NURS 6630 Case 13: 8-Year-Old Girl Who Was Naughty
NURS 6630 Case 13 8-Year-Old Girl Who Was Naughty
In this case, the study involves an 8-year-old girl who was presented to a pediatrician by her 26-year-old mother. The reasons for hospital visit were due to fever and sore throat. On medical assessment, the patient indicated signs of being negative, defiant and disobedient though she denied both. Besides, the medical diagnosis reveals an Attention deficit hyperactivity disorder (ADHD) inattentive type with a comorbid Oppositional Defiant Disorder (ODD). However, on follow-up visits, it was established that the mother’s behavior was similar to her daughter’s as she is disorganized and her response to the ADHD rating scale significantly revealed a mental health condition (Voris, 2016). As such, the intervention was focused on both the child and the mother. In the case of the child, high doses of stimulants were administered, but it was established to cause insomnia to the child and did not adequately manage the oppositional symptoms. To this effect, the patient was also given guanfacine XR, a 2A selective noradrenergic agonist, to improve oppositional symptoms and to stabilize the patient (Cardinal, 2012). For the subsequent analysis, the practicing nurse in the health facility will take the roles of a physician and conduct a clinical interview for the patient. Moreover, the nurse practitioner will also recommend suitable therapies to respond to the patient’s oppositional symptoms.
Patient Clinical Interview Question
As per the clinical case study, the patient manifest disturbances of activity both at home and in school. Her conditions revealed a diagnosis of a combined type of ADHD as evidenced by her character. It was therefore imperative by the charge nurse to establish the reasons behind her behavior and make a diagnosis using comorbidities manifested by the patient (Rolon-Aroyo, Arnold, Harvey, & Marshall, 2016). However, this could be ascertained by asking the following questions to the patient:
What do you hate most in life?
Are you easily angered or irritated at school and home?
How do you cope with frustration and emotional pain in daily life?
These questions indulge the patient to assess for the possibility of anxiety and mood disorder, which might predispose her to ODD. Particularly, the first question helps a nurse to assess the way the child views rules, authority and convey expectations in life. Based on this perspective, the nurse will be able to find out the patient’s reaction to rules, and this will determine her medication adherence. For the second question, the nurse will ascertain patterns of defiance, disobedience, and negativisms to make a diagnosis of ADHD with comorbid condition of ODD (Rolon-Aroyo, Arnold, Harvey, & Marshall, 2016). The third question intends to ascertain the child’s behavior in response to disappointing situations.
Clinical Interview Questions to People in the Patient’s Life
In this case, people close to the patient will be asked questions regarding her patterns of defiant behavior and conduct disorders. The first person to ask question will be her mother followed by her class teacher. These two persons have direct contact with the patient and are in a better position to identify developmental changes in the child. The mother will be asked the following question: Does the child exhibit irritable mood, vindictiveness and defiant behavior at home as she relates to her peers? The above aspects play an important role in establishing oppositional behaviors and impulsivity that arise due to ADHD to help with the diagnosis process prior to therapy (Bezdjian et al., 2011). The school teacher, on the other hand, will be asked the following question: Does the pupil show aggressiveness, truancy, disobedience and have deteriorating grades in the past 8 months? The question will assist to identify the impulsivity as well as the inattentive nature of the child so as to develop a diagnosis on ADHD-combined type.
Physical Examination and Diagnostic Tests
Based on the child’s impulsive behavior, it would be integral for the nurse in charge to investigate mental state examination to reveal psychomotor activity. The physical examination will also constitute an assessment of the child’s attitude towards the examiner and her cognitive functions. The diagnostic tests, on the other hand, would comprise of Electroencephalography, blood biochemistry (specific to thyroid profile) and a Children’s Apperception Test (CAT) (French, 2015). The latter will be used to establish a perception of parental deprivation together with a feeling of a hostile environment by the child. However, MRI of the brain will also be integral for the nurse practitioner to eliminate possible trauma or injuries to the brain.
Differential Diagnoses for the Patient
The primary diagnosis of the patient was combined with comorbid symptoms indicated by frequent temper tantrums in addition to the refusal by the child to comply with rules both at school and home. However, differential diagnoses were as follows;
Comorbidity between ADHD and conduct disorder
Comorbidity between ADHD and oppositional defiant disorder
Comorbidity between ADHD and post-traumatic stress disorder
Nevertheless, from the assessment of the child, the ADHD plus oppositional defiant disorder as the patient has demonstrated the ability to be aggressive, purposefully irritate and bother her little sister, and has hostile, negativist and defiant behavior that has lasted over 6 months.
Pharmacologic Agents
The preferred treatment for the patient’s condition will constitute;
Lisdexamfetamine 5-10 mg daily in the morning
Methylphenidate 10 mg twice daily, which will then be titrated to maximum dosage
Lisdexamfetamine is a pro-drug of d-amphetamine and is used to treat ADHD. According to Briars and Todd (2016), the drug possesses a prolonged pharmacokinetic profile due to its lower liking as well as oral misuse. The drug reaches peak plasma concentration within three hours of administration, which is indicative of its effectiveness. Further, the drug has a bioavailability of over 75%, which also influences its effectiveness. Methylphenidate, on the other hand, is well-absorbed from the gastrointestinal tract and has a short duration of action of between 1-4 hours (Stahl, 2013). Moreover, the molecule achieves its peak duration of action of between 1-4 hours after administration. These pharmacodynamics and pharmacokinetic properties make the drugs preferable in the treatment of ADHD in children.
According to studies, amphetamines work by inhibiting the reuptake of dopamine and norepinephrine into the presynaptic neuron. By doing this, it enhances the rate at which the above monoamines are released into the extraneuronal space (Briars & Todd, 2016). Methylphenidate works by inhibiting the reuptake of catecholamine, principally the dopamine. It similarly acts by norepinephrine and dopamine transporters, leading to enhanced concentrations of the above at the synaptic cleft (Stahl, 2014). Thus, based on the mechanism of action of the two, the methylphenidate will be preferred.
Effect of Ethnicity on Lisdexamfetamine Dosage and/or Contraindications
Studies reveal that pharmacogenetics play an integral role in the dosage adjustment of methylphenidate. The polymorphisms of the gene CYPD26 influence the dosing of any patient with ADHD. In a study conducted on a 6-year-old with a genetic variant of the above gene, the dosage of the drug had to be reduced to 2.5 mg once daily in the morning so as to offset side –effects at the normal dose (Tan-Kan et al., 2016). Specifically, pharmacogenetics testing revealed that the child possessed the CYP2D6*2/*10 isoenzyme. According to other studies, people of Caucasian origins are predisposed to having a variation of the CYPD26 gene, which makes them either slow or intermediate metabolizers. Consequently, they experienced downregulated metabolism of the drug, making it imperative for their methylphenidate dosages to be reduced.
Checkpoint Changes
The patient will be monitored by the mother and through the follow-up visits to the facility to assess adjustment to medications. The child will be evaluated for possible side effects based on the medication regimen. If no side effect is noted, then methylphenidate will continue to be increased depending on the patient’s response. Specifically, the dosage should be tolerated at between 6.9-13.8 mg (Stahl, 2014). However, as already mentioned, the patient will be monitored for tolerability and efficacy so as to determine the optimum dosage.
Lessons Learned
The case study presents a number of lessons that the nurse practitioner can integrate during care. In the first lessons, it is apparent that children suffering from ADHD with comorbid OPP do not have obedience to authority. As such, they may not adhere to the medication regimen administered for their condition. It would be apparent to assist such patients by referring them to psychosocial support to address this challenge. However, patients with ADHD could manifest aggression and impulsiveness, which are also symptoms exhibited by psychosis patients. It will be imperative for a nurse practitioner to undertake various medical investigations to rule out the possibility of psychosis. Apparently, for the ADHD patients, time and route of administrations are of utmost paramount to enhance the efficacy of medications for the patients.
Reference
Bezdjian, S., Krueger, R. F., Derringer, J., Malone, S., McGue, M., & Iacono, W. G. (2011). The structure of DSM-IV ADHD, ODD, and CD criteria in adolescent boys: A hierarchical approach. Psychiatry Research, 188(3), 411–421. http://doi.org/10.1016/j.psychres.2011.02.027
Briars, L., & Todd, T. (2016). A Review of Pharmacological Management of Attention-Deficit/Hyperactivity Disorder. The Journal of Pediatric Pharmacology and Therapeutics : JPPT, 21(3), 192–206. http://doi.org/10.5863/1551-6776-21.3.192
French, W. (2015). Assessment and Treatment of Attention-Deficit/Hyperactivity Disorder: Part 1. Pediatr Ann. 44: 114-120. doi: 10.3928/00904481-20150313-1.
Mager, D. E., & Kimko, H. H. (Eds.). (2016). Systems pharmacology and pharmacodynamics (Vol. 23). Springer.
Rolon-Arroyo, B., Arnold, D. H., Harvey, E. A., & Marshall, N. (2016). Assessing Attention and Disruptive Behavior Symptoms in Preschool-Age Children: The Utility of the Diagnostic Interview Schedule for Children. Journal of Child and Family Studies, 25(1), 65–76. http://doi.org/10.1007/s10826-015-0203-x
Stahl, S. M. (2014). Essential psychopharmacology: The prescriber’s guide, 5th ed. Cambridge, NY: Cambridge Univ. Press.
Stahl, S.M. (2013).Stahl’s Essential Psychopharmacology, 4th ed. New York, NY: Cambridge University Press.
Tan-kam, T., Suthisisang, C., Pavasuthipaisit, C., Limsila, P., Puangpetch, A., & Sukasem, C. (2013). Importance of pharmacogenetics in the treatment of children with attention deficit hyperactive disorder: a case report. Pharmacogenomics and Personalized Medicine, 6, 3–7. http://doi.org/10.2147/PGPM.S36782
Voris, D. S. T. (2016). An exploration of psychotropic treatment of youth diagnosed with serious emotional disturbance within wraparound service delivery. Michigan State University.