CC (chief complaint): According to the Chief Informant, who happens to be BC’s half-sister and legal guardian, ‘He has been having behavioral problems for a long time from prior trauma, and we want to get him help.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

HPI:

The patient is a seven-year-old male of African American origin who presents to the clinic to establish care. BC is accompanied by his elder sister, his legal guardian, her fiancé, and the patient’s eight-year-old sister. The chief informant reports the patient has been manifesting behavioral problems ever since four or five years. He would display violent outbursts, fighting with kids and grown-ups, throwing objects, and temper tantrums. His untoward behavior saw him expelled in four preschools. The sister reports he was evaluated by Florida Diagnostic and Learning Resources System(FDLRS) and had an IEP. AS the legal guardian, she feels BC is in a large class that cannot accommodate his learning needs. The current school has him under a behavioral contract where he is in the second grade. The school suspended him recently after throwing a water bottle at another child’s head for ‘moving too slow in the line.’ Other behavioral issues include but are not limited to crying spells, severe temper tantrums, and yelling to a point where he sometimes passes out. The elder sister reports receiving notifications from both family members and the school that BC inappropriate touches other little girls besides destroying school property. There were instances when he was caught chewing crayons and pencils at school. The patient has also attempted to choke the family dog, break its legs and throw the dog, pointing towards his aggressive behavior. She confirms the boy eats well and averages a 5-8 hour sleep every night. She reports negative of the patient’s threatening to harm herself or others and denies witnessing paranoia or hallucinations ( visual and auditory) episodes. BC denies having imaginary friends. He has a previous diagnosis of delayed development, but a pediatrician attended to him diagnosed ADHD and prescribed methylphenidate 10mg daily. The legal guardian believes the medication is no longer adequate, even as she reports BC has received therapy services for about two months.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Past Psychiatric History:

Diagnosed with ADHD at 4-5 years

General Statement: BC 7-year-old AA male with PMH of developmental delay and ADHD, presents with a long history of behavioral problems including biting, hitting, fighting, and throwing objects for which his sister (guardian wishes to seek psychiatric assistance and treatment. The patient presents to the interview well-groomed in school uniform. He is seated next to his eight-year-old sister, whom he is frequently getting up to talk to and whisper in her ear. He often moves about the seat and gets up out of the chair. He is smiling and pleasant during the interview. He is easily distracted. When questioned, he gives poor eye contact and speaks fast(Comprehensive Psychiatric Evaluation Essay for Nursing Students)
Caregivers (if applicable): The patient is currently under the care of his elder sister, who doubles as his legal guardian because although both parents are alive, they never married, the father has a medical condition, and the mother is a drug addict.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)
Hospitalizations: Has been admitted to a hospital as a neonate for medical or psychiatric illnesses
Medication trials; Methylphenidate 10mg daily to manage ADHD:
Psychotherapy or Previous Psychiatric Diagnosis: ADHD. Has had therapy for two months

Substance Current Use and History:

No history of substance abuse and currently not abusing any substances.

Family Psychiatric/Substance Use History:

BC has a nine-year sister of the same mother, while the legal guardian is a sister from a different family born in a polygamous family with 29 kids. Their parents never married, but the legal guardian reports the two kids spent most of the weekends with her and later realized they were living in a truck with another man. The children were not attending school, promoting the legal guardian to seek permanent custody. The mother occasionally visits them, and the kids have a close relationship with their biological father, but he cannot take care of them due to a medical condition. BC shares a room with his sister, and during outbursts, he tends to hit or pull her hair. (Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Psychosocial History:

The legal guardian reports pot training BC but observed he had a problem soiling his bed and clothes. He also has challenges cleaning himself and putting on clothes correctly, which the guardian is currently working on.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Medical History:

He was previously diagnosed with delayed development, ADHD. BC has no other significant medical history.

Current Medications:

Methylphenidate 10mg daily.

Allergies:

No known allergies or drug reactions.

Reproductive Hx:

Has no reproductive health issues.

Objective:

Review of Systems

Constitutionals: The patient denies feeling hot/ warm. The legal guardian also refuses any weight loss in the boy. However, she reports excessive hyperactivity, inattention not accompanied by lack of comprehension, and impulsivity. He has no sleep difficulties.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

HEENT: The boy reports being harmful to dry eyes, itching, or pain. He has no photophobia. He denies hearing loss, no tinnitus, and is not sneezing. He is also detrimental for runny nose sore throat.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Respiratory: Denies difficulty in breathing, coughing and has no phlegm.

Cardiovascular: Denies chest discomfort, pain, or palpitations.

Gastrointestinal: Guardian reports no vomiting, lack of appetite, or diarrhea.

Genitourinary: The patient denies any burning sensation during urination. No polyuria.

Musculoskeletal: The patient denies any muscle pain or stiffness.

Neurologic: He denies any headache, instability while walking, numbness, or a change in bladder and bowel control.

Psychiatric: Legal guardian reports that the child has a history of abnormal lack of concentration and hyperactivity. She, however, reports negative any depressive or anxiety symptoms in him.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Hematologic/ Lymphatic: Legal guardians and half-brother ( the patient) deny any abnormal bleeding or fatigue. No enlarged nodes.

Endocrine: Legal guardian and half-brother deny excessive urination (polyuria) or excessive water intake (polydipsia). They also deny excessive sweating or heat intolerance.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Allergic/ Immunologic: Legal guardian denies any history of eczema or asthma. Also denies any other seasonal allergies.

Assess for psychiatric comorbidities

Diagnostic results:

The SNAP-IV-C Rating Scale – a revision of the Swanson, Nolan, and Pelham Questionnaire were used to screen for both ADHD and ODD. The 90-item rating scale for ADHD + ODD and aggression symptoms for individuals aged between 6 and 18 years(Hall et al., 2020). The screens for nine signs of ADHD hyperactive-impulsive type and eight symptoms of ODD. The teacher’s score was above 2.56, implying he is inattentive, while the legal guardian’s figure was 1.78(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Assessment:

Mental Status Exam

Attitude Impulsive: yes

Speech Fast: yes

Behavior Desc: Hyperactive

Mood Unremarkable: yes

Process Desc: Patient easily distracted when questioned; the patient does not answer all questions during the interview

Suicidality: no

Sensorium Alert: yes

Memory Unremarkable: yes

Speech Incoherent: yes

Behavior Other: yes

Affect Appropriate: yes

Process Other: yes

Content Unremarkable: yes

Homicidal: no

Orientation Person: yes

BC was initially guarded but quickly opened up, shared information with ease is talkative, and discussed family challenges. Dominating themes are independence and self-sufficiency. He admits not liking school because of too many rules and reports he sometimes feels lonely.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Differential Diagnoses:

Diagnosis Code: F913 |Oppositional defiant disorder confirmed.

According to Ghosh et al. (2017), ODD is diagnosed based on frequent and persistent angry or irritable mood, vindictiveness, and defiance. BC was confirmed with a diagnosis of ODD because he manifests signs and symptoms that conform to the ODD mnemonic of REAL BADS. This is because he is usually resentful, easily annoyed argues with adults, loses temper, blames others, annoys people, deliberately defines rules or requests, spiteful. It is important to note that the disruption in behavior is linked to distress in the patient or others in the patient’s immediate context and is currently negatively impacting the boy’s social, educational, and other vital areas of functioning.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Diagnosis Code: F902 |Attention-deficit hyperactivity disorder, combined type confirmed as comorbidity.

ADHD was also confirmed as a comorbid psychiatric condition because the patient had seven signs indicative of inattention and nine of hyperactivity(Harvey et al., 2016). Inattentiveness was noted because BC fails to give close attention, does not listen, and has difficulties following instructions and organizing tasks. Hyperactivity/impulsivity are that constantly fidgets, has difficulty playing quietly, and talks excessively. He also has challenges waiting for his turn.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Diagnosis Code F Makino84.0 for Autism spectrum disorder Refuted.

ASD has some overlapping symptoms with ODD, like problems with social interactions with others and under or reaction to one of the more five common senses like sight, taste, touch, smell, or hearing(Makino et al., 2021). However, in the case of BC, it was refuted because the patient does not perform repeated actions or body movements like rocking. Neither does he perform self-harm activities like head banging or biting or need for sameness.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Diagnosis code 296.99 F 34.8 for Disruptive Mood Dysregulation Disorder (DMDD) Refuted

Rate and intensity were used to rule out DMDD because the behaviors are less frequent and severe and therefore fall short of the DMDD threshold.

Diagnosis code F91.9 Conduct Disorder –Refuted.

Conduct disorder was also ruled out because, unlike ODD, where the child has problems being controlled, the former involves problems being managed and the need to exert control over others (Noordemere et al., 2016).(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Reflections:

In terms of severity specifier, the patient’s case is currently rated as severe because it occurs in multiple settings at the home, school, or peers. He has problems with grooming at home and does not relate well with his nine-year-old sister, whom they share a room amongst others. He has trouble with authority figures at school, while he always seems to be inappropriately touching the girls. The behaviors do not exclusively happen during psychotic episodes, and disruptive mood dysregulation disorder criteria are not met.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Case Formulation and Treatment Plan:

The patient was diagnosed with ODD comorbid with ADHD. The psychiatric and mental health care practitioner has to consider several factors before formulating a treatment plan. The factors include the child’s age, symptoms severity, and the ability of the child to participate in and tolerate specific therapies. Psychotherapy of cognitive behavioral therapy is developed to reshape the child’s thinking and thus improve behavior. Family therapy would be incorporated to help improve family interactions and communication among family members even as the legal guarding and her spouse are given parent management training to teach these caregivers positive ways to modify the child’s behavior while at home(Hood et al., 2015). There is no formally approved medication to treat ODD but various medications used to treat other disorders to alleviate the symptoms. Because Methylphenidate currently proves to be ineffective, it should be replaced with Atomozetine to alleviate the symptoms of ADHD (Clemow et al., 2017). To improve the patient’s outcomes and prognosis, the provider should use a multimodal treatment approach where psychopharmacology is reinforced with psychosocial interventions.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

References

Clemow, D. B., Bushe, C., Mancini, M., Ossipov, M. H., & Upadhyaya, H. (2017). A review of the efficacy of atomoxetine in the treatment of attention-deficit hyperactivity disorder in children and adult patients with common comorbidities. Neuropsychiatric disease and treatment, 13, 357.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Ghosh, A., Ray, A., & Basu, A. (2017). Oppositional defiant disorder: current insight. Psychology research and behavior management.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Hall, C. L., Guo, B., Valentine, A. Z., Groom, M. J., Daley, D., Sayal, K., & Hollis, C. (2020). The validity of the SNAP-IV in children displaying ADHD symptoms. Assessment, 27(6), 1258-1271.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Harvey, E. A., Breaux, R. P., & Lugo-Candelas, C. I. (2016). Early development of comorbidity between symptoms of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Journal of abnormal psychology, 125(2), 154.

Hood, B. S., Elrod, M. G., & DeWine, D. B. (2015). Treatment of childhood oppositional defiant disorder. Current Treatment Options in Pediatrics, 1(2), 155-167.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Makino, A., Hartman, L., King, G., Wong, P. Y., & Penner, M. (2021). Parent Experiences of Autism Spectrum Disorder Diagnosis: a Scoping Review. Review-Journal of Autism and Developmental Disorders, 1-18.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

Noordermeer, S. D., Luman, M., & Oosterlaan, J. (2016). A systematic review and meta-analysis of neuroimaging in oppositional defiant disorder (ODD) and conduct disorder (CD) taking attention-deficit hyperactivity disorder (ADHD) into account. Neuropsychology Review, 26(1), 44-72.(Comprehensive Psychiatric Evaluation Essay for Nursing Students)

https://www.ncbi.nlm.nih.gov/

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Comprehensive psychiatric Evaluation

Comprehensive Psychiatric Evaluation