Scenario: A 13 year old boy is accompanied by his parents into the community mental health clinic for the evaluation of Attention Deficit Hyperactivity Disorder (ADHD). Both parents are impatient, demanding and requesting for you to start their child on a CNS stimulant medication.
Based on this scenario, respond to the following prompts:
- Which neurotransmitter(s) are involved in ADHD? How will you approach this clinical case?
- According to the DSM V-TR, what is the criteria for this condition? What is the NICHQ Vanderbilt Assessment Scale and how will you apply it to this case study?
- If the child meets diagnostic criteria for ADHD, what diagnostic(s) or lab(s) will you order prior to prescribing a CNS stimulant drug? Why is it important to assess and monitor a child’s weight and height once you start treatment for ADHD?
Full Answer Section
Many CNS stimulant medications work by increasing the availability of both dopamine and norepinephrine in the synaptic clefts, thereby enhancing their signaling and improving executive functions.
Approach to this Clinical Case:
My approach would be multi-faceted, prioritizing a comprehensive evaluation while managing parental expectations and demands.
- Acknowledge and Validate Parental Concerns: I would start by acknowledging the parents' concerns about their child's difficulties and their desire for effective treatment. I would say something like, "I understand you're looking for solutions to help your son, and I appreciate you bringing him in today. We'll work together to figure out the best path forward." This can help de-escalate their impatience and build rapport.
- Explain the Diagnostic Process: I would clearly outline the comprehensive nature of an ADHD evaluation, emphasizing that it's more than just a quick assessment. I'd explain that diagnosis requires gathering information from multiple sources and ruling out other conditions. This sets realistic expectations.
- Gather Detailed History (Separate and Together):
- Child Interview (alone, if comfortable): I would first speak with the 13-year-old boy privately to understand his perspective on his challenges, academic performance, social life, and any symptoms he experiences. This builds rapport with the child and allows for an unfiltered view.
- Parent Interview (together and/or separately): I would conduct a thorough interview with both parents to gather detailed information about the onset, duration, severity, and pervasiveness of symptoms across different settings (home, school, social). I'd inquire about family history of ADHD or other mental health conditions, developmental milestones, medical history, and current family dynamics.
- Specific Questions for Parents: I'd focus on specific behaviors: difficulties with attention, impulsivity, hyperactivity (e.g., struggles with homework, inability to sit still, interrupting others, losing things, difficulty following instructions). I'd ask for concrete examples.
- Information from External Sources: I would explain the necessity of obtaining information from teachers (current and potentially previous ones) to assess symptoms in the academic setting, which is crucial for ADHD diagnosis. This would involve sending out rating scales.
- Differential Diagnosis and Co-occurring Conditions: I would keep a broad differential diagnosis in mind. Many conditions can mimic ADHD symptoms, including anxiety disorders, depressive disorders, learning disabilities, sleep disorders, trauma, or even medical conditions (e.g., thyroid dysfunction). I would screen for these during the history taking. Co-occurring conditions are also very common with ADHD and need to be identified.
Sample Answer
Addressing the ADHD Evaluation Scenario
This scenario presents a common and challenging clinical situation, where parental pressure for medication needs to be balanced with a thorough, evidence-based diagnostic process for ADHD in a 13-year-old boy.
1. Neurotransmitter(s) Involved in ADHD and Clinical Approach
Neurotransmitters Involved in ADHD:
The primary neurotransmitters implicated in ADHD pathophysiology are
dopamine and
norepinephrine (noradrenaline).
- Dopamine: Plays a crucial role in the brain's reward system, motivation, executive functions (like attention, focus, impulse control), and motor regulation. In ADHD, there is believed to be a dysfunction in the dopamine pathways, particularly in the prefrontal cortex and basal ganglia, leading to impaired executive functioning.
- Norepinephrine: Contributes to attention, arousal, vigilance, and executive functions. Dysregulation in norepinephrine systems, especially in the prefrontal cortex, is also thought to contribute to ADHD symptoms.