Case 1: Attention Deficit Hyperactivity Disorder (ADHD)
- Major symptoms of this disorder.
- According to the DSM 5, ADHD is a pattern of “inattention and / impulsivity” that affects day to day functioning (p. 59). Inattentiveness manifests through failure to follow or focus on tasks and exhibiting disorganization (American Psychiatric Association, 2013). Hyperactive behavior manifests as excessive motor activity such as fidgeting, talking, or the inability to sit still when inappropriate (American Psychiatric Association, 2013). Excessive impulsivity refers to actions made without forethought that may risk safety as a way to gain a reward or the inability to delay personal gratification (American Psychiatric Association, 2013). Impulsive behaviors may be perceived as socially intrusive and void of long term considerations (American Psychiatric Association, 2013). However, it is important to note that all symptoms must not manifest due to defiance or lack of comprehension, must be inconsistent with the development level of the individual, have a manifestation before the age of twelve, and be present in two or more settings (American Psychiatric Association, 2013).
- Client’s background
- David is a sixteen-year-old, Caucasian, high school sophomore. He lives in a single parent household and is raised by his mother. David presented as a “regular” teen who likes sports and video games. He claims to have a girlfriend he enjoys spending time with her. Additionally, David takes Wellbutrin and Ritalin throughout the course of the school year, but during the summer he remains medication free. David claims to have always been hyperactive which led to teacher complaints in elementary school. David’s mother loves him, but has allowed his negative behaviors to continue their evolution through her lack of discipline and failing to enforce the vitality of passing grades. David seems to have no schedules or daily routine chores set in play, rather spends hours playing video games and watching television. His mother asks little of him and when she does, he has no consequences for not doing what was asked. When medicated, David tends to do better in school and retains some focus, however, he does not like that the pills make him “lazy and anti-social” (McGraw Hill Higher Education, 2007).
- Possible Predispositions
- Although genetic factors, especially inheritable traits from the father, play a part in the development of ADHD (McGraw Hill Higher Education, 2007)., there was no information disclosed on medical history, therefore a predisposition cannot be acclaimed in David’s case.
- Throughout the course of the interview David was in constant movement. He spoke with hands and fidget in and with his chair. His thoughts were unaligned as he began with one topic and moved to the next and back to the original topic (McGraw Hill Higher Education, 2007). Consistent with the DSM-5 development and course, David claimed to be hyperactive as far as his memory would allow him to recall. David admits that he has difficulty focusing on tasks or schoolwork demonstrating symptoms of inattentiveness as the DSM-5 reports as a primary symptom (American Psychiatric Association, 2013). ADHD inhibits individuals in school performance, and social relationships which may letter cause the development of antisocial personality disorder in adulthood (American Psychiatric Association, 2013) which solidifies David’s struggles in school and his lack of friendships.
- Symptoms or behaviors that are inconsistent with the diagnosis.
- David plays several hours of video games implicating that a video game can hold his attention. He actually claimed that he can beat and entire game in one sitting by the time his mother woke up in the morning (McGraw Hill Higher Education, 2007). This fact is inconsistent with the DSM-5 criterial symptoms which claim a very short attention span and easy distractibility in addition to the inability to quietly indulge in leisure activity for a period of time (“Centers for Disease Control and Prevention”, 2016). The “Center for Disease Control and Prevention” website claims individuals are often unable to listen when spoken to (2016), however, David followed along in the conversation and answered questions promptly. Although he tended to lose track of his thoughts throughout his answers, he often jumped topics, but ultimately returned to his initial thought (McGraw Hill Higher Education, 2007). Another aspect that seemed odd was David’s claim that when reading, words would begin jumping around the page and become blurry causing him to lose focus and attention, but this was not relatable to the DSM-5 criteria (McGraw Hill Higher Education, 2007).
- Development of this disorder.
- The DSM-5 clarifies that ADHD is most identifiable in elementary school as inattention becomes more prominent (American Psychiatric Association, 2013) resulting in educational impairment and teachers identifying behavioral issues to parents as David discussed in the interview. However, it would be interesting to l earn the mother and father’s medical and mental health history. The DSM-5 also explains family interaction has no bearing on the development of ADHD, but may influence the disorders course or development of secondary conduct disorders (American Psychiatry Association, 2013). There is little family time for David and his mother and the void is filled through gaming and lack of discipline and reasonable expectations from the mother. It is possible that the lacks and void filling encouraged the course of ADHD to heighten and possibly lead to worse symptoms of the disorder.
- Medical History
- There was no medical history exposed in the interview to validate a contribution to David’s ADHD.
- Psychosocial and environmental problems
- David is being raised by a single, overwhelmed mother who has little time for him. However, the interview revealed “most of the time” he lives with his mother, implying there is another figure involved in David’s upbringing that is not disclosed in the interview (McGraw Hill Higher Education, 2007). His mother tends to give him tasks, but fails to follow through with any type of recourse for his negative actions or failure to complete a task (McGraw Hill Higher Education, 2007). This was evident when she accepted his failing math and directed him to focus on another subject rather than seek help to aid in him learning the material (McGraw Hill Higher Education, 2007). She does not ask him to do much giving the persona that she reinforces the negative behavior and inability to focus on a task or topic. According to the narrator, it is common to see children from single parent households present with ADHD (McGraw Hill Higher Education, 2007). It is a typical routine for David to play video games which appears to be a distraction from other aspects of life such as schoolwork and chores (McGraw Hill Higher Education, 2007). Additionally, David feels as if many teachers just give up on him rather than attempt to help him improve in learning (McGraw Hill Higher Education, 2007).
- Client’s overall level of safety regarding potential harm to self or others (suicidality or homicidality)
- Regarding David’s safety, he appears stable. However, in the course of the interview, he admitted to being taunted by other kids and seemed to have little knowledge about ADHD (McGraw Hill Higher Education, 2007). He claimed to have friends and a girlfriend, but appeared to be socially awkward and compared himself to another male who was “worse off” than himself (McGraw Hill Higher Education, 2007). Due to his comparisons and the reactions of others to his demeanor, it is essential to closely monitor his self-esteem. Additionally, he does not always make the best choices and his impulsive behavior holds potential for harm even if he does not intend hurting himself (McGraw Hill Higher Education, 2007). According to the DSM-5, as individuals enter early adulthood the risk of suicide attempt increases especially when comorbid with mood, conduct, or substance abuse arises (American Psychiatric Association, 2013). David will soon be entering adulthood and he claims irritation and frustration with certain aspects of his life. Early intervention of possible suicide ideations would reduce the likelihood of David developing suicidal potential.
- Cross-cultural issues that may affect the differential diagnosis?
- According to the interview, ADHD occurs in about five percent of the population and although it occurs across all cultures, it is most prevalent in the United States (McGraw Hill Higher Education, 2007). Additionally, David is male and statistically more prone to a diagnosis of ADHD than female (American Psychiatric Association, 2013).
- Short-term goals of this intervention
- It is essential to reduce David’s video game activity and increase his number of chores. Setting up a chore chart or goal plan with David will help him remember what needs to be completed and by when. The chart and schedule can be utilized for schoolwork, chores, and recreation as it will clearly define expectations. Another short term goal would be to improve grades in school by incorporating a daily homework schedule and seeking out external tutoring programs to help accommodate his problem areas such as math. Additionally, David should join sports team’s year round as this will help him focus his energy in an area he loves and build social skills and develop a teamwork effort.
- Long-term goals of this intervention
- David needs behavior modification to address his impulsive behaviors and replace them with thought out actions and reactions. As a minor, his mother has a major role in David’s life. His mother needs to learn techniques of proper discipline and basic parenting skills that provide an environment that includes rewards for positive behavior and consequence to negative behavior.
- Therapeutic strategy
- The psychosocial approach to ADHD includes Direct Contingency Management focuses on a direct approach for rewarding desired behavior (Brinkman & Epstein, 2007). David has not experienced consequences for his behaviors, instead his mother just accepted whatever he did. Encouraging good grades and completion of homework assignments and chores with a reward would allow David to perceive that good behavior and deeds earns positive feedback and he carries potential to do good. Clinical Behavior Therapy will allow David’s mother to learn basic parenting skills to help manage ADHD in day to day activity and settings (Brinkman & Epstein, 2007). Teaching David’s mother the proper skills will allow her to create an environment that rewards desired behavior hopefully implanting a drive in David to take on responsibility that will allow him to use some of the excess energy he fights (Brinkman & Epstein, 2007). Additionally, David should continue his medications as they allow him to focus and have proven an improvement in school. However, it may be necessary to alter medications as he may have built up a tolerance and the medication is not as effective as it once was.
- Therapeutic modality
- A multimodal approach of Psychotherapy in conjunction with medications seems to be the most appropriate modalities in David’s case. A study of the Multimodal Treatment approaches conducted by Brinkman and Epstein which included only direct contingency management and Cognitive Behavioral Therapy reported 34% of the children reported a remission of symptoms (Brinkman & Epstein, 2007). The study concluded that 56% of the children who were treated only with medication reported positive benefits to the medication, although 50% reported mild side effects (Brinkman & Epstein, 2007). In a combination treatment of both medication and therapeutic services, 68% of the children reported remission of symptoms after fourteen months (Brinkman & Epstein, 2007). However, it is important to note that although these statistics have a wonderful turnaround, both patient and parent, must choose goals that align with both desires of outcome as well as both must be willing to stick to the regimen to have the most effective results (Brinkman & Epstein, 2007).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Brinkman, W. B., & Epstein, J. N. (2011). Treatment planning for children with attention-deficit/hyperactivity disorder: treatment utilization and family preferences. Patient Preference and Adherence, 5, 45–56. http://doi.org/10.2147/PPA.S10647
Centers for Disease Control and Prevention. (2016). Retrieved from http://www.cdc.gov/ncbddd/adhd/diagnosis.html
Chien, W. T., & Yip, A. L. (2013). Current approaches to treatments for schizophrenia spectrum disorders, part I: an overview and medical treatments. Neuropsychiatric Disease and Treatment, 9, 1311–1332. http://doi.org/10.2147/NDT.S37485
Clubhouse International. (2016). Retrieved from http://www.iccd.org/whatis.html
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