Counseling Points - Family/Pediatric Nurse 11/08 - (Page 10)

Case Study M aureen, an 18-year-old preparing for college, comes to the therapy office for relief of “depression and anxiety attacks.” She has been engaged in interpersonal psychotherapy and has been receiving a selective serotonin reuptake inhibitor for 6 years with only partial resolution of mood symptoms. She reports excellent school achievement in the primary grades. However, as academic demands intensified in middle school, she says she felt less and less able to keep up with her peers despite stepping up her efforts. She changed high schools, hoping for smaller, less competitive classrooms. She recalls that a drop in her grades preceded her current feelings of anxiety and low self-esteem. She has struggled with anxiety and depression throughout high school, and now is very concerned about starting college and facing additional pressures. Maureen denies hyperactivity or impulsivity and has no history of learning disabilities. She reads well and her mathematical skills are adequate. She was never identified by teachers as having “learning difficulties,” and has been described as a “good student.” However, Maureen knows that she has had difficulty with organizational skills at school, and shyly admits to procrastination. She has successfully held part-time retail jobs during the summers. She reports no symptoms of exaggerated, fluctuating mood, but describes feeling easily overwhelmed by school deadlines. She denies a history of a decreased need for sleep accompanied by increased energy. She reports neither alcohol nor use of other substances. There is no family history of substance abuse. She has had neither grandiose nor morbid thoughts (differential symptoms of bipolar disorder and suicidality), but does complain of feeling depressed sometimes to the point of sleeping most of the day and arising at night. Upon investigation, Maureen reveals that her brother, away at college, has recently been diagnosed with ADHD. At first, she is reluctant to consider a diagnosis of ADHD for herself, but when she is educated about the signs and symptoms of the disorder and its familial nature, Maureen is eventually relieved to receive the diagnosis. In September, Maureen leaves for art college. She continues on her antidepressant, with the addition of a long-acting stimulant. She is referred for cognitive behavioral therapy (CBT) to manage her anxiety and panic symptoms, which is a big success. Maureen has discovered patterns in her behavior. She has learned to ask for help at her college’s Learning Center BEFORE becoming overwhelmed by academic deadlines. With the documented diagnosis of ADHD, Maureen now qualifies for additional time for test-taking and assignments. Perhaps most importantly, as her family has recently said, “We have our star back. Maureen believes in herself again.” Maureen’s ADHD has not been cured, but she now has many more tools to help her pursue a healthy, happy, and productive life. themselves because their work or relationships are not going well. They may also seek help upon referral of the evaluators of their children, the courts, or be brought to couple’s therapy by a chagrined and frustrated spouse. Sometimes, they self-refer; as their children’s behavior is identified and explained, they reflect upon their own similar life-long challenges with schedules, organization, impulsivity, concentration, and moodiness. While children may be diagnosed with ADHD over the course of an office visit or two (especially if school records accompany the child), adult diagnosis takes longer, and should include expert interviews by an advanced practice psychiatric nurse, or by a psychiatrist, developmental pediatrician, clinical psychologist, or clinical social worker, with adequate time given to recall memories. Recovery of school records should be attempted. If possible, symptom corroboration from family members, friends, or associates should be sought.21,27 With prolonged interviews and evaluations, the clinician begins to find out about life events or struggles that point toward underlying attention problems and their possible causes. COUNSELING POINTS™ Identification of ADHD in Parents and Other Family Members Because ADHD is now understood to be so inheritable, the health care professional should consider that other family members, including one or both parents, may also carry some measure of the disorder. This information should be presented carefully and sensitively to the parent or family. A mother who struggles with undiagnosed ADHD herself may feel guilty that her little girl has been described as “spacey,” “lacking focus,” “underachieving,” or worse yet, “lazy.” The mother whose husband has ADHD may be extra sensitive to the way men and boys “don’t listen to what they’re told” or “don’t think before they act.” Parents can become scared, angry, and frustrated at being reminded of the hidden shortcomings of their own childhood expressed in their child’s behavior. For instance, the father with undiagnosed ADHD who has struggled to contain his own impulsivity and temper may have little patience for the son who is disruptive or inattentive. Dyslexia can limit the usefulness of printed materials intended to teach the parent more about the child’s disor- 10

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Counseling Points - Family/Pediatric Nurse 11/08

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