Attention Deficit Hyperactivity Disorder in Teenager

Introduction

The patient is a 15-year-old Hispanic male who was diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) six years ago. The patient and his mother have visited the healthcare provider to receive the medication refill to overcome the symptoms of ADHD associated with the period of non-taking the previously prescribed medicine. The patient reports increased hyperactivity, problems with concentration, and anxiety. The purpose of this report is to summarize the results of three visits to the healthcare provider in terms of stating the diagnosis, describing the assessment, and discussing interventions.

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DSM-5 Diagnosis and NANDA Diagnosis

Initially, the patient was diagnosed using the ICD10-CM to have ADHD of an unspecified type (F90.9). According to the DSM-5 classification, the patient’s diagnosis is 314.01 – Combined presentation (F90.2). The reason is that the patient demonstrated symptoms associated with both inattention and hyperactivity-impulsivity during the past six months.

The presence of such symptoms as the lack of attention and concentration, the difficulty in organizing activities, distraction, and interrupting behaviors among others provides the reason for excluding some diagnoses. They are 314.00 (F90.0) – Predominantly inattentive presentation and 314.01 (F90.1) – Predominantly hyperactive/impulsive presentation. Therefore, the final diagnosis according to the ICD10-CM is F90.2 – Attention-deficit hyperactivity disorder, combined type.

Relevant medical diagnoses that are proposed in the context of the differential diagnosis are F39 – Unspecified mood [affective] disorder, F41.9 – Anxiety disorder, unspecified, and F91.9 – Conduct disorder, unspecified. They are considered for ruling out because the assessment results do not indicate all signs typical of these disorders. The test results indicate that the patient has the signs typical of the combined type of ADHD. Two NANDA diagnoses can be formulated to address the patient’s problem. The first diagnosis: Ineffective concentration related to inattention and hyperactivity as evidenced by frequent distractions. The second diagnosis: Anxiety related to inattention and hyperactivity as evidenced by the patient’s restless behavior.

Case Formulation (Theory-Based Assessment)

A brief cognitive case formulation is selected for the current assessment. Negative automatic thoughts identified during the communication with the client can be formulated in the following way: “I always make mistakes when performing tasks,” “It is impossible for me to be organized.” The associated dysfunctional emotions are moderate sadness and hopelessness. Somatic symptoms include tiredness, distraction, and the patient’s inability to concentrate during different activities. Associated behaviors in this case are the lack of motivation and avoidance of those activities that require concentration during a long period of time.

The core belief that can be discussed as underlying the determined automatic thoughts can be formulated as follows: “If I have problems with performing some tasks, I will never stop making mistakes.” Another assumption can be presented as follows: “If I have problems with concentration and focusing attention, I will always fail in my activities.”

Treatment Interventions with Rationale

Pharmacology

Depending on the client’s age, health status, and lifestyle, it is appropriate to continue the prescription of Concerta (36 mg PO daily in the morning). The fact that the patient used this medication in the past allows for avoiding the stages associated with the dosage titration and augmentation. The proposed dose was reported as appropriate for treating the patient’s state because it was effectively adjusted previously.

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The rationale for selecting this medication is presented in the recent studies. Thus, Concerta is actively used in adolescents to treat ADHD because its main component methylphenidate is proved to address symptoms of hyperactivity and inattention (Weyandt et al., 2014). This medication should be selected because its effect are observed during 12 hours, and taking it in the morning will help the patient be productive and attentive at school (McCarthy, 2014).

Diagnostic Tests/Lab Work

To further support the provided diagnosis and exclude co-existing conditions or diseases with similar symptoms like mood disorders, learning disabilities, or autism, it is necessary to conduct several tests that will take about an hour. It is appropriate to apply two different ADHD rating scales to support the type of ADHD identified in the patient and exclude the possibility of other conditions. The focus should be on selecting scales that are developed for adolescents and that include other symptoms to consider. In addition to the conducted test of specific abilities (memory recall), it is necessary to conduct tests using broad-spectrum scales (Chang, Wang, & Tsai, 2016).

The reason is screening for possible emotional and psychiatric problems that can cause identified symptoms. Further testing is required for ensuring that the diagnoses are correct, and it is useful for developing a treatment plan if the patient has some co-existing conditions.

Evidence-Based Non-Pharmacologic Interventions

Cognitive behavioral therapy (CBT) is selected for the patient as a non-pharmacologic intervention. The reason is that CBT as the form of psychotherapy is aimed at achieving changes in people’s thinking. In the case of the patient, CBT is important to overcome his negative automatic thoughts and views regarding his abilities depending on past experiences (Sprich, Burbridge, Lerner, & Safren, 2015). To implement CBT, the patient should visit a counselor once a week per 2 months. The proposed intervention will be effective if the patient changes the way of thinking and gets rid of negative thoughts in eight weeks after starting CBT (Sprich, Safren, Finkelstein, Remmert, & Hammerness, 2016).

Patient and Family Education

The patient should be educated regarding possible approaches to organizing daily activities to take required breaks and promote productivity. The importance of balancing daily activities and having enough time for sleep should be accentuated. Much attention should be paid to proposing a healthy diet for the adolescent in order to guarantee he receives all vitamins and minerals influencing people’s mood and the level of energy.

Referral(s) If Indicated

The referral to the counselor is required for the patient to visit CBT sessions.

References

Chang, L. Y., Wang, M. Y., & Tsai, P. S. (2016). Diagnostic accuracy of rating scales for attention-deficit/hyperactivity disorder: A meta-analysis. Pediatrics, 137(3), 1-8.

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McCarthy, S. (2014). Pharmacological interventions for ADHD: How do adolescent and adult patient beliefs and attitudes impact treatment adherence? Patient Preference and Adherence, 8, 1317-1327.

Sprich, S. E., Burbridge, J., Lerner, J. A., & Safren, S. A. (2015). Cognitive-behavioral therapy for ADHD in adolescents: Clinical considerations and a case series. Cognitive and Behavioral Practice, 22(2), 116-126.

Sprich, S. E., Safren, S. A., Finkelstein, D., Remmert, J. E., & Hammerness, P. (2016). A randomized controlled trial of cognitive behavioral therapy for ADHD in medication‐treated adolescents. Journal of Child Psychology and Psychiatry, 57(11), 1218-1226.

Weyandt, L. L., Oster, D. R., Marraccini, M. E., Gudmundsdottir, B. G., Munro, B. A., Zavras, B. M., & Kuhar, B. (2014). Pharmacological interventions for adolescents and adults with ADHD: Stimulant and nonstimulant medications and misuse of prescription stimulants. Psychology Research and Behavior Management, 7, 223-231.

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