pediatrician. She states that, over the fall school semester, he has been having more “hyperactive, impulsive behavior” and has been “on the go” constantly. His teacher states that DB does not listen to them, does not follow instructions like his peers, gets easily bored during activities, does not wait his turn, and has difficulty engaging in games for longer periods of time. DB’s mother will be forced to move him to a private school if his behavior does not improve.

 

(During the visit, DB is constantly moving, easily distracted by noise, and constantly interrupts you and his mother).

 

PMH:

No other medical issues; no previous psychiatric Hx; vaccines current.

 

FH:

Mother has stress headaches/migraines. Father had ADHD as a child.

 

SH:

Single child in middle class home.

 

All:

NKDA

 

Meds:

Zyrtec 5ml (5mg) PO QD PRN seasonal allergies Flintstones MVI QD

 

PE:

Gen–Healthy, well appearing, well-nourished boy in NAD

 

Labs:

All WNL

 

  1. AP note
  2. Present the problem

DB presents today to his Pediatrican for hyperactivity reported by his mother at school and impulsive behaviors. He has no other complaints today. Per his mother over the fall semester, which is about 4-5 months, he has been very distracted easily, impulsive, unable to follow instructions, or wait his turn. Mother is very frustrated with the thought she will have to put him in a private school.

 

  1. Risk Factors
  • Family Hx of ADHD.
  • Only child.

 

  1. Assessment
  2. Evaluation:

DB is a 7 YO M who presents to his Pediatrician today for hyperactivity and impulsitivity at school.  Decreased concentration and unable to wait his turn at school. Constantly moving ang talking. Teachers are stating he does not listen or wait his turn. Mom seems overwhelmed with this school issues to the point that a new school is being considered. The child is in either the first grade kindergarden, this could be a stressful time him as well being in a new school or grade. Being the only child and a male not getting all the attention could be a way of him acting out.

 

Home medications:

Zyrtec 5ml (5mg) PO QD PRN seasonal allergies

Flintstones MVI QD

 

  1. Determine appropriateness of current medications:

 

Zyrtec–Appropriate.

 

  • Indications: Management of seasonal allergies.

 

  • Interactions: Medication should be used with caution in various medications especially with various antidepressants. Which can cause increased risk of CNS depression and psychomotor impairment. This needs to be considered if an antidepressant is needed to be added.

 

  • Dosing: Initial oral dose is 5mg/day and dose can be adjusted at an additional 5mg daily increments as determined. Max 10mg/day.

 

(d)       Compliance: Mother claims compliance with medication and says he “never misses a dose.”

 

  • Outcomes: Control related to allergies.

 

Flintstones MVI–Appropriate.

 

  • Indications: General wellness/nutritional supplement.

 

  • Interactions: There are minimal interactions. If on tetracycline it can block absorption due to iron and calcium. Possible adverse effects og GI upset should be consider.

 

  • Dosing: Initial oral dose is 1-2 tablet or gummy daily.

 

(d)       Compliance: Mother claims compliance with medication

 

(e)        Outcomes: General Health increase.

 

 

 

  1. Additional Information Needed:
  • Vital signs..
  • Thyroid panel
  • Full PE with neuroexamination
  • Height and weight.
  • Vision and hearing screen.
  • ADHD questionnaire (Conner).
  • Teacher ADHD questionaire.
  • Home ADHD questionaire.
  • Home life, previous schooling, if any (daycare, preschool)
  • Behavior at home and other places
  • Get more family hx to rule out thyroid or cardiac diseases.
  • Rule out other diagnoses consider coexisting conditions such as ODD, conduct disorder, depression,anxiety, learning disabilities and bipolar disorder. So various questionaires and testing may be needed.
  • Any social issues.
  • Consider symptom triad of inattention, hyperactivity, and impulsivity.
  • Does JB fit the DSM-V criteria for ADHD: 1. 6 diagnostic symptoms before age 12 and persistent for 6 month 2. Symptoms present in two or more settings and adversely affect functioning in social situations, school or work. 3. Meet DSM-V for ADHD. 4. Symptoms cannot be explained by another mental disorder

 

  1. Desired Therapeutic Outcomes

(a) Short Term Goals

For School:

  • IAP track/ Reasonable school accommodations for completing work..
  • Classroom behavior modifications.
  • School follow ups monthly on progress.
  • Classroom accommodations to decrease distractions and emcourage on-task behaviors.
  • JB to have better focus in class, completing assignments, reduced hyperactivity.

 

For Home:

  • (Same as above in addition to below).
  • Exercise for at least 30 minutes sessions, 3-4 times a week.
  • Put together a schedule at home.
  • Provide more tie to complete projections.
  • Psychotherapy individual.
  • Family counseling.
  • Boundaries set at home.

 

 

(b) Long Term Goals:

  • Maintain calmness
  • Behavior modification
  • Reduce or stop medication.
  • School success
  • Continuing to thrive emotionally and physically.
  • Continue therapy as indicated

 

 

  1. Plan (P)

 

  1. Recommendations

(a) Non Pharmacological therapy:

  • Increase physical activity for 3–5 times weekly for at least 30 min. sessions each time.
  • Monthly in office follow-ups for 3 months, then every 3 months with full vital signs, Height, weight, and physical exam (preferred by me).
  • Healthy diet with snacks. Decrease in sugary foods and caffeine.
  • Request follow-up notes or questionaires by the school on performance.
  • Follow up questionaires for parents as well
  • Sleep hygiene review and practice.
  • Parent training for children with ADHD
  • Encouraging academic organization
  • Classroom behavior modification as well at home
  • CBT, social skill training groups
  • Yoga, herbal therapy as needed like valerian root, lavender, ginkgo biloba, ginseng, Vitamin D, Zinc, Iron, Melatonin, magnesium.
  • Other holistic options such as amethyst stones, lepidolite,Fluorite, hematite.
  • Mental health clinical f/u monthly, then quarterly.

 

(b) Pharmacologic Therapy: JB’s medication regimen will include the current medications and new medication for ADHD. Although I would prefer a non-stimulant regimen to start; guidelines state to start with a stimulant initially and use non-stimulants if the stimulant is a failure or the need to add-on a medication to the stimulant. The medication of choice based on the current information would be Concerta. This stimulant for ADHD is long acting, which can be great for once a day dosing lasting even ro after school needs. This however, would be important depending on what time the day starts and may not be the be option for weekends. Closely mnitor for cardiace events. The initial dosing would be 18 MG every morning.

 

 

 

 

 

 

NEW MEDICATION

 

(1)        Concerta–Stimulant.

PO dose: 18 mg/dose every morning before school. Dose can be increased at 36–54 mg adjustments; Max daily is 54 mg. Outcome will be closely monitored for weightloss, insomnia, and concentration.

*Will consider using just during school week or possibly holidays off medication.

 

 

E or AE Parameter Method Goal Alter Tx When/If
E Management of ADHD Parent reports behavior changes at home and school Increase attention and decrease impulsitivity If there is no change in behavior or insomnia, lack of appetite
AE insomnia Pt or parent reports not able to fall asleep at reasonable hour or lack of full nights sleep No s/s of insomnia Pt unable to go to sleep and affecting mood or growth
AE Loss of appetite Pt or parent reports lack of eating or appetite Healthy appetite and regular eating schedule Weight loss, excessive or anorexia
         
AE Exacerbation of tics or overstimulation Parent reports excessive movement or unable to get child calm No tics or overstmulation Reduce medication dosing or change medication if needed.

 

 

 

 

 

 

 

 

 

(2)        Zyrtec–Anti-histamine.

Initial dose: 8 mg PO QD.

Can be increased up to 10 mg QD if indicated.

Continued medication

 

E or AE Parameter Method Goal Alter Tx When/If
E Treatment of allergies Pt reports and Monitoring Reduction in allergies If allergies increase or no longer controlled
AE CNS depression Monitoring breathing and blood pressure No CNs depression If develops stop medication immediately

 

(3)        Flinstone MVI–.

 Dose: 1 tab PO daily.

Medication will be increased by no more than 1 tab additionally daily.

Continuation of medication

 

E or AE Parameter Method Goal Alter Tx When/If
E Nutritional supplement Pt reports changes in health that could be related to vitamin deficiency Maintain general health Add vitamins or supplements as needed for defiencies as needed
AE GI upset Pt reports nausea, vomiting, diarrhea, etc No GI upset If the GI upset continues or becomes worse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

 

Jonathan P. Heldt, M., & D, J. P. (2017). Memorable psychopharmacology. Createspace Independent Publishing Platform.

 

Sadock, B.J., Sadock, V.A., Ruiz., P (2015). Kaplan and Sadock synopsis of psychiatry (11th

 

ed.). Baltimore, MD:Williams & Wilkins.