Attention Deficit/Hyperactivity Disorder 

Introduction

Attention deficit/hyperactivity disorder (ADHD) is often comorbid with anxiety disorder among other mental health conditions.  According to D’Agati, Curatolo and Mazzone (2019), ADHD and anxiety present a comorbidity rate of 25% with each other. This sometimes complicates the management of patients and thus requires the assessment of developmental course to inform individual treatment. This paper examines a case study of a 13-year-old Caucasian male who present to the clinic with his adopted mother for psychiatry evaluation and treatment for ADHD and anxiety. In addition, it relates the case to the practicum objectives, offers a diagnosis and a differential diagnosis, examines symptoms, proposes a care plan, health promotion and counselling, patient and family education and finally explores the management of the patient’s condition in the context of the Christian Worldview. Attention Deficit/Hyperactivity Disorder Case Study

Case selection

This case study presented a client who was struggling with past traumatic experiences that resulted in the onset of his current ADHD and anxiety symptoms. The reason for selecting this patient’s encounterwas to be able to understand the comorbidity of these illnesses and how they had affected the client. On the other hand, this case was important for me in understanding how to differentiate such disorders and how one would come up with accurate diagnosis in such cases. Moreover, the case presented a significant opportunity to follow the development course of these mental conditions and eventually helped improve my experience in care plan formulation.

Practicum objectives

The objectives that this encounter assisted in meeting for this practicum experience include conducting an initial clinical interview for the clients via integration of Christian worldview. The assessment of this pediatric client helped in incorporating prayers in the treatment plan. Another objective that was met through this case was the ability to make differential diagnosis for mental pediatric disorders. Here, I was able to employ my knowledge on etiological genetic factors, pathophysiology, and other causative factors associated with psychiatric disorders. The DSM-5 criteria were also used to assist in the differentiation (Kaplan& Sadock, 2020). Attention Deficit/Hyperactivity Disorder Case Study

The third practicum objective met through this experience is demonstration of interdisciplinary collaboration. The management of the client’s mental condition demanded the involvement of different experts that created an interdisciplinary team from their diverse areas of specialization. These included physical and psychological therapists, pharmacists and primary care provider among others. More so, I was able to establish a client’s treatment plan incorporating both the appropriate pharmacologic and psychotherapeutic approaches. This created a foundation for development of evidence-based interventions to manage patients’ conditions in the future practice. Other objectives met include undertaking disease prevention and health promotion as well as care plan evaluation to develop follow-up plans. This was achieved by teaching the client and the family of relapse prevention and review of treatment with the coordination of other healthcare professionals. Attention Deficit/Hyperactivity Disorder Case Study

Part 2

Differential diagnoses

Attention-deficit hyperactivity disorder, combined type (F90.2)

     ADHD is described as a psychiatric condition characterized by abnormal hyperactivity and impulsive behaviors. This mental health disorder is also associated with trouble focusing the attention of an individual on a single task and they cannot sit still for a long duration. The major symptom of this illness is impulsivity and it can affect both children and adults. According to DSM-5 criteria, ADHD is a persistent inattentiveness and hyperactivity-impulsivity patterns of behavior that disrupt the normal development and functioning of an individual. The combined presentation of ADHD is diagnosed when the patient’s symptoms of hyperactivity-impulsivity and inattention persist for more than 6 months(Osland, Steeves&Pringsheim, 2018). In this case, the patient was diagnosed with ADHD at the age of 6 years which has persisted till the current age of 13 years. He has difficulty focusing, is easily distracted, difficulty sitting still, hyperactive inattentive, fidgety, forgetful and needs constant reminders. Moreover, he struggles to do his school work and daily and experiences excessive nervousness, worries with feeling of restlessness, irritability, fatigue, difficulty falling and staying asleep, trouble concentrating and focusing on daily task. Attention Deficit/Hyperactivity Disorder Case Study

Generalized anxiety Disorder (GAD)(F41.1)

This psychiatric disorder is associated with uncontrolled, excessive and irrational worry regarding apprehensive expectations of particular activities or events. The DSM-5 criteria classifyGAD as persistent excessive anxiety and worry of uncertain events or activities lasting for 6 months or more. The symptoms should not be caused by any other underlying mental issue or substance use. The patient has had a physically and mentally traumatizing childhood being abused by his biological mother before being taken to foster care and eventual adoption.He reports experiencing excessive nervousness, worries with feeling of restlessness,irritability, fatigue, difficulty falling and staying asleep, trouble concentrating and focusing. Attention Deficit/Hyperactivity Disorder Case Study

Adjustment disorder with anxiety (F43.22)

The DSM-5 criteria describe adjustment disorder as the presence of behavioralor emotional symptoms in response to a stressor that can be identified having taken place within three months of its occurrence. It is somewhat a n emotional response towards a stressful event and therefore is not considered to be a serious mental illness. symptoms include feeling anxious, overwhelmed and worried and hence cannot concentrate as well as remember normally. Often, children develop this disorder when they are separated from their parents and loved ones. The client in this case probably fears to be separated from his adopted mother thus demonstrating fear, worry, anxiousness and nervousness.

Post-traumatic stress disorder (F43.10)

This mental condition develops as a result of past severe emotional, mental or physical injury or distress. It is triggered by terrifying events that cause severe anxiety, nightmares and flashbacks which would frighten or stress an individual even when they are out of the danger. According to the DSM-5 criteria, this condition is characterized by expected or unexpected reoccurring, intrusive, involuntary upsetting memories linked to a particular traumatizing event. Since the client has experienced traumatic physical and psychological events in his life which trigger anxiety, it is likely that he could be suffering from PTSD. Attention Deficit/Hyperactivity Disorder Case Study

Epidemiology

Attention-deficit hyperactivity disorder, combined type (F90.2)

9.4% of children in the US were diagnosed with ADHD in 2016. ADHD prevalence is approximately 8-13% with a 4.5% incidence among the adult population.

The population likely to be affected by ADHD are persons with a family history of mental disorders, those exposed to environment with toxins and those involved in maternal drug use.

Generalized anxiety Disorder (F41.1)

The incidence of GAD is estimated to be higher in women 3.4% than in men1.9%.  the approximate prevalence among adults is 3.1% with the lifetime prevalence of about 5%. The risk population for this disorder include women, persons with a family history of anxiety disorders, individuals experiencing a history of stressful events, people with chronic illnesses and those that abuse substances such as alcohol and tobacco which increase the risk of contracting the disease. Attention Deficit/Hyperactivity Disorder Case Study

Adjustment disorder with anxiety (F43.22)

            The incidence of this disorder is approximately 5 to 21% among adult’s psychiatric consultation services in the US.Adjustment disorder is more prevalent in women with 17.2% than in men with 13.8%(Osland, Steeves&Pringsheim, 2018).The risk population for adjustment disorder with anxiety include the aged and persons with exposure to multiple stressors. Persons who have lost jobs involuntarily also tend to suffer the disorder.

Post-traumatic stress disorder (F43.10)

PTSD prevalence is estimated to be 6.8% among the American adult’s population. Globally, 7% to 8% of the population will have PTSD at a particular point in their lives with at least 8 million of the adult population being diagnosed with the disorder annually. In the US, the lifetime prevalence of the condition among women was 9.7% and 3.6% among men in the current past year. For children between 12 and 17 years, 6.3% of girls and 3.7% are likely to suffer PTSD according to the U.S Department of Veterans Affairs (Gradus, 2020). The incidence rate of PTSD per 1000 person-years in the active-duty US military personnel is 3.84. Anyone is at risk of PTSD regardless of the age. The war veterans are the most vulnerable considering their work environment followed by children and persons who have been through sexual and physical assault, accident, abuse, disasters and other serious events. Attention Deficit/Hyperactivity Disorder Case Study

Etiology and Pathophysiology

ADHD is caused by a combination of environmental, neurological and genetic factors which cause its heterogeneous phenotype and pathogenesis. The pathophysiology of ADHD is unclear even though it is associated with abnormalities in the cognitive function, brain structure and neurotransmitter functioning. Notably, GAD is caused by prolonged or recent exposure to stressful situations, family history of anxiety and excessive abuse of tobacco or caffeine. Its pathophysiology is linked to increased noradrenergic system activity and low serotonin system activity. On the other hand, the etiology of adjustment disorders is characterized by significant stressors or changes in life. The pathophysiology of this disorder causes impairment in the emotional, behavioral and general functional responses of an individual towards particular identifiable stressful changes or events. Consequently, PTSD etiology is linked to experiences of serious physical injury, threats, death or sexual assault. Complex trauma occurs from repeated child abuse and there is a likelihood of not recovering completely from the illness. The pathophysiology of PTSD is associated with hyperactivity of the autonomic nervous system’s sympathetic branch. This causes changes in skin conductance level, blood pressure, heart rate and other psychophysiological measures. The pharmacological challenges also occur from increased noradrenergic reactivity. Attention Deficit/Hyperactivity Disorder Case Study

Clinical manifestation

The ADHD clinical manifestations evident in the client include a past diagnosis at 6 years, difficulty focusing, is easily distracted, difficulty sitting still, hyperactive inattentive, fidgety, forgetful and needs constant reminders. Moreover, he struggles with school work and daily tasks and experiences excessive nervousness, worries with feeling of restlessness, irritability, fatigue, difficulty falling and staying asleep, trouble concentrating and focusing on daily task. In addition, GAD is demonstrated by experiences of excessive nervousness, worries with feeling of restlessness, irritability, fatigue, difficulty falling and staying asleep, trouble concentrating and focusing. Adjustment disorder symptoms includefears to be separated from his adopted mother, worry, anxiousness and nervousness while clinical manifestations for PTSD are increased anxiety towards traumatic events as experienced in the past. The expected mental status examination findings are appearances and behaviors, emotion, affect, speech processes, delusions or hallucinations, thought content, insight and judgment and cognition. These findings are used to differentiate between the four differential diagnosis. Attention Deficit/Hyperactivity Disorder Case Study

Diagnostics

In order to inform each differential, several diagnostics are necessary. For instance, ADHD can be diagnosed using a self-screening questionnaire that helps recognize the adulthood signs(Leahy, 2018). However, there is no simple test for diagnosis of this disorder and hence a detailed assessment is critical. In GAD, physical examination looks for signs while blood and urine tests differentiate other medical conditions. For PTSD, physical examination for symptoms and medical issues, psychological evaluations are conducted while adjustment disorder is diagnosed using the DSM-5 criteria, history and mental exam. Physical assessment is cheap, reliable and easy to conduct compared to blood tests and is universal for the four differentials. If appropriately done, there is no need for further diagnostics. It also eliminates the risk of misdiagnosis.

Final diagnosis

The final diagnosis for the client is Attention-deficit hyperactivity disorder, combined type (F90.2). This is because, the client conforms to the DSM-5 criteria for this disorder and presents all the clinical manifestations for ADHD. He has also been diagnosed with the illness at 6 years hence confirming this diagnosis. The patient has difficulty focusing, is easily distracted, difficulty sitting still, hyperactive inattentive, fidgety, forgetful and needs constant reminders. Moreover, he struggles with school work and daily tasks and experiences excessive nervousness, worries with feeling of restlessness, irritability, fatigue, difficulty falling and staying asleep, trouble concentrating and focusing on daily task. Attention Deficit/Hyperactivity Disorder Case Study

Care plan

The treatment plan of the client will involve pharmacotherapy, education and psychotherapy approaches. However, there is no particular cure for the disease. The patient will be prescribed stimulants which are fast-acting in relieving symptoms in children. 10 to 30 mg/day of Focalin XR, a long-acting stimulant, will also be prescribed to increase the ability to stay focused, pay attention, decrease hyperactive and impulsive behavior.20 mg of Escitalopram will be administered to alleviate the anxiety symptoms in the client. 1–4 mg per day of Guanfacine is the most effective treatment for ADHD in children below 17 years helping them to strengthen the working memory, improve impulse control and attention as well as reduce distraction(Sayal et al., 2018). Cognitive behavior therapy will entail relaxation techniques, exposure therapy, change in ideations, emotions and behavioral patterns of the client thus reducing anxiety, nervousness, worries and other symptoms. Family and individual therapy as well as education will help support the treatment plan. No referrals will be given for the patient yet and they are expected to return to the clinic after every two weeks for monitoring. Attention Deficit/Hyperactivity Disorder Case Study

Health promotion and counselling

Risk assessment/preventive screening for the client will help prevent criminal ideations associated with ADHD and its comorbidities. Their family members could also be assessed since the condition is often hereditary. The environment can be assessed for toxins that might trigger the disorder and relapse. Both individual and family counselling will be conducted to the client to help change their behavior and improve the symptoms of ADHD as well as engage them and their families in treatment and social support. Health promotion and counsellingwill entail the understanding of symptoms, onset, treatment and maintenance as well as coping efficacies. Self-management skills will be taught to the client including development of self-esteem and personal skills.

Christian Worldview

Christian worldview considers health as the status of body and mind wellness. It expects the PMHNP to provide of holistic care guided by spiritual issues. In this case, the patients care will involve engagement in prayer for the patient to get well and caring directed towards em