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WALDEN UNIVERSITY NURS 6630 WEEK 9 DISCUSSION CASE BOARD/ COMPLETE SOLUTION
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WALDEN UNIVERSITY NURS 6630 WEEK 9 DISCUSSIONCASE BOARD/ COMPLETE SOLUTION
Case 1 Week 9
Case 1: Volume 1, Case #13: The 8-year-old girl who was
naughty
COL LA PS E
Week 9 discussion
Case 1: Volume 1, Case #13: The 8-year-old girl who was naughty
Three Questions & Rationale
1. What do you like most and least about school?
Rationale: The purpose of this question is to inquire how the client is adjusting to school by
discovering areas of weakness and strengths.
2. Tell me about your relationships with your family and friends?
Rationale: The purpose of this question is to inquire how the client interacts with others from
her perspective.
3. How long does it take you to finish tasks (schoolwork, chores, etc.)?
Rationale: The purpose of this question is to inquire about the client’s level of organization.
People in Patients Life to Interview & Questions Asked and Why
Parents (mother and father):
1.) Tell me a little about the client’s organizational skills at home?
2.) How does the client interact with the family at home?
3.) What age did you notice the onset and duration of symptoms?
Rationale: The client’s parents will be able to describe the client’s behavior when at home. The
client’s parents will also be able to explain any defiant behavior such as if the client does not
obey rules at home or loses her temper frequently.
Teachers:
1.) Can you explain how the client interacts with other students?
2.) Can you describe the client’s organizational skills when given tasks to perform?
3.) What type of learning difficulties have you noticed in this client?
Rationale: The client’s teacher will be able to disclose how the client interacts with other
students and explain how organized the client is. In addition, the teacher will be able to report
if functional impairments exist that could contribute to the client’s behavior in school.
Explanation of Physical Exams & Diagnostic Tests and How They Would be Used
According to the client and the client’s mother, the patient currently presents with a sore
throat and fever but does not have a history of any other medical conditions (Stahl, 2013).
However, the client’s mother does report that the client presents defiant behavior at home as well
as disobedience at school, academic problems, temper tantrums, and conflicts with children at
school (Stahl, 2013). Therefore, a physical examination from head to toe will be performed, first,
addressing the clients fever and sore throat. Throat cultures and nasal swabs would be collected
to rule out URI pathogens (Meneghetti, 2018). Next, a vision and hearing test will be
conducted.According to Smucker and Hedayat (2001), hearing and vision impairment can
sometimes contribute to inattention and poor school performance and can be mistaken as ADHD.
Also, Smucker & Hedayat (2001), explain how oftentimes children who present with learning
disabilities can be mistaken for having ADHD, thus, should receive cognitive testing. Therefore,
a neurologic examination will be performed to determine if the client has developmental
,disabilities, emotional disorders, brain diseases, or intellectual disabilities that could be mistaken
for ADHD (National Institute of Health (NIH), 2016). In addition, the Conner’s Parent and
teacher rating scales test will be given to determine if the client presents with symptoms of
ADHD and oppositional defiant disorder. For example, The Conner’s Teacher Rating Scale is a
scale used to determine if the client presents with the following problems that include:
hyperactivity, emotional, passive, anxious, attention problems, conduct disorder, daydreaming, or
asocial behavior (Goyette et al., 2005). On the other hand, the Conners’ Parent Rating Scale
assesses twelve criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (for
children between the ages of 3-17 years old) that cover symptoms of ADHD and oppositional
defiant disorder, by inquiring how frequently the client presents with various symptoms (Kumar
& Steer, 2003).
Three Differential Diagnoses
ADHD comorbid with ODD
Based on the client’s presentation of symptoms it was determined that the most
likely differential diagnosis would be ADHD comorbid with Oppositional Defiant Disorder.
According to Forehand et al. (2016), ADHD is a neurodevelopmental disorder that is
distinguished by the following symptoms: inattentiveness, impulsivity, excessive activity,
difficulty concentrating/focusing, short attention span, hyperactivity, absent-mindedness,
and mood swings. American Psychiatric Association (2016) reports that oftentimes clients
will present with ADHD comorbid with ODD. Thus, in addition to presenting symptoms of
ADHD, clients may also present a minimum of four symptoms that include: patterns of
irritability, anger, argumentative, defiant behavior, or losing temper easily (American
Psychiatric Association, 2016). However, these symptoms will generally last approximately
six months and will occur with one individual who the client is not related to (not including
sibling) (American Psychiatric Association, 2016).
After analyzing the results of the Conner’s Parent/Teacher Rating Scale it was
determined that the client presented with difficulty following instructions are given from the
teacher and mother by making careless mistakes, disobedient and argumentative behavior
in class and at home, disorganized, excessive talking in class, forgetfulness, inattention, and
easily distracted (Stahl, 2013). The client does not present symptoms of hyperactivity but
does resent inattentiveness (Stahl, 2013). Thus, based on the client’s symptoms ADHD
comorbid with ODD would be the most likely diagnosis for this client.
Learning Disability:
Clients that present with a learning disability will have difficulty processing and
receiving information (Bhandari, 2018). Individuals will generally have problems with
comprehending directions, reading, math, and writing (Bhandari, 2018).
Developmental Delays:
Individuals with developmental delays will generally present with impaired learning,
behavior, physical, and language abilities (Centers for Disease Control and Prevention (CDC),
2018). Individuals with developmental delays may be impacted by daily functioning that may
begin during the developmental period and last throughout their lifetime (CDC, 2018).
Two Pharmacologic Agents & Dosing for ADHD Therapy Based on Pharmacokinetics &
Pharmacodynamics & Rationale
,Methylphenidate (D,L) is a drug that is most commonly prescribed for both children and adults
to treat attention deficit disorder (ADHD) (Stahl, 2014b). This drug works by inhibiting
dopamine reuptake while increasing norepinephrine and dopamine activity which enhances
concentration, attention, hyperactivity, and wakefulness (Stahl, 2014b). Due to the client’s age
(some children not liking to take tablet form), she would be administered a transdermal patch
starting at 10 mg every 9 hours which may be increased by 5 mg every week to treat symptoms
of ADHD (Stahl, 2014b). Clients may be administered a maximum dose of 30 mg/9 hours (Stahl,
2014b). According to Drugs.com (2017), the pharmacokinetics of methylphenidate (D.L.) in
children present a delay in minimum peak concentrations and second peak concentrations when
compared to adults causing children to have higher concentrations of the drug, due to their
smaller body size and the total volume of distribution.
Guanfacine XR is a norepinephrine receptor agonist drug that works centrally on alpha 2A
agonist sites in the prefrontal cortex of the brain and is a nonstimulant for individuals with
ADHD (Stahl, 2014b). This drug may be used to treat both ADHD and oppositional defiant
disorder which are both conditions the client in this case study presents with which is why this
drug would be chosen over methylphenidate (Stahl, 2014b). This drug works in the prefrontal
cortex region of the brain by assisting with attention, memory, impulsivity, planning, and control
(Stahl, 2014b). This drug would be dosed on a mg/kg basis (0.05 mg/kg to 0.12 mg/kg) to ensure
the client is being prescribed the appropriated dose based on her weight (Sthal, 2014b).
No Checkpoints noted for this case study
Explanation of Lessons Learned
The lesson learned in this case study is that in some instances more than one drug
regimen may be prescribed in children with ADHD comorbid with ODD. It was initially believed
that prescribing guanfacine XR alone would suffice in treating this client because it is a drug
that, unlike methylphenidate, works to treat both ADHD and ODD. However, after reviewing the
results and the final outcome in this case study it was learned that oftentimes children diagnosed
with this condition may be prescribed augmented drug therapies to achieve effective results.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders
(5th ed.). Washington, DC: Author.
Bhandari, S. (2018). Detecting learning disabilities. Retrieved on July 25, 2018, from
https://www.webmd.com/children/guide/detecting-learning-disabilities#3
Centers for Disease Control and Prevention (CDC). (2018). Developmental disabilities.
Retrieved
on July 25, 2018, from https://www.cdc.gov/ncbddd/developmentaldisabilities/facts.html
Drugs.com. (2017). Ritalin LA
Forehand, R., Parent, J., Sonuga-Barke, E., Peisch, V. D., Long, N., & Abikoff, H. B. (2016).
Which Type of Parent Training Works Best for Preschoolers with Comorbid
ADHD and ODD? A Secondary Analysis of a Randomized Controlled Trial
Comparing Generic and Specialized Programs. Journal of Abnormal Child
Psychology, 44(8), 1503-1513.
Goyette, C. H., Conners, C. K., Ulrich, R. F., Epstein, J. N., Willoughby, M., Valencia, E. Y., &
, ... Hinshaw, S. P. (2005). Conners' teacher rating scale--Revised. Journal of Consulting
and Clinical Psychology, 73(3), 424-434.
Kumar, G., & Steer, R. A. (2003). Factorial Validity of the Conners' Parent Rating Scale-
Revised: Short Form with Psychiatric Outpatients. Journal of Personality
Assessment, 80(3), 252-259.
Meneghetti, A. (2018). Upper respiratory tract infection workup. Retrieved on July 25, 2018,
from https://emedicine.medscape.com/article/302460-workup
National Institute of Health (NIH). (2016). How are learning disabilities noticed. Retrieved on
July 25, 2018, from
https://www.nichd.nih.gov/health/topics/learning/conditioninfo/diagnosed
Smucker, W.D., & Hedayat, M. (2001). Evaluation and treatment of ADHD.
Am Fam Physician, 64(5), 817-830.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and
practical
applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University
Press.
Case 1: Volume 1 Case #13 :the 8 year old girl who was
naughty
COL LA PS E
NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology
INITIAL POST:
Case Study 1: Volume 1, Case # 13: The 8 year old girl who was naughty
The three questions that would be asked to the patient are:
How long have you been having difficulty focusing at home and/or school?
Have something contributed or triggered such behavior?
Are you aware of some of the behaviors that you have been doing? If so what have
you noticed?
The individuals of the patient’s life I would need to speak with to get feedback and to
further assess would be the patient’s mother, teacher and PCP. The questions asked to the
mother are When did you notice the behaviors? Do you think any possible stressors or
triggers contributed? Do you feel safe with your daughter in the home? What is the
interaction amongst your daughter and her sibling? The questions asked to the teacher
would be, When did you notice the change or start in behavior? What are some of the
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