Answer

• Patient was brought in by both parents to be evaluated for ADHD. According to his mother since he has been doing home school for the past year- she has noticed that he cannot focus on his studies.  The patient states “I have hard time paying attention in class”. She states that he struggles to stay on routine or work independently. His grades have suffered this past year.   In the past year he was diagnosed with hypothyroidism.  His mother describes that he began to have behavioral changes.  He began to experience anxiety as well as depression.  The mother states that 2 months ago he admitted to a family member that he did not want to live.  According to the patient “ I feel sad sometimes and nervous”. He has withdrawn from many activities that he used to love.  He states that he has felt sad and nervous for the past 6 months.  The patient feels SOB, racing heartbeat and upset stomach when he gets nervous.  He relates this nervousness to when his mother has to leave the home. The patient typically throws temper tantrums when he does not get what he wants.  She also states that he refuses to sleep on his own.  The mother sleeps with him every night in his room. His mother also states that he has refused to go to the bathroom on his own.  She has to wipe him.  When asked what would happen if she makes him perform this task himself  she states that he will deliberately hold his bowel movements for days.  The patient denies any current suicidal or homicidal ideations.  He denies any auditory or visual hallucinations, and paranoia. He was also questioned alone for any possible abuse implications- he denies them.  
• Previous diagnosis: This is an initial visit. Patient has not seen a mental health provider before. 
• Previous admissions: None
• Previous suicide attempts: No past attempts or plan in place.
• Previous self-harm- Denies any self-harm activities
• The patient’s mother states her sister and maternal grandmother suffer from depression. Both grandmother and sister received medication treatment.   The father denies any psychiatric history on his side.  Both parents deny any psychological issues with his half-siblings

 Treatment Interventions with Rationale

Pharmacology–

• Fluoxetine 10mg q am. (Prozac). It is an SSRI antidepressant.  It is indicated for the treatment of depression in children, OCD, panic disorder and bulimia.  Patient education includes side effects.  Side effects are listed as nervousness, nausea, insomnia, headache, diarrhea, change in appetite.  Fluoxetine is a CYP3A4 inhibitor. 
• Treatment Interventions with Rationale Continued
  • He will need CBT (cognitive behavioral therapy) and an evaluation to be completed for ADHD (completed my his parents and teacher). 
  • Cognitive Behavioral Therapy has been chosen since it is an approach that will help the client to modify his thoughts, belief and even perceptions on life ((Diefenbach et al., 2019)). Eventually, it will lead to a change in behavioral pattern.
  • First we need to address his depression (as he said he was suicidal at one point). I only want to add one medication at a time i.e. depression medication to make sure he tolerates it before adding a second one.  He will need to follow up with his primary care physician to make sure that his thyroid levels stay under control while on meds. Diagnostic tests/Lab work- 3 months?
  • Evidence-based non-pharmacologic interventions.
  • He will need to return for a follow up in 2 weeks (medication management). CBT with family therapy every two weeks.
  • Encourage reward system with tokens. Every time he uses the bathroom on his own he can earn a token from Mom.  He can then use those tokens as money exchange with mom to buy a toy.
  • Mom should start a goodnight ritual whereby she says goodbye and leaves the child’s room at bedtime (Lee & Han, 2019).
  • She should state that she is simply going to bed and will see him in the morning as an offer of reassurance (Lee & Han, 2019).
  • Mom should be determined not to give in to the child’s demands.