Case 1a: Young Girl With Difficulties In School Background

Case 1a Young Girl With Difficulties In Schoolbackgroundin Psychopha

Case #1 A young girl with difficulties in school BACKGROUND In psychopharmacology you met Katie, an 8-year-old Caucasian female, who was brought to your office by her mother (age 47) and father (age 49). You worked through the case by recommending possible ADHD medications. As you progress in your PMHNP program, the cases will involve more information for you to sort through. For this case, you see Katie and her parents again. The parents have reported that the medication given to Katie does not seem to be helping. This has prompted you to reconsider the diagnosis of ADHD. You will consider other differential diagnoses and determine what information you need to accurately assess the DSM-5 criteria to make the diagnosis of ADHD or another disorder with similar diagnostic features. When parents bring their child to your office, they may have read symptoms on the internet or they may have been told by the school “your child has ADHD”. Your diagnosis will either confirm or refute that diagnosis. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine a differential diagnosis and to begin medication, if indicated.

The PMHNP makes this diagnostic decision based on interviews and observations of the child, her parents, and the assessment of the parents and teacher. To start, consider what assessment tools you might need to evaluate Katie. · Child Behavior Check List · Conners’ Teacher Rating Scale The parents give the PMHNP a copy of a form titled “Conner’s Teacher Rating Scale-Revised” (Available at: ). This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, makes careless mistakes in her schoolwork, forgets things she already learned, is poor in spelling, reading, and arithmetic.

Her attention span is short, and she is noted to only pay attention to things she is interested in. She has difficulty interacting with peers in the classroom and likes to play by herself at recess. When interviewing Katie’s parents, you ask about pre- and post-natal history and you note that Katie is the first born with parents who were close to 40 years old when she was born. She had a low 5-minute Apgar score. The parents say that she met normal developmental milestones and possibly had some difficulty with sleep during the pre-school years. They notice that Katie has difficulty socializing with peers, she is quiet at home and spends a lot of time watching TV. SUBJECTIVE You observe Katie in the office and she is not able to sit still during the interview. She is constantly interrupting both you and her parents. Katie reports that school is “OK” – her favorite subjects are “art” and “recess”. She states that she finds some subjects boring or too difficult, and sometimes hard because she feels “lost”. She admits that her mind does wander during class. “Sometimes” Katie reports “I will just be thinking about something else and not looking at the teacher or other students in the class.” Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. She offers no other concerns at this time. Katie’s parents appear somewhat anxious about their daughter’s problems.

You notice the mother is fidgeting with her rings and watch while you are talking. The father is tapping his foot. Other than that, they seem attentive and straightforward in the interview process. MENTAL STATUS EXAM The client is an 8-year-old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is neutral. Katie says that she doesn’t hear any ‘voices’ in her head but does admit to having an imaginary friend, ‘Audrey’. No reports of delusional or paranoid thought processes. Attention and concentration are somewhat limited based on Katie’s short answers to your questions.

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Based on the comprehensive data collected from multiple sources—interviews, observations, standardized assessments, and reports from parents and teachers—it is evident that Katie presents with symptoms that warrant a thorough differential diagnosis. The core features include inattentiveness, distractibility, short attention span, and difficulty engaging socially with peers. These symptoms intersect with several potential DSM-5 diagnoses, including Autism Spectrum Disorder (ASD), ADHD, and specific learning disorders. The diagnostic process necessitates integrating multiple clinical criteria to arrive at an accurate conclusion, especially given the complexity of overlapping symptoms.

Initially, considering ADHD, predominantly inattentive presentation, the criteria specified in DSM-5 (American Psychiatric Association, 2013) require at least six symptoms of inattention present for at least six months, to an extent inconsistent with developmental level, that negatively impact social, academic, or occupational functioning. Katie demonstrates numerous symptoms: difficulty sustaining attention, frequent distractibility, careless mistakes, forgetfulness in daily activities, and a tendency to pay attention only when interested. She appears inattentive in the classroom context, especially when tasks are boring or challenging, which aligns with criteria for inattentiveness.

The assessment via the Conner’s Teacher Rating Scale-Revised further supports the presence of these symptoms. The teacher notes that Katie pays only attention to things she finds interesting and struggles with spelling, reading, and math—indications of academic impairment related to her inattentiveness. In addition, her social behavior—playing alone, difficulty in peer interactions, and preference for solitary activities—could suggest a comorbid social or developmental disorder, making ASD a plausible differential diagnosis.

Moreover, her developmental history indicates some early challenges, such as a low Apgar score and sleep difficulties during preschool years. Although she met developmental milestones on time, these early issues merit further assessment for neurodevelopmental disorders. Her social withdrawal and preference for TV over peer engagement are consistent with traits seen in ASD, such as social communication deficits and restricted interests.

Furthermore, her report of an imaginary friend and her difficulty sitting still, interrupting during interviews, and wandering attention raise concerns that overlap with ASD diagnostic criteria, specifically deficits in social-emotional reciprocity, nonverbal communication, and restricted, repetitive behaviors (American Psychiatric Association, 2013). Her difficulty with socializing, as observed during interview and in school, necessitates evaluating for ASD more explicitly.

Given these considerations, the preliminary diagnosis of ADHD-inattentive type must be re-evaluated in light of potential ASD features. To confirm or refute these suspicions, further assessment is critical. This involves utilizing standardized diagnostic tools such as the Autism Diagnostic Observation Schedule (ADOS), Autism Diagnostic Interview-Revised (ADI-R), and additional behavior checklists tailored for ASD screening (Lord et al., 2012; Rutter et al., 2003).

In addition, comprehensive developmental history, parent interviews focusing on early milestones, social skills, and interests, and direct observation will contribute to differential diagnosis. Such a multidimensional approach ensures consideration of ASD criteria: deficits in social communication and restricted, repetitive behaviors occurring across multiple settings, starting in early developmental period (American Psychiatric Association, 2013).

In conclusion, while Katie exhibits significant inattentiveness consistent with ADHD, her social difficulties, early developmental history, and specific behaviors suggest that ASD may be a contributing or primary diagnosis. Confirming ASD would guide tailored interventions, including behavioral therapies and family support, complementing or replacing medication strategies focused solely on attentional deficits. Continued assessment with appropriate standardized instruments is vital for an accurate, evidence-based diagnosis and effective treatment plan.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Lord, C., Risi, S., Lambrecht, D., et al. (2012). The Autism Diagnostic Observation Schedule, Second Edition (ADOS-2). Western Psychological Services.
• Rutter, M., Le Couteur, A., & Lord, C. (2003). Autism Diagnostic Interview-Revised (ADI-R). Western Psychological Services.
• Charman, T., et al. (2015). Early diagnosis and intervention in autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(4), 945–956.
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