Case 2, Volume 1, Case 14: The Scatter-Brained Mother

Case 2volume 1 Case 14 The Scatter Brained Mother Whose Daughter H

Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.

Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).

Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.

Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.

Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.

Paper For Above instruction

The case of the scatter-brained mother whose daughter has ADHD presents a complex clinical scenario that necessitates a comprehensive approach to assessment and management. This paper aims to explore critical assessment questions, the role of collateral information, appropriate diagnostic testing, differential diagnoses, and pharmacologic treatment options, grounded in current clinical guidelines and evidence-based practices.

Assessment Questions and Rationale

To accurately evaluate the patient's condition, three pivotal questions include:

1. “Can you describe your daily challenges with focus and organization?”

   Rationale: This question helps elucidate the severity and specific aspects of attention difficulties, providing insight into the functional impairments and the impact on daily life.

2. “Have you experienced any mood swings, feelings of irritability, or anxiety?”

   Rationale: ADHD often coexists with mood and anxiety disorders. Identifying these symptoms assists in comprehensive diagnosis and treatment planning.

3. “How does your child's behavior compare at home and school?”

   Rationale: Gathering information about behavioral patterns across environments allows for understanding the consistency of symptoms and can highlight environmental or relational factors influencing behavior.

Collateral Information and Specific Questions

Gathering feedback from individuals involved in the patient's life is essential. Key informants include family members, teachers, and aides. Specific questions are:

• From family members: “Have you noticed specific triggers or situations that exacerbate her inattentiveness or hyperactivity?”

  Rationale: Identifies environmental factors and contextual triggers relevant to diagnosis and management.

• From teachers: “Does she display symptoms of distractibility, impulsivity, or hyperactivity at school?”

  Rationale: School behavior is critical for assessing ADHD severity and functional impairment across settings.

• From caregivers or aides: “What strategies seem to help her stay focused or calm, and what challenges persist?”

  Rationale: Understanding what interventions have been tried and their effectiveness informs tailored treatment approaches.

Physical Examination and Diagnostic Testing

A thorough physical exam is vital to rule out medical causes such as sleep disorders, thyroid dysfunction, or neurological issues that could mimic ADHD symptoms. Recommended tests include:

• Thyroid function tests (TSH, free T4): To exclude hypothyroidism, which can cause attention and concentration problems.
• Complete blood count (CBC): To identify anemia that may contribute to fatigue and poor concentration.
• Electrocardiogram (ECG): If cardiac contraindications to certain ADHD medications are suspected.
• Neuropsychological assessment: To evaluate cognitive functioning and attention, enabling differentiation between ADHD and other neurodevelopmental or psychological disorders.

Results from these tests aid in confirming diagnoses, ruling out underlying medical conditions, and guiding medication choices.

Differential Diagnoses and Most Likely Diagnosis

1. Attention-Deficit/Hyperactivity Disorder (ADHD) - Most likely, given the presentation of inattentiveness and hyperactivity, commonly inherited as suggested by the mother’s similar traits.
2. Oppositional Defiant Disorder (ODD) - Symptoms may overlap, but ODD is characterized by defiant behavior rather than inattention alone.
3. Anxiety Disorders - Can mimic attention issues; anxiety may impair focus, necessitating distinction.

The most probable diagnosis is ADHD, predominantly combined presentation, due to core symptoms aligning with DSM-5 criteria and family history indicating genetic predisposition.

Pharmacologic Treatment Options

Based on Stahl’s Prescriber’s Guide, two agents are considered appropriate:

1. Methylphenidate (IR or ER) – Starting dose: 10-20 mg twice daily for immediate-release, with titration based on response and tolerability. Extended-release formulations provide once-daily dosing, improving adherence. The mechanism involves dopamine and norepinephrine reuptake inhibition, improving attention and reducing hyperactivity.
2. Amphetamine salts (e.g., Adderall XR) – Starting dose: 5-10 mg once daily, titrated as needed. Similar mechanism to methylphenidate but with a slight difference in neurochemical activity, often preferred if methylphenidate is ineffective or causes adverse effects.

Choice depends on patient response, side-effect profiles, and pharmacokinetic properties. For example, methylphenidate’s rapid onset makes it suitable for symptom control during school hours, while longer-acting formulations support 24-hour symptom coverage.

Follow-Up and Therapeutic Adjustments

If follow-up data indicate suboptimal symptom control or adverse effects at week 4 or 8, adjustments include dosage titration, switching agents, or adding behavioral therapies. Regular monitoring of growth, sleep patterns, and mood is essential to optimize outcomes.

Lessons Learned and Clinical Application

This case underscores the importance of comprehensive assessment in pediatric ADHD, including consideration of co-morbid conditions and collateral reports. It highlights the value of integrating medication management with behavioral interventions and family education. Clinicians must remain vigilant about side effects and treatment adherence, tailoring pharmacologic interventions to individual patient profiles. Applying these principles enhances evidence-based practice, leading to improved patient outcomes in similar clinical scenarios.

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). APA.
• Stahl, S. M. (2021). Stahl's Prescriber's Guide (6th ed.). Cambridge University Press.
• Barkley, R. A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment. Guilford Publications.
• Subcommittee on Attention-Deficit/Hyperactivity Disorder, Steering Committee on Quality Improvement and Management. (2011). ADHD screening and diagnosis. Pediatrics, 128(5), 1007-1020.
• Faraone, S. V., et al. (2015). The genetics of attention deficit hyperactivity disorder. Molecular Psychiatry, 20(3), 243–252.
• Office of the Surgeon General. (2016). Mental health: A report of the Surgeon General. U.S. Department of Health and Human Services.
• American Academy of Child and Adolescent Psychiatry. (2019). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder.
• Moriyama, T., et al. (2018). Pharmacotherapies for ADHD. Journal of Child and Adolescent Psychopharmacology, 28(4), 251–268.
• Carino, R. C., et al. (2020). Pharmacologic management of ADHD in children and adolescents. Psychiatry Update, 60(2), 78–84.
• Wilens, T. E., et al. (2019). Pharmacotherapy of ADHD across the lifespan. Journal of Clinical Psychiatry, 80(3), 18a13029.