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
Approach to this Clinical Case:
My approach to this clinical case would be
patient-centered, comprehensive, and collaborative, while also firmly adhering to evidence-based guidelines and managing parental expectations.
- Initial De-escalation and Active Listening (Managing Parental Demands):
- Acknowledge the parents' concerns and their desire for a quick solution, but gently reframe the initial focus to a comprehensive evaluation.
- "I understand you're looking for solutions quickly, and you believe medication might be the answer. My priority is to thoroughly understand your son's difficulties and ensure we arrive at the most effective and safe treatment plan for him."
- Emphasize that a proper diagnosis requires time and a multi-faceted assessment, not just prescribing medication based on presenting complaints. This sets expectations from the outset.
- Gathering Comprehensive Information (Multi-informant Approach):
- Interview with Parents:
- Obtain a detailed history of the child's symptoms: onset, duration, pervasiveness across settings (home, school, social), impact on academic performance, peer relationships, and family dynamics.
- Ask about developmental milestones, medical history (including birth history, previous illnesses, head injuries), family history of ADHD or other psychiatric disorders, substance use, and learning disabilities.
- Explore specific examples of inattentive, hyperactive, and impulsive behaviors.
- Interview with Child:
- Speak with the 13-year-old separately to gather his perspective on his challenges, how they affect him, his feelings about school, friends, and family. This also helps build rapport and assess his insight.
- Observe his behavior during the interview (e.g., restlessness, distractibility, ability to sustain attention).
- Information from School: This is critical. Request permission from parents to contact the school (teachers, counselors) to obtain information about academic performance, classroom behavior, social interactions, and specific difficulties observed in that setting. School reports are essential for confirming pervasiveness and impact in another major setting.
Sample Answer
Which neurotransmitter(s) are involved in ADHD? How will you approach this clinical case?
Neurotransmitters Involved in ADHD:
The primary neurotransmitters implicated in ADHD are
Dopamine and
Norepinephrine (Noradrenaline).
- Dopamine: Plays a crucial role in reward, motivation, pleasure, executive functions (like attention, planning, impulse control), and motor control. In ADHD, there's believed to be dysregulation in the dopamine pathways, particularly in the prefrontal cortex and striatum, leading to impaired executive functions and difficulties with sustained attention and impulse control.
- Norepinephrine: Contributes to attention, arousal, vigilance, and the "fight-or-flight" response. Dysregulation in norepinephrine pathways in the prefrontal cortex is also thought to contribute to problems with focus, impulsivity, and hyperactivity.
While less definitively established,
Serotonin also plays a role in mood regulation, impulsivity, and anxiety, which can be co-occurring symptoms with ADHD. Some research suggests its involvement in modulating dopamine and norepinephrine systems.