1.
Tests or Screenings
The following tests will be incorporated to establish baseline values
Liver function tests- since amphetamine , methylphenidate, and atomoxetine are metabolized in the
liver. Additionally, their is a cause-effect relationship between the use of atomoxetine and reversible
hepatic failure.
Renal function tests- most drugs are excreted through the kidneys.
Thyroid function hormone levels to rule out hyperthyroidism.
Screening
Cognitive testing using Wechsler Intelligence Scale for children
Vision and hearing screening due to Sarah's academic struggles hence need to rule out sensory issues as
an etiological factor.
Depression screening using PHQ-9.
Sleep assessment due to history of sleep problems to rule out insomnia.
2. Differential diagnoses and questions to ask
Oppositional defiant disorder- the patient fits on the performance criteria in both teacher and parent
assessment even though she does not fit the symptom criteria in either case
Questions ;history of defiance towards authority figures, irritability , and revengeful.
Anxiety and depression - the patient fits the performance criteria in both teacher and parent assessment
and scored 1 in 3 symptom questions in teacher assessment scale though she does not fit the criteria.
Questions ; history of reduced appetite, feeling anxious, fatigue.
Conduct disorder- 1 positive symptom in parent assessment chart and fits in the performance criteria .
She also has a history of bullying
Questions; history of destruction of property, aggression towards people and animals.
Sleep disorder- due to history of difficulty falling asleep. I would ask questions such as how many times
the patient takes a nap, the duration of sleep difficulty, whether she seems tired during the day.
Adjustment disorder- due to the constant change in her living arrangements.
Learning disability due to academic struggles from kindergarten.
3. Working diagnoses and DSM
Severe ADHD combined inattention and hyperactivity- since the patient satisfies both criteria I.e
Predominantly innatentive type- Scored 2-3 in 9 questions from 1-9 and scored 4-5 in 5 questions from
48-55
Predominantly hyperactive type - scored 2-3 in 7 questions from 10-18 and also scored 4-5 in 5
questions with reference to question 48- 55.
This diagnosis is confirmed by the fact that impairment from inàttention and hyperactivity is present in
at least 2 settings I.e school and home, and has interfered with developmentally appropriate social or
academic functioning.
Diagnostic Statistical Manual -5th edition - Text Revised ( WV ACC Guidelines, 2022).
A. A persistent pattern of inattention and/or hyperactivity -impulsivity that interferes with functioning or
development , as characterized by (1) and/or (2):
1) Inattention- six or more of the following symptoms have persisted for at least 6 months to a degree
that is inconsistent with developmental level and that negatively impacts directly on social and academic
or occupational activities
Often fails to give close attention to details or make careless mistakes in schoolwork, at work or other
activities.- the patient does make lots of mistakes in her assignment as stated in the film.
Often does not seem to listen when spoken to directly- there are many instances in the film where the
patient didn't seem to listen to the questions.
Often does not follow- through on instructions and fails to finish school work or chores- the history of
presenting illness states that her grand mother scolds her frequently for forgetting to complete chores
or not listening to instructions
Often has difficulty organizing tasks and activities such as difficulty managing sequential tasks , difficulty
keeping materials and belongings in order, disorganized work, poor time management, fails to meet
deadlines - the patient meets this criteria as indicated in both teacher and parent assessment scale.
Often avoids , dislikes , or is reluctant to engage in tasks that require sustained mental effort such as
schoolwork, homework- Sarah meets this criteria as depicted by both patent and teacher assessment
scale.
Often loses things necessary for tasks or activities such as school materials- the patient satisfies this
criteria since she stated in the film that she often misplaced books and bracelet.
Often easily distracted by extraneous stimuli-
Is often forgetful in daily activities such as doing chores as stated in the history of presenting illness and
also the assessment scale.
2. Hyperactivity and impulsivity: six or more of the following symptoms have persisted for at least 6
months to a degree that is inconsistent with developmental level and that negatively impacts directly on
social and academic or occupational activities:
Hyperactive symptoms-
Squirms when seated or fidgets with feet or hands
Marked restlessness that is difficult to control such as leaving their place in the class toom
Often on the go I.e. unable to be of uncomfortable being still for extended periods of time as in
restaurants or meetings.
Lacks ability to play or engage in leisure activities in a quiet manner
Incapable of staying seated in class
Overly talkative
Impulsive symptoms
Difficulty waiting turn such as waiting in line.
Interrupts or intrudes into a conversation and activities of others
Impulsively blurts out answers before questions are completed or completes people's sentences or
cannot wait for their turn in conversations.
B) symptoms should be present prior to age 12 years - the patient is 8 years old
C) Symptoms not better accounted for by a different psychiatric disorder such as mood disorder, anxiety
disorder and do not occur exclusively during a psychotic disorder.
D) Symptoms not exclusively a manifestation of oppositional behaviour.
E) There is clear evidence that the symptoms interfere with, or reduce qualityof, social, academic, or
occupational functioning.
Difficulty sustaining attention in tasks - the patient states in the film that she shifts from one painting to
another.
4. Biophysical formulation
Presenting symptoms- forgetfulness, fidgeting, misplacing items, shifting from one activity to another ,
poor sleep,
Precipitating symptoms - financial struggles.
Predisposing symptoms - family history of ADHD, history of childhood trauma , history of maternal
smoking during pregnancy.
Perpetuating symptoms- financial struggles, family dynamics, sleep deprivation.
Protective Symptoms - family support from the mother, no history of comorbid disorders, school
support from the teacher.
5. Medications and evidence based rationale
Methylphenidate- Ritalin 0.3-1mg/kg tid up to 60mg per day. She can start at 5mg OD in the morning.
Inhibits dopamine and norepinephrine reuptake by blocking dopamine transporter hence increases
dopamine and nor-adrenaline in the frontal cortex and subcortical region involved in reward and
motivation .It also protects the dopaminergic system against the ongoing weating off by securing the
substantial reserve pool of the neurotransmitter, stored in presynaptic vesicles (Jaeschke et al., 2021).
According to Huss et al., (2017 ), methylphenidate reduces the social , health, economical, and
functional impairments experienced by patients with ADHD. Moreover , Jaeschke et al., (2021) states
that Methylphenidate is moderately effective against the core ADHD symptoms, and the accompanying
emotion regulation deficits.
Amphetamine such as dexamphetamine- adderall 0.15- 0.5mg/kg bid to maximum of 40mg/day. It is a
nervous system stimulant that functions by increasing the amount of dopamine, norepinephrine , and
serotonin in the synaptic cleft through a variety of mechanisms. It also inhibits the metabolism of
monoamine neurotransmitters by inhibiting monoamine oxidase ( Martin & Lee, 2020). Accoŕding Punja
et al., (2016), to amphetamine improved total ADHD core symptom severity according to parent
ratings, teacher ratings, and clinical ratings
Atomoxetine 0.5 to 1.8 mg/kg bid to a maximum of 80mg/day - blocks noradrenaline transporter hence
increases level as of noradrenaline in the brain. Clemow et al., (2017), states that atomoxetine is the first
line therapy for patients at risk of substance use disorders and is often preferred over stimulants for
patients with ADHD and comorbid tic disorders or anxiety. The presence of a comorbidity did not
adversely impact the efficacy of atomoxetine in treatment of ADHD. Additionally the use of atomoxetine
does not exacerbate any of the comorbid conditions.
Bupropion preparations - wellbutrin 3- 6 mg/kg bid to a maximum of 300mg/day . It is an aminoketone
antidepressant and non- competitive antagonism of nicotinic acetylcholine receptors. According to
Verbeeck et al., (2017), bupropion decreased the severity of ADHD symptoms, and increased the
proportion of participants achieving clinical improvement , and reporting an improvement in the clinical
global impression.
Alpha adrenergic agonists such as Clonidine- 0.1mg tid. - effective for treatment of ADHD symptoms
such as hyperactivity , impulsivity, and sleep difficulties in children and adolescents with or without
comorbidities in nine out of ten trials (Ming et al., 2011).
6. Non- Pharmacological treatment options and respective rationale
Parent training in behaviour management
Behavioural classroom intervention - involves incorporating specific accommodation such as reducing
the number of homework problems without decreasing content , providing tests in a quiet place,
dividing tests into smaller tests, modifying format of a test, providing a quiet place to study, providing
simple and clear directions for assignment, and creating communication notebook between parents and
teachers. Studies have shown enhanced academic performance but improvement lasted only as long as
interventions (Shrestha et al., 2020).
Peer based interventions- first, peers facilitate each other's learning by engaging in social interaction
activities like sharing, instructing and praising. Secondly, a peer is selected and trained so that they
facilitate change in the child with Agent.Lastly, peer proximity intervention where a peer with better
skills sit in close proximity to the child with ADHD. A study showed that this intervention improved
relationship between peers and helped increase social competence ( Shrestha et al., 2020).
Physiological treatment- includes physical activity of at least 1 hour per day to improve cognitive
functioning such as memory and attention. A study that compared 31 min of physical activity in form of
games vs 31 minutes of sedentary activity showed that the latter group demonstrated lower parent and
teacher rated ADHD symptoms (Shrestha et al., 2020)
Training interventions such as cognitive training, neurofeedback organization- neurofeedback in children
with ADHD showed significant improvement after only 3 months of therapy (Shrestha et al., 2020).
Cognitive behavioural therapy - 2 studies showed that parents had improved ratings of ADHD symptoms
(Shrestha et al., 2020). The technique helps patients to learn better ways of thinking and coping with
psychological problems thereby alleviating their symptoms and improving their functioning.
Dietary intervention- incorporating vitamin D, omega fatty acids , free fatty acids and avoidance of food
colour. Studies have shown that low levels of vitamin D during neurodevelopmental and perinatal period
is linked to higher risk of developing ADHD later in life (Shrestha et al., 2020).
Mind- body interventions- include meditation, yoga, tai chi, mindfullness . A 2018 analysis of
randomised controlled trials showed that these interventions had moderate improvement on childhood
ADHD symptoms , especially inattention symptoms ( shrestha et al., 2020).
Sleep hygiene education to enable the patient improve sleep.
7. Referrals and community resources
Community resources
Attention deficit disorder Association - enables Sarah's mother have access to large variety of virtual
peer support group which will enable her to learn from parents who have more experience on the same.
Facebook groups and online forums so that Sarah's mother can share experiences with other parents
going through the same and share tips of how to adjust daily living to meet the experiences of the child
(PsychCentral, 2021).
CDC's ADHD information center- will equip the mother will information about the condition for her to
understand Sarah's behaviour and also teach family members about the same.
ADDitude Magazine's forum- allows the mother to receive validation and answers from people
throughout the world.
Podcasts - I would advise Sarah's mother to use such an online resource since they contain lots of
concepts to learn. They include ADHD 365 and All Things ADHD, ADDitude's ADHD Podcast, ADHD
rewired, Hacking Your ADHD, Taking Control: The ADHD Podcast, Distraction with Dr. Ned Hallowell
(PsychCentral, 2021).
Referrals
Social worker- to help with the living arrangements so that Sarah and her mother can live better and
afford treatment.
Psychologist who will deliver psychotherapy to bith Sarah and the family and help the patient develop
coping and problem solving skills.
Academic counselling to facilitate implementation of school based interventions hence improve
academic performance.
Psychiatrist for medical management and further evaluation of ADHD.
8. Preventive or health promotion topics to discuss with the patient
Preventing unintentional injuries due to inattention and impulsivity such as falls, drowns, burns and
poisoning
Supporting child's mental health since they are at risk of disorders such as anxiety, depression,
substance use, suicide, and sexual risks behaviours
Promoting physical activity, nutrition, and sleep since children with ADHD are at a risk of obesity (CDC,
2024).
Preventive healthcare services such as regular screening for both physical and mental health.
Sleep hygiene education to alleviate her sleeping problems- include consistent sleep and wake time,
winding down an hour before bed, cut out bedtime drinking and snacking, make the room comfortable,
get out into natural light as soon as is practical in the morning.
9. A)Impact of cultural background on doctor- patient interactions
Sarah may have trust issues with authority figures since she received limited parental support and also
had unpredictable and difficult childhood. Therefore, the doctor should use high level of competence
in order to develop trust translating to better treatment adherence. Lastly, the reluctance of paternal
grand parents about psychiatric consultation suggests that there could be unwillingness to accept
treatment due to cultural perceptions of mental health.
B)Impact of patient's socioeconomic standing on the treatment plan
The current financial situation may render the patient unable to afford treatment hence need for
referral to social services for financial assistance. Moreover, services provided to Sarah should be
affordable but quality.
The living arrangements could also lead to inconsistent access to care.
