Assessing and Treating Children and Adolescents with Disruptive Behaviors

Assessing and Treating Children and Adolescents with Disruptive Behaviors: The Case of the Hyperactive Child
Client Assessment
The client is an African-American child aged between 8 and 12. Her identifying symptom is the inability to remain calm when the situation requires her to, such as during counseling, where she keeps nagging the counselor to play (APA, 2013). She also talks excessively during the session, displays intrusive behavior such as using the counselor’s things without permission, and seeks to play in situations when play is inappropriate (APA, 2013). She displays a tendency to blurt out answers without giving the same much thought, such as when she refers to the counselor as ‘stupid’ for leaving his things out. Further, she seems to be ‘on-the-go’ as if anxiously waiting for the session to end so that she can play. She plays with a toy throughout the session, signifying lack of concentration. The client also displays some symptoms of inattention (APA, 2013). For instance, she expresses a dislike for homework and wishes that she could make it disappear. She is also easily distracted by the toys in the counselor’s office and immediately begins to play with them. However, she does not meet the DSM-V criteria for inattentiveness, which requires an individual to meet at least six symptoms in category A.
Diagnosis: ADHD, predominantly hyperactive presentation 314.01(F90.1)
Therapeutic Approach
The client wishes that she could disappear and that her parents would leave her alone. She hates the fact that her parents will not let her play video games, perhaps because she is unable to manage her time and complete her homework or other chores in time. The client’s case could be formulated as: she finds homework boring (prompting event) and chooses to play video games instead, but her parents refuse to understand (problem thought). They prevent her from playing, leading to sadness, anger, boredom, and frustration that make her want to disappear (target behavior) (Wheeler, 2014).
Given this formulation, the PMHNP needs to initiate combined therapy that incorporates pharmacotherapy and behavior therapy. Studies have shown combination therapy to be more effective than either pharmacotherapy or behavioral therapy alone (Abokoff, 1997). Behavioral interventions could include behavioral parental training, behavioral interventions in the classroom, response cost contingencies, and positive reinforcement. Wheeler (2014) emphasizes the need to empower parents and involving them as partners in their children’s treatment. Parental training could involve educating the client’s parents on ADHD and the most appropriate strategies for managing the child’s hyperactivity. For instance, they could be trained to spend more time with their child, assist her with homework, and use positive reinforcements such as compliments and gifts to encourage her to take up more challenging tasks. The client’s teachers could also be trained on how to make homework more enjoyable for the client given her situation (behavioral classroom interventions).
The FDA approves two classes of medication – stimulants and non-stimulants – for the treatment of ADHD in children (Kolar et al., 2008). Three non-stimulants – Kapvay (Clonidine), Intuniv (Guanfacine) and Straterra (Atomoxetine) - are approved for children unable to tolerate the adverse effects of stimulants (Kolar et al., 2008). Stimulants – Methylphenidate and Amphetamine - are the recommended first-line treatment for ADHD in both children and adults. Trials have also found stimulants to be the most effective treatments for ADHD, with a responsiveness range of between 70 and 80 percent (Kolar et al., 2008). Methylphenidate stimulants are preferred to Amphetamine because of their ability to realize high efficacy levels at low doses, hence less intense adverse effects and lower risks of addiction (Kolar et al., 2018). As the PMHNP for this client, I would initiate Concerta (a Methylphenidate stimulant) at an initial dosage of 10mg daily in the morning and make observations after four weeks.
Expected Treatment Outcomes
The PMHNP expects a reduction in ADHD symptoms by the time of the next review. The reduction in symptoms is evidenced by an improvement in body functions, more sustained attention, and improved attitudes towards home and school work, which translates to better academic performance (Loe & Feldman, 2007).
References
Abikoff, K. H. (1997). Behavior Therapy and Methylphenidate in the Treatment of Children with ADHD. Journal of Attention Disorders, 2(2), 89-114.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of Adults with Attention-Deficit/ Hyperactivity Disorder. Neuropsychiatric Disease and Treatment, 4(2), 389-403.
Loe, I. M., & Feldman, H. (2007). Academic and Educational Outcomes of Children with ADHD. Journal of Pediatric Psychology, 32(6), 643-54.
Wheeler, K. (Ed.) (2014). Psychotherapy for the Advanced Practice Psychiatric Nurse: A How-to Guide for Evidence-Based Practice. New York, NY: Springer Publication Company.