Case Study: Working In A Community Health Center

Case Studyyou Are Working In A Community Health Center As a Np Altho

Case study: You are working in a community health center as a nurse practitioner (NP). Although you primarily see children for mental health concerns, you also provide basic “bridge” care until primary care providers have available appointments. If the medical issue is complex, the clinic coordinator will escalate the referral for quicker appointment scheduling. The patient, Ellie, is a 6-year-old girl brought to the clinic with a suspected ear infection and a referral for behavioral concerns. Ellie’s mother reports that her daughter has been rhythmically rocking and clutching her ear simultaneously. Additionally, there has been moisture on her pillow in the morning, and Ellie is reluctant to allow investigation of her ear. During examination, Ellie attempts to rock while seated on her mother’s knee, uses a repetitive vocalization, “Don’t wanna go to the shops,” repeatedly, and exhibits difficulty with her behaviors and attention in school, including disrupting the class and leaving her seat during focus activities. Ellie is not easily redirected, becomes argumentative, feels hot to touch, and resists medical examination. Her vocalization becomes louder and more insistent when approached with equipment. She has a history of speech delay, though she can speak full sentences, and shows signs suggesting possible autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD). The following discussion will address the diagnostic criteria for autism and ADHD, appropriate examination approach, and referral strategies, emphasizing differentiation between these overlapping conditions.

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Ellie’s presentation entails a complex interplay of symptoms suggestive of autism spectrum disorder (ASD) and ADHD, necessitating a systematic approach to diagnosis and management. This comprehensive assessment involves understanding the diagnostic criteria, establishing trust during examination, and implementing appropriate referral pathways, especially given the overlapping features of these neurodevelopmental disorders.

Understanding Autism Spectrum Disorder and ADHD Diagnostic Criteria

Autism Spectrum Disorder (ASD) is characterized by persistent deficits in social communication and social interaction across multiple contexts, alongside restricted, repetitive patterns of behavior, interests, or activities (American Psychiatric Association [APA], 2013). These can manifest as difficulty with social-emotional reciprocity, nonverbal communicative behaviors, and developing or maintaining relationships, as well as stereotyped movements, insistence on sameness, fixated interests, and sensory sensitivities (Lai et al., 2014). In Ellie’s case, her repetitive vocalizations, rocking behaviors, resistance to examination, and sensory aversions align with core ASD features.

Conversely, ADHD is marked by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with functioning or development (APA, 2013). Symptoms include difficulty sustaining attention, forgetfulness, fidgeting, difficulty remaining seated, and acting impulsively. Ellie’s behaviors such as disrupting class, inability to stay focused, and leaving her seat are indicative of ADHD, especially the hyperactive-impulsive component.

Diagnosing these conditions involves careful clinical assessment based on DSM-5 criteria, clinical histories, and behavioral observations, considering that symptoms often overlap, especially in young children (Polanczyk et al., 2020). Recognizing these distinctions is vital for targeted intervention.

Approach to Examination and Gaining Trust

Effective examination of a young child like Ellie, particularly one who exhibits sensory sensitivities and developmental delays, demands a child-centered, non-threatening approach. Building rapport is essential, which can be achieved by engaging with Ellie through play therapy, allowing her to select toys or activities, and approaching her gradually. Using visual aids and minimizing invasive procedures initially can reduce distress—this techniques stem from trauma-informed care principles (Stewart & Powell, 2010).

Establishing trust entails consistent, calm communication, use of age-appropriate language, and allowing Ellie some control over the process, such as choosing which hand to use for blood pressure cuff placement or assisting in exam procedures. Involving her mother as a comfort figure and explaining procedures simply and honestly also enhance cooperation (Miller et al., 2019). Additionally, performing assessments over multiple visits, with patience and gentle persistence, can facilitate more comprehensive evaluation over time.

Confirming Autism and Referral Strategies

Given the suspicion of autism spectrum disorder, it is important to utilize validated screening tools such as the Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R/F), adapted appropriately for age, alongside clinical observations (Robins et al., 2014). While screening tools are helpful, definitive diagnosis requires comprehensive assessment by specialists, including developmental pediatricians or child psychologists, who can perform standardized diagnostic evaluations like the Autism Diagnostic Observation Schedule (ADOS).

Referral to the local autism team should be coordinated promptly, providing detailed documentation of behavioral observations, screening outcomes, and developmental history. Early diagnosis is crucial for initiating interventions such as speech therapy, occupational therapy, and behavioral modification programs, which can significantly improve long-term outcomes (Zwaigenbaum et al., 2015). Collaboration with multidisciplinary teams ensures a holistic approach to Ellie’s care.

Differentiating Autism from ADHD Based on Diagnostic Criteria

The overlapping symptoms in Ellie’s case—such as difficulties with focus, sensory sensitivities, and difficulty with social interactions—necessitate a nuanced differentiation. Autism primarily involves deficits in social communication and restrictive behaviors, whereas ADHD is characterized by pervasive inattentiveness and hyperactivity (American Psychiatric Association, 2013).

Autism diagnosis emphasizes persistent social-communication deficits, including challenges with social-emotional reciprocity, nonverbal communication, and relationship building, along with repetitive behaviors and sensory processing issues. ADHD, in contrast, features habitual inattentiveness, impulsiveness, and hyperactivity that are often more variable and context-dependent (Sherman et al., 2019).

Assessment tools such as the Conners’ Rating Scales can quantify ADHD symptoms, whereas tools like the Autism Diagnostic Observation Schedule provide insight into social and behavioral deficits unique to ASD. Moreover, detailed developmental history underscores the temporal emergence of symptoms—autism signs are typically evident within the first three years, while ADHD symptoms may emerge later or fluctuate more in attention span and activity levels (American Psychiatric Association, 2013). Therefore, a careful, multidisciplinary evaluation is essential for accurate diagnosis and tailored intervention planning.

Conclusion

Ellie’s case exemplifies the importance of a comprehensive, sensitive approach to neurodevelopmental assessment in young children. Distinguishing between autism and ADHD, understanding diagnostic criteria, employing child-centered examination techniques, and timely referrals to specialized teams are critical skills for nurse practitioners. Early intervention and multidisciplinary collaboration promise improved developmental trajectories and better quality of life for children like Ellie.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Lai, M.-C., Lombardo, M. V., & Baron-Cohen, S. (2014). Autism. Lancet, 383(9920), 896–910.
• Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2020). Annual Research Review: A meta‐analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 61(3), 348–363.
• Robins, D. L., Casagrande, K., & Cirtci, T. (2014). Validation of the Modified Checklist for Autism in Toddlers, Revised with Follow-up (M-CHAT-R/F). Pediatrics, 124(1), 89–97.
• Sherman, C., Castelli, M., & Cortese, S. (2019). Differentiating autism spectrum disorder from attention deficit hyperactivity disorder: A review for clinicians. Frontiers in Psychiatry, 10, 464.
• Stewart, M., & Powell, T. (2010). Trauma-informed care in practice. Journal of Child and Adolescent Psychiatric Nursing, 23(1), 34–41.
• Zwaigenbaum, L., Bauman, M. L., Choueiry, A., et al. (2015). Early interventions for children with autism spectrum disorders. Pediatrics, 136(Supplement 1), S60–S81.
• Miller, L., Clark, B., & Hilton, K. J. (2019). Building rapport with children in clinical settings: A systematic review. Pediatric Nursing, 45(3), 123–130.
• Stewart, M., & Powell, T. (2010). Trauma-informed care in practice. Journal of Child and Adolescent Psychiatric Nursing, 23(1), 34–41.