The 8-year-old girl who was naughty


     There are a few questions that come to mind when reading this case. One of the things that stood out was the fact that the patient does not see her father a lot. If possible, I would want to speak with her father to find out if the types of behaviors described by the teacher and mother also exist when the patient is with him. This would give me a more holistic view of the patient’s behavior. For example, the diagnosis may change if the patient does not act this way when her father is present.
            The timeline of the patient’s tantrums is not very clear, and I would ask her mother to clarify them. She states that the patient has had tantrums since age 5, but then states that she has been resentful since her younger sister was born (they are two years apart). She also states that her tantrums are improving. I would like to know if this is really related to the birth of her sister, or if other factors contributed to her behavior. Was her behavior influenced by her belief that her mother’s attention had to be shared? Was she showing signs of being angry or resentful toward her mom before her sister was born?
            Finally, I would also speak with the child’s grandmother to see if she too shares the same feelings about the child’s behavior. Is the child “negative” and defiant with her? Does she seem difficult to deal with as well? This will help me to see if the child’s behavior is the same in all settings or if she is deliberately this way with certain people. Once again, this may alter her diagnosis.
People to Speak with in the Patient’s Life
             As previously stated, the persons I would like to speak with (besides her mother and teacher) are her father, grandmother, and sister. These are three people at different ages who interact with the patient in different settings and may be able to provide other perspectives not given by the mother or teacher.
Physical Exam and Diagnostic Tests
             While there is no specific test to diagnose ADHD, the DSM-V lists that criteria that the child or adolescent must meet in order to be diagnosed with this condition (Felt et al., 2014). It is also important to note that there are other conditions that may mimic and/ or coexist with ADHD. These include anxiety disorder, autism spectrum disorders, fetal alcohol syndrome, hearing loss, intellectual disability, mood disorder, oppositional defiant disorder (ODD), sleep disorder and speech and language disorder and finally, problems with hearing or vision (Felt et al., 2014). Behavioral rating scales are also used in the assessment of ADHD. There are several but Conner’s scale was used in this scenario.
Differential Diagnoses
            Three differential diagnoses include:

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ADHD comorbid with reactive attachment disorder
ADHD comorbid with Disruptive mood dysregulation disorder
Conduct disorder

The differential diagnosis I believe most suitable for this patient with ADHD comorbid with disruptive mood dysregulation disorder (DMDD). While the ADHD symptoms are clear with this patient, there are other behaviors that may suggest DMDD. These include, irritability, anger, and temper outbursts (National Institute of Mental Health (NIMH), 2017); all of which have been described by the teacher and her mother. Trouble functioning due to irritability has also been described by both the patient’s mother and teacher, which is another criterion for this diagnosis (NIMH, 2017).
Pharmacologic Agents
              Extended-release stimulants are the first-line treatment for children with ADHD (Brown et al., 2018). Either Methylphenidate or Amphetamine should be chosen and depending on how the patient tolerates the drug, as well as how well their symptoms improve will depend on dosing. This patient was initially given D-methylphenidate, however, she had insomnia and her ODD symptoms persisted and as a result the medication had to be changed. Lisdexamfetamine (Vyvanse) proved to be the most beneficial for this client.
Lessons Learned
            Treating a child with ADHD can be tricky. There are several different preparations that one must consider before initiating treatment. I also noted that while stimulants are good for treating ADHD and ODD, in this case, polypharmacy was more beneficial as there were no changes with her ODD symptoms until guanfacine was added. These cases have shown me how imperative it is to get complete assessment before diagnosing so that nothing (or very little) will be missed. Ruling out other possible neurodevelopmental disorders is essential so that treatment can be efficient and accurate.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
            (5th ed.). Washington, DC: Author.
Brown, K. A., Samuel, S., & Patel, D. R. (2018, January). Pharmacologic management of
attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Translational Pedicatrics, 7(1), 36-47. doi:10.21037/tp.2017.08.02
Conduct Disorder. (2018, June). In American Academy of Child and Adolescent Psychiatry.
Retrieved from
Disruptive Mood Dysregulation Disorder. (2017, January). In National Institute of Mental
Health. Retrieved from
Disruptive Mood Dysregulation Disorder (DMDD). (2019, May). In American Academy of
Child and Adolescent Psychiatry. Retrieved from
Felt, B. T., Biermann, B., Christner, J. G., Kochhar, P., & Van Harrison, R. (2014, October 1).
Diagnosis and Management of ADHD in Children. American Family Physician, 90(7), 456-464. Retrieved from
Stahl, S. M. (2017). Essential Psychopharmacology Prescriber’s Guide (6th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical
            applications (4th ed.). New York, NY: Cambridge University Press.

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