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NURS 6630 CC I have Trouble Paying Attention at
School - Sarah Higgins a 9 Year Old Girl 2025
CC: “I have trouble paying attention at school” HPI: Sarah Higgins is a 9 year old AA girl who came in with her mother for mental evaluation. The patient has been inattentive most of the time at school. Sarah admits that she cannot remember all her assignments and the teachers have to write down the list of these assignments. However, the patient forgets where she has placed the list almost on daily basis. The mother has to write the list on her phone to keep reminding the child. She starts that the child has been forgetting her assignment since when she was in her kindergarten. The girl also has a problem of fidgeting and sitting still on her chair. She only sits a few minutes when she is reading an interesting book. However, she notes that she cannot recall what she has read on the book. Also, if a teacher reads the book for her, she cannot remember immediately what is being read. The patient has a tendency of loosing things. She starts leaving her geography book in a bus and a bracelet she was given by her mother in a bathroom in a restaurant. The child reports being upset when her teacher asks her to do something because she cannot hear the instructions most of the time. She states that she daydreams playing with her dog, Conley while at school. She is frustrated because she makes a lot of mistakes while doing her assignments. During the interview, the girl presents with some level of inattentiveness and the mother keeps reminding her that the question was directed toward her. The patient admits she cannot recall what she was being asked during the interview because she was thinking about a picture on the wall. The mother reports that the patient has a behavior of running of a painting to another. The teacher’s reports highlighted that the patient has a problem waiting for her turn. The mother recounts a scenario where when the child was young, they could not take her to the Zoo because put her hands inside the cages of dangerous animals. The child admits that she had a problem with her attention span and she needed help. Past Psychiatric History General Statement : The child entered treatment 2 months ago after separation of her parents Caregivers: Parents (50% each of their time with the child) Hospitalization: None Medication: None Substance Use History : No history of substance use Family Psychiatric History: Father, 36, alcoholic, mother, 32, no psychiatric conditions. No family
history of suicides or mental illnesses Social History : Sarah Higgins is the only child of Mr. and Mrs Higgins. Her parents are currently separated and they are working towards their divorce. They have sought counseling on who the divorce could affect their only child. The couple has tried to work things out, but it seems they are drifting away from the reconciliation. However, each parent spends 50 percent of their time with Sarah and their home to avoid disrupting the child. However, Sarah worries about the anticipated divorce of their parents. The couple acknowledges that they have challenges with their parenting styles. Although the mother acknowledges the important of psychiatric evaluation of their child, the father is resistance of the services citing that what Sarah was undergoing was a normal developmental stage. However, the father agreed that the child should seek psychiatric services in fear of a potential divorce. The mother is a dentist while the father is a database manager working in a large IT firm The child is a average student at school. She sometimes scores poorly because of her inattentiveness. She cites that her mother is her primary source of support. She has a dog that likes playing with. Her best friend is her next door child and they have known each other since kindergarten. She gets into trouble with her friends because she can be over excites and impatient waiting for her turn while playing. Sarah is good at 1:1 friends and likes interacting with other children. The parents reports that their divorce may negatively impact or worsen the condition of their child. Her inattentiveness at school and home has caused both couple and individual stress for these parents. The father relates her condition as behavioral issue because Sarah has full attention while playing video games, but has reduced attention while doing her attention. On the other hand, the mother things that her inattentiveness is something more than just a behavior by a mental issues that should be addressed with urgency. The father also noted some fluctuation in social activities because the child scores very well in some while at home and misses almost every pass while at away field. Medical History : All childhood vaccinations up to date including flu shot, tetanus booster, Tdap. No history of chronic conditions such as asthma. No history of hospitalizations or surgical history. Current Medications: none Allergies : Penicillin allergies-causes rash. No food allergies or cold allergies. Reproductive Hx : Deferred ROS: GENERAL: No weight changes, appetite changes, fevers, chills, or changes in energy levels. HEENT: No headaches or head injuries. No eye pain, double vision, vision changes, eye drainage or eye redness. No ear pain, ringing ear, or ear drainage. No nasal congestion, runny nose, or changes in smell. No sore throat, mouth sore, or ulcerations NECK: No neck pain or swelling
Numbers marked on the front or back pages are automatically transferred to a center section for use by the physician. On a scale of 0 to 3, the teachers score how often the kid demonstrates the behavior indexed by each item. The therapist noted from the teacher's report that the kid demonstrated some inattentiveness, trouble following instructions, and forgetting tasks in the case study. A neuropsychological testing is a thorough evaluation of behavioral and cognitive functions that use a set of standardized tests and procedures, including paper and pencil and question and answers. It is a useful tool for accurately diagnosing ADHD and learning disabilities. Neuropsychological testing is also used to evaluate other cognitive issues that may arise as a result of a brain damage, a neurological illness, or a medical or emotional condition. A wide range of functions, including intelligence, problem-solving, language, emotion control, attention, memory, learning, and more, may be tested during testing. Based on the findings, treatment plans and recommendations can be created to help improve functioning in daily life. A medical ailment, such as a thyroid condition, can sometimes induce ADHD-like symptoms. To rule out these diseases and determine whether a person may safely take ADHD medication, a complete medical checkup is performed, which may include laboratory tests. During the physical examination, the doctor takes note of the patient's temperament, mental state, and actions. Your doctor may request that you watch your child play in order to observe any potentially worrisome behavior. Depression, generalized anxiety disorder, and oppositional defiant disorder (ODD) are all common emotional problems that accompany ADHD. When a kid exhibits symptoms of one of these illnesses, a mental health professional may conduct an emotional assessment. When there are unresolved emotional difficulties, ADHD treatment can be hampered. A youngster with depression, for example, may not react well to treatment unless the symptoms of depression are addressed first. ASSESSMENT Mental status exam: Sarah is a 9 year old girl who has met her developmental milestones. She is dressed appropriately with no tattoos. She appears inattentive during the interview and does not sit still on the chair. She is also restless, fidgety, and forgetful. Her speech is within the normal range, but sometimes is somehow loud due to impulsivity. When asked what was being discussed during the interview, she only recalls talking to her dog. She is a very polite girl with no depressed mood. She does not present any anger or irritability. No racing thoughts or pressure speech. No signs of hallucinations or delusions. She has intact and logical thought content appropriate to her age. No signs of homicidal/suicidal ideations. She has impaired concentration and impaired recent memory as indicated by her inability to remember the interview topics. She demonstrates some level of inattentiveness because the mother has to remind her that she is being asked a question. Her orientation, remote memory, and abstraction are intact. Attention deficit/hyperactivity disorder (ADHD) combined presentation ( F90.2) Specific learning disorder (F 81.0)
Generalized anxiety disorder Opposition deficient disorder (F 91.3) The primary diagnosis for this child is ADHD combined presentation. ADHD is a psychiatric disorder that has been recognized as having an impact on children's capacity to function. Individuals with this illness have tendencies of inattentiveness, hyperactivity, or impulsivity that are developmentally inappropriate. For the past 6 months, the mixed presentation has been distinguished by inattention and impulsivity/hyperactivity. Making mistakes that appear to be careless at school for children or at work for adults, having issues maintaining attention on school, reading, or during pleasurable activities, or problems following instructions are all common inattentive signs. Children experiencing inattentiveness do not complete a task because of losing focus or being sidetracked. Also, inattentiveness is marked by a frequent behavior of loosing items such as books or being easily distracted by external events. Hyperactivity is marked by having problems sitting still or squirming and difficulty in staying seated. These children often experience restlessness and being unstable and they have a lot of energy. They also tend to answer questions before they are being asked and they have difficulties in waiting for their turn. When compared to child diagnosed with either the mainly hyperactive or predominantly inattentive form of ADHD, having ADHD combined type does not inherently imply that the ADHD is more severe. A child with a generally hyperactive-impulsive personality type, for example, may nonetheless exhibit certain symptoms from the inattentive symptom list. He or she would not, however, exhibit all five or six symptoms required for a combined ADHD diagnosis. When a patient is diagnosed with mixed type ADHD, the symptoms are more likely to be split evenly between the two types. Based on the above outlined DSM-guidelines for ADHD combined type, the patient satisfies most of the requirements to be diagnosed with the condition. The girl exhibits some level of inattentiveness during the interview. Also, the teacher reports showed that the child has problems paying attention at school. The girl admits daydreaming playing with her dog while at school. The girl has problems recalling her assignments. She makes a lot of mistakes with her assignments because she cannot remember most of the instructions. She also an history of loosing things such as a bracelet and textbooks. The girl has problems seating still, she is restless, and fidgets. Although the girl appears very polite during the interview, the gets into trouble while playing with her peers because she cannot wait for her turn. Her hyperactivity poses a risky behavior that can put the child into danger. Specific learning disorder is another potential etiology for this patient. This condition means a disorder in at least one of the basic psychological processes that are involved in understanding or using language, written or spoke, that may present itself in impaired ability to speak, read, listen, spell, write, or do arithmetic calculations. It includes conditions such as dyslexia, minimal brain dysfunction, brain injury, or perceptual disabilities. However, specific learning disability disorder include learning problems resulting from motor, hearing, or visual disabilities, serious emotional disability, or intellectual disability. Specific learning disability was selected as a possible diagnosis because the Sarah presented with some
not be able to perform properly. They often need frequent reinforcement regarding their performance from caretakers, instructors, and others, even if this reassurance just gives temporary comfort from their anxiety. This condition is ruled out as the primary diagnosis because the child did resented restlessness but did not present any excessive worry that can satisfy the GAD diagnosis. Another possible diagnosis for this child is opposition defiant disorder (ODD). Notably all children present some oppositional behavior from time to time, especially when stressed, hungry, tired, or upset. They can disobey, talk back, argue, or defy teachers, parents, and other adults. Thus, oppositional behavior is a normal developmental part of children and adolescents. However, children diagnosed with ODD present an ongoing pattern of defiant, hostile, and uncooperative behavior towards authority figures, significantly interfering with the daily functioning of a child. Some of the ODD symptoms outlined in the DSM-5 include temper tantrums, questioning rules, anger and resentment, spiteful attitude, and excessive arguing with adults. These symptoms should present at different settings such as at school or at home. Although Sarah presents with oppositional behavior playing with her peers, she is very polite and no history of disobeying rules or arguing with authority figures such as teachers or parents. Reflection: This case scenario was an eye opener to me on how parents can be confused on what is affecting their children. Mr. Higgins thought that inattentiveness of their child was behavioral while the mother thought that it was a mental issues that needed immediate psychiatric services. Also, I learned that family issues such as anticipated divorce can worsen the level of inattentiveness of children with ADHD. What I would do from this case scenario is to get the perspective of the father about the condition of their child. Despite what the couple was going through, I would encourage them to attend the sessions together with their child The ethical issue of informed consent may arise from this case scenario. The parents should give and informed consent for the treatment of their child. During the process of obtaining an informed consent, the ethical dilemma may arise on whom to seek the consent from since both parents are separated. Since the father agreed that the child can attend psychiatric services, the mother who brought the child to the clinic can give the consent. The father feared that failure to give the consent may cause him loosing the custody of the child, something that she does not want to. The couple are working towards solving their issues instead of seeking for divorce which can affect the prognosis of the child. The various drugs available to treat ADH should be familiar to primary care providers. First-line agents are stimulant medicines. Stimulant (methylphenidate [Ritalin] have been the mainstay of ADHD treatment for the past 40 years, though there is no evidence that one stimulant is better than another. Atomoxetine (Strattera) is a second-line agent that has been shown to be effective in placebo-controlled trials. Bupropion (Wellbutrin) and tricyclic antidepressants are examples of drugs with less evidence to support their use. For ADHD, there are a number of well-researched behavioral therapies. To gradually modify the child's thinking and conduct, most behavioral techniques focus on reinforcing desired behavior and imposing consequences for unwanted behavior. Tokens or points, for example, could be handed to the child right
away to encourage good conduct or work. Support groups, which connect parents with children who have similar problems, and parenting skills training, which teaches parents ways and tools for regulating their child's behavior, are two interventions that assist reinforce parental participation. A stressful home environment, an improper educational setting, less structure and fewer regulations at home than at school, and high-frequency digital media use are all factors that contribute to inattention, impulsivity, or hyperactivity. Increased parental stress or mental health difficulties are two psychosocial factors contributing to parent complaints of inattention, impulsivity, or hyperactivity (eg, depression)
