Mental Health Case Study: Attention-Deficit/Hyperactivity Disorder (ADHD)

Kortney Squibbs

Youngstown State University

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Abstract

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common behavioral

disorders in children. The DSM-V identifies ADHD was the persistent pattern of inattention and

impulsivity/hyperactivity that interferes with development and/or functioning. Six or more

symptoms of inattention must be present for children up to the age of 16, must be present for at

least 6 months and are inappropriate for developmental age. A patient must also have six or more

symptoms of hyperactivity and impulsivity for children 16 years old and younger, must be

present for 6 months and to an extent are disruptive and inappropriate to developmental age.

Both symptoms of hyperactivity and inattention must be present before 12 years old and must

occur in two or more settings. These symptoms must also interfere with quality of work, social

and school functioning. Finally, the symptoms cannot be explained better by another mental

disorder. It has a high comorbidity with other psychiatric problems such as oppositional defiant

disorder (ODD). The purpose of this study is to develop a better understand of ADHD, how it

can manifest into other disorders, and proper treatment to increase functioning. This case study

will examine an individual, however, these symptoms will apply to more than just ADHD, and it

will be important to learn the other disorders associated with ADHD.

Keywords: ADHD, ODD, Mental Disorder

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Objective Data: On November 3rd 3030, I examined a 12-year-old male who was

diagnosed with Oppositional defiant disorder, attention-deficit/hyperactivity disorder and

disruptive mood dysregulation disorder. To abide by HIPPA regulations I will refer to the

individual as “KC.” Along with the above disorders, KC is also diagnosed with post-traumatic

stress disorder, anxiety, and depressive disorder. KC does not have any previous drug or alcohol

use. The patient was admitted to the unit on October 30th and had a previous hospitalization in

another psychiatric unit less than 30 days before that. The patient was admitted voluntarily with

the consent of his mother. In the admission note it stated that the patient was admitted in the ER

on the 29th of October for trying to commit suicide by cutting himself with a butter knife and

punching holes in the wall. On the day of care I gathered information before having direct

communication with the patient. During this time, I gathered information including lab results,

medications and the reason for the admission into the psych unit. In KC’s lab results I found that

the only lad that was slightly elevated was his TSH levels, but no other testing was done, so no

T4 levels were drawn. KC was on Focalin (stimulant), Zoloft (SSRI-antidepressant), and

Clonidine (antipsychotic-antihypertensive). He was given the Focalin to help treat his ADHD, it

helps stimulate the central nervous system. Zoloft was prescribed to help treat KC’s depressive

disorder, PTSD and DMDD. Clonidine helps regulate brain activity and can also be used to help

treat aggression. With his current admission, KC was discontinued on all the above medications.

He is currently taking Depakote (antiepileptics). Depakote can be used to help children with

temper dysregulation and severe mood swings.

Next I wanted to interview KC. I knew before going into the interview that he enjoyed

rock music, so I used this to my strength. During my objective observations KC was dressed in a

neat appropriate fashion, had animated facial expressions and was relaxed. Once I began by
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telling him I was going to just sit and talk with him he became very paranoid, he kept asking why

him and other statements as such. KC did not want to disclose why he was admitted, just that he

was “sad”. Patient was said on admission to have suicidal ideations and hallucinations that he did

not interact with. After the interview began, KC became more comfortable and made the

comment asking, “why does everyone wants to know about my family and not me”. At this point

I turned my interview to focus on the patient and what he liked. KC manages his symptoms with

prescribed medications as well as group therapy session, which he participated in during my day

of care.

Discussion of Mental Illness: Attention-deficit hyperactivity disorder (ADHD) is

characterized by overactivity, impulsiveness and inattentiveness. ADHD is associated with

cooccurring disorders such as disruptive, mood, anxiety and substance abuse. ADHD affects an

estimated 4-12% of children worldwide and epidemiological studies has documented high rates

of concurrent learning disorders as well as psychiatric disorders. Childhood conduct disorder has

also been documented at high rates as well as adult antisocial disorders. ADHD also has a two-

fold increase in depressive disorders. (Wilens 2010).

Many children who were diagnosed with ADHD were also diagnosed later in life with

bipolar disorder. The difference is that bipolar also is characterized by mood instability,

pervasive irritability/rage, grandiosity, psychosis, cyclicity and lack of response to structure. It is

important to know that these people can be at higher risk for substance abuse, especially when

children are given stimulants to treat the disorder.

Identify: Pertaining to my patient KC, there were key stressors and behaviors that

precipitated his current hospitalization. KC was admitted “voluntarily” but was forced to be

admitted by his mother due to his attempt to take his own life, and him being a minor. The
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patient was brought to the emergency room before admission to the psych unit. Before coming

into the emergency room, KC was having extreme mood swings at home. He tried to commit

suicide with a butter knife by stabbing himself in the arm. Along with this, he was aggressive

towards his mother and was punching the wall and broke off some drywall. Patient supposedly

tried to take the drywall and stab himself. After being medically cleared, KC was transferred to

the psych unit. I sat with the patient to find out factors that lead up to this hospitalization. The

patient stated that, “I was just feeling sad.” When I tried to dig deeper into the situation, such as

getting family history KC stated, “I don’t know why you all keep asking about my family, why

can’t it be about me, why does my family matter.” At this point I tried asking how he copes

when he gets angry and KC said that he likes playing with his band. He then kept jumping from

topic to topic, but all within rock music. The patient told me that he took his medications, but he

did not feel like they were working. He would not talk about his outbursts. The only comment he

kept making was about his aide in school. He stated that when he was being punished his aide

would force him to hold stacks of books for long periods of times. The client then kept talking

about how he missed his family and would start crying. I found this to be interesting when I

reviewed his lab work. KC’s TSH was 5.62 which is elevated for his age. It is reported that high

TSH and low T4 are linked to ADHD in preschooler and some ADHD medications may also

affect thyroid function (Chen 2018). Increased TSH can also be linked to depression or

depressive feelings. The suicidal ideations/depressive state could be related to the change in

TSH. This could be another reason that his current medications were discontinued.

Discuss: As I discussed earlier, KC was not too willing to talk about his family history.

One topic I did get some information about was KC’s twin brother. KC’s twin brother is

diagnosed with Autism. As it also sounds, KC also has an IEP that was written in the chart, but
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the specifics of it were not disclosed. Twin studies find great similarity between ADHD and

components of the syndrome (Wilens 2018). KC would not talk much about his brother in the

sense of behaviors so his brother could technically have some components of ADHD, which can

compare to Autism. KC’s chart does not show any psychiatric history within his family. He

currently lives with his mother, grandmother, grandfather and twin brother. His father is not in

the picture and is currently in jail.

KC’s mother disclosed some abuse (in his chart) that occurred in his early childhood.

When KC was in kindergarten he was sexually abused by a classmate in the bathroom. Also, a

child who was older than KC used to come over to “play”. KC disclosed that this was not the

case and was also sexually abused then. 9 months ago, KC was in a residential facility and

supposedly had consensual sex with an older patient. His mother believes that this was also

sexual abuse and was not consensual. It was not disclosed to me, but in KC’s chart during one of

his sessions he did state that he did not know his sexuality but believes he might be gay. I also

learned that KC’s grandfather was very religious, and he was afraid of coming out in fear of

retaliation.

Describe: During my day of care I observed evidence-based nursing care with my patient

KC. Treatment of ADHD consists of medication. In KC’s case, his doctor decided to switch to

Divalproex (Depakote). Depakote can be seen to remit aggression (which is extremely beneficial

to KC because he did not only struggle with ADHD but also with oppositional defiant disorder

(Blader 2009). Due to KC’s past, therapy and support groups are important for him. He has had

multiple traumas and abuse in his past. Along with his trauma it is written in his chart that he

also suffers with PTSD. Therapy can help him work through his negative outlook and behaviors

and how to help him process his trauma. Family therapy would also be beneficial for KC to
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discuss his sexuality. It will allow him to resolve conflicts and communicate with his mother

more effectively. Parent training would be beneficial for KC’s mother when his behavior is

inappropriate and has many moments of aggression. In this setting he will learn what is expected

of him with his behaviors. If he does not comply, he will have behavior consequence model

which will give him consequences due to his actions (Wilens 2010). ADHD can be treated with

medications. This will include stimulants such as Focalin (which KC was prescribed),

Atomoxetine, Antihypertensives, antidepressants and tricyclic antidepressants. Another option to

help ADHD would be accommodating the surroundings to facilitate attention (in the sense of

school). Eliminating environmental distractions and implementing token economies can be

beneficial in schools to help promote attention. If the child know they will receive a gift or token

for being on task, they might be more willing to oblige (Wilen 2010). KC went to group therapy

during my time of care. For this session, the leader of the group wanted the children to look into

self-esteem and what good qualities they had. However, KC did not take this topic very well. He

showed distress and depression multiple times. However, when given attention his mood did get

better. One thing that was done here that was bad was the fact that he was encouraged for his

disruptive behavior by the aide helping with the group. KC also listens to rock music in his free

time.

Analyze: Cultural, ethnic and spiritual influences my patient’s life and care. KC falls

under the white/Caucasian ethnic group. This does not have a major impact on his life. When it

comes to spiritual influences KC does identify with being religious but did not disclose a specific

religion. What I do know is that whatever religion that he identifies with is not accepting of

gay/bi/lesbian identification. KC mentioned multiple times during therapy sessions that he was

afraid of his grandfather not accepting him because he is so religious. However, from the
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understanding I got, his family just wants him to get better. So, KC does have a lot of family

support. KC expressed multiple times that he missed his family, so he accepted his support

system. KC does not express any cultural influences, so there are no influences in my patient’s

care and life.

Evaluate: At this point in KC’s treatment, I cannot tell if he is responding well. The

patient is complying with his medication, going to group therapy, and receiving therapy from

social work and nursing staff. Looking in his chart I see improvements in his mood. During the

first day of his admission, KC showed signs of distress and sadness at almost every meeting with

the nursing staff. Since his admission, he has not had any aggressive outbursts. Due to KC’s age,

I do not believe he completely understands his medications and what they do. When I was

interacting with KC, he was alert and oriented and did not have any disturbances. KC does not

have good judgment however, but that could also be related to his age. Overall, even with some

issues, the treatment plan seems appropriate for KC.

Summarize: KC’s care team is developing a specific plan upon discharge. KC from my

understanding, is still planning on going to some therapy sessions to help him deal with his

childhood trauma as well as help him figure out his sexuality. KC’s mother with keep a close eye

on his compliance with his medication. Since this is also a new medication regimen, the doctor

will have to keep a close eye to make sure the medication is working effectively. As mentioned

earlier, KC’s mother will also create disciplinary actions to help keep KC’s aggression in check

and at bay. With the new information about hypothyroidism, KC will most likely get TSH and

possible T4 levels drawn as a precaution. KC’s mother will also be given teaching about adverse

side effects and what to report to the doctor. It will also be important for KC’s mother and family

to be open to hearing what issues he is experiencing to hopefully prevent aggressive outbursts.

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Helping develop coping mechanisms and distracting techniques will teach KC how deal with his

anger. He will play his bass guitar, listen to rock music, and hopefully hanging out with his

friends and family. One of KC’s big goals for now would be to start a band with his friends. His

mother’s goals would include KC acting appropriately and excelling in school.

Prioritized List of NANDA diagnoses:

 Defensive coping r/t feelings of inadequacy and need for acceptance from others.

 Impaired social interaction r/t developmental disabilities (hyperactivity).

 Altered thought processes r/t personality disorders.

 Risk for parental role conflict r/t children with ADHD.

 Risk for injury r/t ineffective orientation.

 Risk for delay in growth and development r/t mental illness and lack of

concentration.

List of potential nursing diagnoses:

 Disturbed sleep pattern r/t depression.

 Self-care deficit r/t anxiety.

 Chronic low self-esteem r/t PTSD.

 Inattention r/t hyperactivity.

 Social isolation r/t depression

Conclusion: In conclusion, we have discussed ADHD and how it has influenced the care

of my patients. It is important to understand the other issues that can come along with ADHD.

Knowing the signs and symptoms as well as other diagnoses that can be misinterpreted are

important to develop a treatment plan for each individual patient. ADHD can cause other mental

illnesses, so understanding the disorder can help prevent further issues. We have looked at all the
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data through my interview and the chart to help form conclusions and treatment plan for my

patient. Stressors, family history, and other factors played a role in this case study. To help

develop the best plan possible patients we must understand that there is not always a cure.

Sometimes teaching them how to deal with the symptoms of their disorder can allow them to be

successful. Understand that every patient is different, and we must look into the differences in

each patient to ensure the best care and treatments possible.

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References

Blader, J. (2009, December). Adjunctive Divalproex Versus Placebo for Children with ADHD

and Aggression Refractory to Stimulant Monotherapy. Am J Psychiatry. 166 (12). 1-19.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2940237/pdf/nihms-

182635.pdf

Chen, P. (2018, July). Correlation between attention-deficit/hyperactivity disorder, its

pharmacotherapy and thyroid dysfunction: A nationwide population-based study in

Taiwan. Clinical Endocrinology, 89(4). Retrieved from https://onlinelibrary-wiley-

com.eps.cc.ysu.edu/doi/full/10.1111/cen.13817

Ghosh, A. (2017 October). Oppositional defiant disorder: current insight. Psychology Research

and Behavior Management, 353-367. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5716335/pdf/prbm-10-353.pdf

Tapia, V. (2018, September). Disruptive Mood Dysregulation Disorder. The Journal for Nurse

Practitioners,14 (8), 573-581. Retrieved from

https://www.npjournal.org/action/showPdf?pii=S1555-4155%2818%2930139-9

Wilens, T. (2010, September). Understanding Attention-Deficit/Hyperactivity Disorder from

Childhood to Adulthood. Postgrad Med, 122(5), 1-21. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3724232/pdf/nihms-496781.pdf