case study 7

I’m studying for my Health & Medical class and need an explanation.

Brian, a 9 yr old who presents with his mother to the psychiatric nurse practitioner’s office for an initial evaluation, seems of normal height and weight.His mother explains that they came in at the father’s insistence that Brian be evaluated for ADHD. He has never been to a mental health office before, and has never taken medication for mood, behavior or ADHD.Brian’s parents have been divorced for 1½ yrs, and have shared custody of him and his 7 yr old sister Emily.The shared custody agreement is on file in Brian’s chart.The children spend alternating weeks with their father and stepmother, and with their mother.

Brian’s mother describes his behavior as normally active for a boy his age.He’s always had a lot of energy.He makes A’s, B’s and C’s in school, and his current 4th grade teacher has expressed concern about his hyperactivity and inattention; last year’s teacher never mentioned it.He seems to be having a little more trouble this year keeping up with assignments.Mom reports that she sits with Brian while he does homework to help him stay on task.She reports that Brian met all developmental milestones, has no medical problems, and has never repeated a grade.He has been sent to the principal’s office 3 times this year for excessive talking in class.He does require several reminders at night to go to bed and to stay in bed.He likes to “do one more thing”.His room has always been messy, as has his sister’s.Mom denies that he has any unusual behavior problems.He enjoys all sports but is not on any teams.He can play a video game for over 2 hours at a time, but doesn’t seem to watch TV for more than 15-20 minutes without wanting to do something else.He quarrels with his younger sister, but Mom doesn’t think this is out of the ordinary for siblings.When asked why Dad believes Brian may have ADHD, Mom reports that Dad complains of Brian not listening, not following instructions and not being able to sit at the table and complete his homework.Mom attributes the increased difficulty in school this year and any behavior problems at Dad’s house to difficulty adapting to the divorce, and to his new step-mother of 4 months.Mom reports that Brian has complained of the step-mother being too harsh, and not feeling comfortable during his weeks with Dad.

Brian has been fidgeting through most of this discussion, but has remained in his seat next to Mom.He rarely interjects any comments.When asked directly about the situation, he mumbles some answers, making little eye contact.He becomes more interactive describing his favorite video game, and listing the friends he plays basketball with at both houses.There is a basketball hoop in both driveways.He is reluctant to discuss conditions at Dad’s house, or his relationship with his father or step-mother.He seems to have an appropriate vocabulary for his age.

When the nurse practitioner later calls Dad for more information, he is quite vocal about Brian’s difficulties at his house.Brian doesn’t seem to listen, he forgets to follow through with tasks, even within a span of 3 minutes.Brian’s step-mother does supervise homework, and is frustrated that one math work sheet can take over an hour because Brian loses focus and starts doing other things.He cannot seem to resist arguing with his sister, and has to be reminded repeatedly not to talk back or argue with the adults.Emily is much easier to handle and seems to enjoy spending time with their step-mother.He reports that they use time out and restriction of privileges for punishment of bad behavior, and these seem to work, but Brian seems to soon impulsively repeat the offending behaviors again without seeming to have learned anything.Dad has talked with Brian’s teacher and she reports frequent talking in class, blurting out answers when it’s not his turn, and difficulty staying in his seat.She has arranged the room so Brian is directly in front of her desk, but he is still easily distracted.Dad suspects that Mom helps Brian so much that she doesn’t even notice that he has more difficulty than other boys his age.Dad would like to get Brian into a community basketball league, but he’s not sure he could concentrate and follow instructions.The step-mother wants him to be more caught up in school and better behaved at home before he joins a team.

Include:

Any differential diagnoses

Your diagnosis and reasoning

Any additional questions you would have asked

Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.

Any labs and why they may be indicated

Screener scales or diagnostic tools that may be beneficial

Additional resources to give (Therapy modalities, support groups, activities, etc.)