Questions
1. Which medication is FDA approved to treat anxiety and depression in children?
2. Is cultural sensitivity relevant to adolescent mental health?
3. To what extent are parents included in adolescent patient visits?
Subjective:
CC (chief complaint): ” We have been trying to get help for James.” The patient’s mother sought an appointment because he is resistant to help for his unstable mood, racing thoughts, anxiety, and angry outbursts. He avoids talking about his illness and kicks holes in the wall at home.
HPI: The patient is a 13-year-old African American male who restarted treatment after a previous visit in June 2021. Due to nausea side effects, he was non-compliant with prescribed clonidine and ADHD medications. He denies mood swings, outbursts, and low motivation reported by his mother. The mother reports a history of suicidal ideation, and the patient states it was “just to get your attention .”The mother states he minimizes symptoms to providers and denies property destruction. The patient states ‘you tend to be very annoying’ about his mother. He dislikes the way she talks to him and argues with her frequently. He was diagnosed with MDD, anxiety, and ADHD, at age 8, at the Children’s hospital. The patient had six months of psychotherapy at Children’s Hospital, which the mother states was unsuccessful because he was “not receptive and wouldn’t open up .”The patient reports that his mother forces him to play sports he hates, and the mother replies that the coaches perceive his lack of interest. He refers to school friends and accuses his mother of preventing him from seeing some of them. The mother replied those friends were unsuitable. He reports getting along with his father. He is provided extra time to complete school work due to ADHD and gets good grades. Past medications include Focalin and Methylphenidate.
Substance Current Use: None reported
• Medical History: Ht: 5′ 7”, Wt: 196 lbs, BMI: 30.70
• Current Medications: Zoloft 50 mg oral daily, Guanfacine ER 1 mg at bedtime.
• Allergies: No known allergies
• Reproductive Hx: No reproductive history
ROS:
• GENERAL: Patient is overweight.
• HEENT: Vision and hearing adequate, no coughing, sneezing, or congestion.
• SKIN: Normal coloration for ethnicity
• CARDIOVASCULAR: No complaints of chest pain or discomfort.
• RESPIRATORY: No shortness of breath or cough.
• GASTROINTESTINAL: Good appetite.
• GENITOURINARY: No burning with urination
• NEUROLOGICAL: The patient has insomnia and difficulty focusing.
• MUSCULOSKELETAL: Broken ankle from playing basketball.
• HEMATOLOGIC: No labs available
• LYMPHATICS: None reported
• ENDOCRINOLOGIC: No diabetes
Objective:
Diagnostic results: None
Assessment:
Mental Status Examination: The patient is alert and oriented x 3 with clear, appropriate speech and concentration. He is well-groomed and looks his stated age of 13 years. He maintains eye contact during conversations appropriately. His affect is flat, and he displays irritability towards his mother, exhibited by frequent arguments. He shows poor insight and difficulty accepting responsibility for his actions. The patient’s racing thoughts, triggered by school work, are displays of anxiety. He denies current suicidal or homicidal ideation and auditory and visual hallucinations. The patient’s fund of knowledge includes a standard awareness of current and past events.
Diagnostic Impression:
Major depressive episodes recurrent moderate (disorder)
The patient meets DSM-5 criteria for depression because he displays irritability, lost interest in activities, increased appetite, insomnia, and decreased ability to concentrate and energy. According to DSM-5 recurrent major depressive episodes of depression are separated by at least two months without significant symptoms of depression. The patient’s depressive symptoms significantly impair major areas such as school and home life. They are not the result of medical conditions or medication (APA, 2013).
Anxiety disorder (disorder) (F41.9/300.00)
Anxiety disorders are differential diagnoses for depressive symptoms because they are frequently associated. Differentiating anxiety disorders with depression and depressive disorders with marked anxiety is difficult (Sadock, 2015). The patient reports anxiety triggered by school expectations and struggling to maintain good grades. His struggles are focusing due to symptoms of ADHD, further triggering anxiety. The patient is a stress eater due to anxiety and has gained
weight. Anxiety influences thinking and perceptions by distorting the meaning of events, perception, thinking, and learning (Sadock, 2015). The patient displays interpersonal deficits, cognitive distortions, over-generalization, mental filtering, and emotional reasoning. He has difficulty accepting responsibility for his actions, such as blaming his mother for his low interest in sports.
Attention-deficit Hyperactivity Disorder Predominantly Inattentive Type (ADHD) (F90.0/314.0)
Attention, Deficit Hyperactivity Disorder is characterized by persistent inattention, hyperactivity and impulsivity that causes significant functioning impairment (Saddock et al., 2015). The patient meets DSM-5 criteria for ADHD due to difficulty focusing on school work; he is easily distracted, struggles to meet deadlines, and avoids house chores requiring sustained attention. The patient is allowed extra time in school to complete work due to difficulty focusing and completing tasks on time.
Case Formulation and Treatment Plan:
Treatment plan
Start Zoloft 50 mg PO QD for depression and Guanfacine ER 1 mg PO QHS for sleep and ADHD. The patient will continue outpatient therapy with a referral for psychotherapy.
Follow-up with primary care physician for somatic complaints recommended. The PMHNP patient and mother to abstain from alcohol and non-prescribed drugs—patient education about the importance of treatment compliance and the benefits and risks of medications. The patient is encouraged to stop medications for intolerable side effects and call 911 or go to the ED if feeling suicidal or homicidal. The PMHNP discussed the diagnosis, treatment options, drugs, benefits, and side effects with the patient and mother, who verbalized understanding and agreement. The patient’s next follow-up appointment is in 2-3 weeks.
Reflections
Objectives
This paper aims to complete a grand rounds presentation on a 13-year-old male patient with MDD, Recurrent moderate, Anxiety Disorder, and ADHD. Individuals viewing this presentation will identify symptoms of MDD Recurrent moderate, Anxiety Disorder and ADHD in adolescents and name appropriate first-line medications and nonpharmacological treatments. Viewers will recognize the relevance of culturally sensitive treatments to patient outcomes.
Rule out Disruptive Mood Dysregulation (DMDD) (296.99 (F34.81)
This PMHNP will rule out DMDD, a depressive disorder characterized by severe tantrums, chronic irritability, and angry mood with outbursts for future patients with similar symptoms (Sadock et al., 2015). Pervasive irritability and intolerance of frustration characterize DMDD (APA, 2013). The behaviors occur in at least two settings, at least three times a week, for at least a year, starting at the age of at least ten and before age 18. Children with DMDD frequently have bipolar disorder, ADD, ADHD, and intermittent explosive disorder as comorbidities (Sadock et al., 2015). The patient has ADHD, irritability, and frequent outbursts affecting his family relationship significantly that meet DSM-5 criteria.
Mentoring programs
This PMHNP will encourage a future patient to join a mentorship program. Studies indicate strong relationships with a nonparental adult positively affect at-risk adolescents in areas such as self-esteem and academic achievements (Boat et al., 2019). The patient with difficulty getting along with his mother and school work may benefit from mentoring.
Cultural identity
This PMHNP reflects that the patient dislikes how his Jamaican mother talks to him and argues with her frequently. He is a mixed-race child of a Jamaican mother and Caucasian father whom he admits to getting along better. Mothers, as the primary caretakers, play an essential role in ethnic identity affirmation and the healthy development of children. Studies indicate mother / adolescent communication with exchanged dialogue, talking, and listening fostered feelings of love and support in youth. The relevance of this is the patient’s parents may benefit from a culturally sensitive, strength-based family intervention program indicated by studies to improve self-regulation, communication, and youth outcomes (Ahn et al., 2021). Studies also suggest that parenting is equally vital to adolescent self-control across cultures and ethnicities (Li et al., 2019).
Questions
1. Which medication is FDA approved to treat anxiety and depression in children?
2. Is cultural sensitivity relevant to adolescent mental health?
3. To what extent are parents included in adolescent patient visits?
References
Ahn, L. H., Dunbar, A. S., Coates, E. E., & Smith-Bynum, M. A. (2021). Cultural and Universal Parenting, Ethnic Identity, and Internalizing Symptoms Among African American Adolescents. Journal of Black Psychology, 47(8), 695–717. https://doi.org/10.1177/00957984211034290
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Boat, A. A., Weiler, L. M., Bailey, M., Haddock, S., & Henry, K. (2019). Mentor’s self-efficacy trajectories during a mentoring program for at-risk adolescents. Journal of Primary Prevention, 40(6), 575-589. doi:https://doi.org/10.1007/s10935-019-00566-z
Li, J.-B., Willems, Y. E., Stok, F. M., Deković, M., Bartels, M., & Finkenauer, C. (2019). Parenting and Self-Control Across Early to Late Adolescence: A Three-Level Meta-Analysis. Perspectives on Psychological Science, 14(6), 967–1005. https://doi.org/10.1177/1745691619863046
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.
