You are a child and adolescent psychiatrist working in an urban-setting group practice that includes adult psychiatrists. One of your collegues refers Stacey, the 15-year-old daughter of one of his patients, for evaluation of what her father asserts is "the same problems I had when I was her age, but I never got help." The father understands from your conversation on the phone to arrange the appointment, that you wish to meet alone with Stacey for the first session. The father agreed to come in by himself for a second appointment. Stacey and her father show up for their evaluation appointment on time and immediately you note the constricted affect of the girl. Stacey does not offer you eye contact. She slowly enters the room, puts her feet on her chair and rests her head against her knees. She is thin, wears glasses, and her hair is partially held from her face by a colorful, albeit dirty, headband with a silk flower affixed to one side. She is wearing a necklace of brightly colored jewelry, several bangles on her wrists, and her tennis shoes are decorated with flowers drawn in magic marker. She appears somewhat disheveled, is wearing sweatpants and a blue polo shirt with her school's emblem.
The father taps her head and says, loudly and assertively, "C'mon, Stace, get up. Don't behave like that in a doctor's office." He looks at you and shrugs.
You politely ask the father to step out of the office so you might interview Stacey alone. He agrees, but on his way out he uses his hand to lift the girl's head up and says to her, brusquely, "Come on, Stacey! Sit up! You are in a doctor's office. Is this how you behave?" The patient returns her head to her knees and the father leaves. You reintroduce yourself to the patient, and ask her how she is feeling right now. She does not answer. You wait. After a few minutes you notice that her breathing has slowed and she appears to have fallen asleep. You move your chair closer and call her name. She moans quietly and shakes her head. You decide to shift the focus of your questions to something that might engage her, commenting on her colorful jewelry, how pretty it is, and ask whether she makes her own. She nods, although she does not lift her head. You ask what other hobbies she has. She does not answer and seems to have fallen asleep.
After a few moments you gently tap her on the shoulder and say that you know this may be uncomfortable for her to be in the psychiatrist's office, but you would like to know more about her. You ask her what time she went to sleep the previous night, a Sunday. She shrugs. You offer suggestions: "11 o'clock? 12 o'clock?" She holds up four fingers without moving her head from her knees. "Four in the morning?" She shrugs again. You ask what she was doing all night in her room until she fell asleep. Barely audible, she mumbles something about her computer. You ask her to please lift up her head because you want to hear what she has to say. After a couple of minutes she lifts her head, but pulls her long, somewhat unkempt hair over her eyes. She sighs loudly. "I don't want to be here," she tells you in a soft, monotone voice. You wait. "It's not fair what they're doing to me," she says. "I can't help it if I can't sleep."
You ask if she stays up late every night. She says, using a tone suggesting some contempt, "What do you care?" You explain that you were asked to see if there is some way to help her with what seems to have become a difficult year. You then offer, "Sometimes kids stay up all night because it is quiet and they can think for themselves. Does this happen to you?" She nods. You ask, "What is it like for you at home?" Stacey pulls her hair aside, but looks off to the side. Her affect is still quite constricted, and there is little prosody in her speech. "My mother is always screaming at me to do my homework. So is my dad. I can't stand it." You comment that it must be difficult living in a home where everyone is always "on your case." She nods in agreement. "I do my work," she says, "although I do forget to turn in assignments, or I just lose them, or … I don't know. But the teachers are all idiots anyway. Why should I listen to them when they don't even know how to do the work they assign us?"
You ask if she has trouble staying organized. She nods. You say that she must be very smart to be able to accomplish so much in a very difficult school despite having trouble keeping track of things. She says, "Yeah, but they all know I'm smart. Some of the other kids are just idiots. I don't know how they got into my school." You ask if she likes her school. She says she does, but lately they have been picking on her "for some reason." You mention that you heard she sleeps through a lot of her classes. "Yeah," she says, "but I'm tired." You notice that there are only 10 minutes left to the session. You ask her to describe her mood. "Blah," she tells you. You ask if she feels depressed. "I don't know," she says, "probably." You ask if she has friends. She tells you she used to, but one friend did something to turn her other friends against her and now "everyone thinks I'm weird or something. I don't care. They're like little kids. They will not let go of things. Like picking my nose, or pretending I'm a cat. Well, they did let go of those things, but they haven't let go of saying that I lost my virginity to a dog. They've said that since first grade. I haven't lost my virginity."
A week later, the father comes alone for the individual appointment to which he had agreed. He thanks you for seeing Stacey and begins to list what he feels are the main concerns. "She was diagnosed with ADHD [attention deficit-hyperactivity disorder] when she was 10 and she took [methylphenidate] until last year. Her pediatrician prescribed it. She started complaining about headaches and was losing weight, so we stopped it last summer. She started out okay, but now it's impossible to get her out of bed in the morning. She usually misses her first class because I can't get her going. It is a daily struggle. Half the time she does not eat breakfast, even if I prepare something I know she likes. Then all the way to school she complains that her stomach hurts." He says she has not gained or lost any significant amount of weight. "She's always been thin, but she eats, usually in the evening or at night." "She stays up all night," continues the father, "playing alternate reality games on the computer. I've tried taking the computer out of her room, but she will start screaming and I have to give it back or all hell breaks loose."
The patient's father tells you he is also raising his son, Nick, 2 years older, who had a diagnosis of oppositional defiant disorder and ADHD, had started smoking marijuana, and was being treated at the same clinic by a different child and adolescent psychiatrist until recently when he refused to return for treatment. The father also has a young child with his current live-in girlfriend. Stacey and Nick's biological mother now lives a block away. "She's nuts." "I don't know what's wrong with her, but she is always screaming at Stacey." He explains that the situation at home was "unstable at best" for the past 10 years, since he and his wife separated and the mother of his youngest child, moved into the first floor to live with him. Stacey's mother continued to live in the home on the second floor until a few months ago. "It's a duplex," he tells you, "but there is only one entrance; she had to come in through the first floor to get upstairs. There's no physical separation of the units."
Without prompting, the father tells you, "I've got depression. I've been taking an antidepressant for 10 years and it has helped a lot. I think I had the same attention problems as a kid as Stacey and Nick but I overcame them without medications. They really did not have much to treat it back then. I think they called me ‘hyperactive’ or something. It did not matter, though, because I had the brains." You ask what he does for a living. "I'm a biotech researcher here at the [Ivy League] University right up the street. But I do a lot of work at home from my computer." He is obese, wearing shorts and a wrinkled button-down, short-sleeved shirt.
Stacey is in eighth grade, attending a school for gifted children. He tells you that she has not had formal psychological testing except for a test in first grade, which indicated that she should be placed in a gifted academic program. ADHD was diagnosed by her pediatrician and the school psychologist when she was in second grade and a trial of long acting methylphenidate titrated to 36 mg daily, was initiated. This helped her focus; she did well in school and was considered one of the top students. She never had behavior problems. She has been at the same school since that time, and there are only 3 months remaining in the current year. The school is very demanding, and the students are required to maintain an 85% average to matriculate to each successive level. "Stacey is really smart. I mean really smart. She's also very artistic. Her teachers all love her. According to her father, during the past year she has been sleeping through classes and will crawl under a table in the classroom and sleep or surround her head with books at her desk. During a recent gym class she went to sleep in the corner on a mat, when the teacher asked her to get up and participate in a game, she responded, "Why can't you just leave me alone?" Her behavior has been disruptive to each of her classes because she is "always sleeping," but when called upon to answer a question, she will lift up her head and know the right answer. Because of her "amazing intelligence" her behaviors have been overlooked until recently, when the school asked Stacey's father to have her evaluated by a psychiatrist. He tells you the school is considering expelling her unless she "shapes up" and "does what she's supposed to do. We had a meeting about this 2 weeks ago. I knew she was struggling a little bit for the past few months, but I had no idea they have been cutting her breaks all year."
He tells you, "We even went to the neurologist at the beginning of the year to see if she had narcolepsy or a sleep disorder." The results of a sleep study were negative, he tells you. The doctor at the sleep disorders clinic told the patient's father that her problem was due to "staying up all night."
Given what you know about the patient so far, what steps would help you reach a clear diagnostic picture? Points awarded for correct and incorrect answers are scaled from best (+5) to unhelpful but not harmful (0) to dangerous (−5).
|A1.||You know enough. ADHD had already been diagnosed and since she stopped taking long acting methylphenidate 36 mg daily, her performance has suffered. As a result of the reemergence of her ADHD symptoms, she is having increasing difficulty in school, which you regard as the etiology of what seem to be mood symptoms.|
|A2.||You do not question the diagnosis of ADHD, but you believe that she has a mood disorder, probably depression, given her sleep disturbance, irritability, poor appetite, endorsement that she may be depressed, and her "blah" mood.|
|A3.||You do not question the diagnosis of ADHD, especially since her symptoms abated with the use of methylphenidate. There is also a strong family history of ADHD, both in her brother and possibly her father. You are concerned that she may have a mood disorder, so you request that the father bring the patient back the following week to continue the evaluation. You also provide a referral to obtain laboratory values for thyroid-stimulating hormone (TSH), a complete blood count (CBC) with differential, and urine drug toxicological analysis to rule out organic causes such as hypothyroidism, anemia, or drug abuse.|
|A4.||You suspect the diagnosis of ADHD may be appropriate, but you will require collateral information from teachers and more information from her father about how she behaves at home. You ask the father to fill out a Conner's ADHD metric and give him one for her primary teacher to fill out. You also request the father return with the patient the following week to further explore the possibility that she may have a mood disorder. You ask permission to speak with the mother for collateral history regarding that relationship and more family mental health history.|
|A5.||You require collateral information from the school and the parent about ADHD symptoms. You ask for permission to speak with the teacher, ask the father to fill out a Conner's ADHD metric, and give him one for her primary teacher to fill out. You ask for permission to speak with the mother for further collateral history, and you ask the father to return the following week to obtain more detailed information about the patient's history, family life, social stressors, and any further symptoms that may suggest an additional diagnosis. You provide a referral to obtain laboratory values for TSH, a CBC with differential, and urine drug toxicological analysis to rule out organic causes such as hypothyroidism, anemia, or drug abuse.|
The patient and her father return the following week to continue the evaluation. During the week you were able to speak with her primary teacher and school psychologist. They inform you that it is true that Stacey is "close to being asked not to return" the following year. They tell you her grades are good enough to finish the year, but not good enough to excuse her oppositional and disruptive behaviors. "She does things she knows she is not allowed to do," the teacher tells you. "Like having a cell phone in class, sleeping, or talking back. When we tell her about these things she acts oblivious, as though she never considered her actions to be against school policy. She knows the rules." The teacher did not fill out the Conner's metric, but she can tell you that Stacey has not been able to maintain concentration during the year. She knows the patient's mother stopped the ADHD medication and sees the negative effects of that discontinuation. "She is talented and smart, though," continues the teacher. "I feel bad. I know things in her home are not stable, but this is a unique school and the students have to maintain a high grade point average. Stacey is not able to do that this year. I ask her a question and it's like she's on another planet." She says that Stacey often forgets her homework, has left her bookbag and books at school on several occasions or forgets to bring them to school at all, and complains when she is asked to perform any sort of academic tasks in school. She tells you that her behavior seems oppositional this year and that she has never had a problem with hyperactivity. The school psychologist tells you that she meets regularly with Stacey, and the patient typically goes to sleep during their sessions. "Yes, it is annoying, but I let her sleep. I do paperwork while she sleeps in the chair."
You attempted three times during the week to reach the patient's mother. You left voice-mail messages asking her to please call you. You check with the patient's father and the number you have been trying is correct.
Stacey and her father are in the waiting room when you arrive at your office, and Stacey is asleep on a chair. You ask the patient to come into your office. After a great deal of effort by her father, the patient gets up, saunters into your office, plops down on a chair and puts her feet on your desk. She is again somewhat disheveled, her sweatpants appear unwashed, and she presents similarly to the first visit. You ask her to please remove her feet from your desk and she refuses. "I'm tired," she tells you. You ask her again, and she reluctantly takes her feet down. Then she puts her feet on her chair as she had the first time you met. You ask her to please try and stay awake so you can learn more about her. "Why?" She demands. "Everyone is picking on me." She pounds her head with her fists. "I can't take this." You ask her what is bothering her right now. She looks at you incredulously for a moment, and then averts her gaze to your bookshelf. "You talked to my teacher. She told me. Now they're treating me like I'm retarded."
You assure her that you contacted her teacher to find out how she is doing in school because that is the area about which her family is most concerned. "I don't know," she tells you. "I'm sure I'm going to pass because I always do." Then she looks around the office. "How much time do we have left?" You ask her how late she stayed up the previous night. She shrugs. You offer that you know that sometimes kids will stay up late because it is quieter and they feel as though they can finally relax if there is too much commotion going on in the home during the day and evening. She says, "Yeah, I guess that is part of it. My mother is always screaming at me. She does not care about anything except my computer." You mention that you know her mother now lives out of the home. "I spend every stupid weekend with her. I can't stand it. All she does is cater to Nick. He's always doing stuff and never gets in trouble. I never do anything and I'm always in trouble. It's just not fair." You ask who Nick is and she responds, incredulously, "my brother. Didn't my father explain all of this to you?"
You ask if she ever becomes tearful and if she finds herself crying for no reason. She nods. You ask if she gets angry easily. She nods. Then she announces, "No, I've never tried to kill myself. I think that is stupid. My school counselor asks me that all the time." Then she sighs loudly and puts her head down on her knees. "People at my school are so stupid. They don't get me. They just want to punish me all the time. Now they think I'm crazy." You ask what she thinks. She does not respond. You mention that you notice that she seems angry today. Without lifting her head, she answers, "Well, I guess that is because maybe I hate it here?" You wait. "My mother was supposed to take me shopping. I waited for her to pick me up for FIVE HOURS!" She slams a fist against one of the arm rests, yet her affect seems unchanged, as if the reaction was entirely mechanical. "What was I supposed to do? I waited and waited, and then I got onto the computer. So, when she came home, guess what she did?" She looks off to the side. "She yelled at me. Big surprise." She shifts in her chair. "So, I refused to go to the store with her and she took Nick. She bought him stuff and then took him to dinner. I just sat at home. I called my dad to pick me up. The next day, she wanted me to come over and bake cookies. What the hell is that?" You note that despite the increased volume and occasional sarcastic tone, much of her speech is either devoid of affect, or with incongruent affect.
You inquire her how long she has felt like this. She tells you, "I don't know, for the past month. I guess since my mother moved out. I thought I would feel better because she wouldn't be there screaming at me every stupid second. I mean, it was nice not having her yelling at me. I don't understand how my dad could bring this other woman to live in our home while he is still married to my mother. And they have a kid." You ask how long ago the other woman came to live with them. She said, "About 10 years ago. We have a duplex that is connected inside, so my mother lived upstairs and my father, Michael, and Nancy live downstairs." You ask where her bedroom is. "On the first floor, but it is full of boxes with my father's stuff in them. Nick lives in the basement. Sometimes I went upstairs and slept on my mother's couch."
You ask the patient if she has ever smoked cigarettes. She shakes her head "no." You ask about alcohol and she again shakes her head "no." When you ask about marijuana she does not reply. "Sometimes kids try smoking marijuana to see what it is like. Sometimes they smoke it every day or every week." Stacey remains still in her chair. "I'm not the police," you tell her. "I just need to know if you use marijuana or other drugs because it will help me better understand what's happening." She lifts her head and then looks around the room. "Are you going to tell my father?"
The patient has indicated to you that she probably has tried marijuana and wants to know whether you will reveal this to her father. How should you respond? Points awarded for correct and incorrect answers are scaled from best (+5) to unhelpful but not harmful (0) to dangerous (−5).
|B1.||"Yes." Explain to her that she is only 15 years old, and this is dangerous behavior for someone her age. Because she is a minor you are obligated to tell her father. Apologize for having to break her confidence, but it is for her own good.|
|B2.||"Yes." Explain that there are a several issues that you must share with her parents given her age. One is whether she is in danger of hurting herself or others, and the other is if she admits to using illicit drugs.|
|B3.||"No." Tell her that everything you share in the office is entirely confidential.|
|B4.||"No." Tell her that almost everything you share in the office is confidential except if you learn that she intends to harm or kill herself or others.|
|B5.||Ask her more questions about her usage. If she has tried it but no longer uses it, and if her drug toxicology screen results confirms this, you will keep this information confidential unless she again uses the drug.|
|B6.||Ask her more questions about her usage. If she is still using the drug with any frequency, you will have to share this information with her father as this would represent a dangerous behavior about which her parents must be made aware.|
|B7.||Ask her more questions about her usage. If she used it in the past, has stopped, and can agree to be honest about her use with you and even submit to unannounced urine toxicology screening (if this is permitted by your state law), you will keep her confidence for now. Discuss with her the evidence that most people with substance abuse problems have a greater chance of maintaining abstinence if their family is involved.|
You thank Stacey for being honest with you and sharing details that are obviously troubling. "Well, what do you expect?" She asks. "My house is wacko." You ask if she ever did anything to harm herself. "I cut," she says plainly. She lifts up her head and holds out her right arm. You note several superficial horizontal cuts near her wrist. You ask if she ever tried to kill herself by cutting. "No." she responds. "I told you I don't want to kill myself. Don't you listen?" You tell her, "Sometimes kids cut themselves because it makes them feel better. Sometimes it is because of the pain, seeing the blood, or both. When do you cut yourself?" She shrugs. Then she offers, "When I'm angry. I also get headaches. Like right now." You ask if she ever took pills for her headaches. She answers, "Yes." You ask if she ever took more than 2 tablets for a really bad headache. "Yes," she tells you. "Once I took about 8 or 10 and I went to sleep. I ended up waking up and puking." You ask if she intended to die. "No. I told you that already. Don't you listen?" She admits she took the pills after a fight with her mother about a year ago. Since then she admits only to cutting, which she says she last did a few days earlier after an argument with her father about schoolwork.
She tells you she does not have racing thoughts. "They ask me this at school sometimes when I act goofy." She tells you she often ruminates about things, but was never told by anyone that she spoke too fast or that her speech was unintelligible. She denies having any sexual partners and never goes on spending sprees ("I save my money"). You ask about a decreased need for sleep, which she denies.
You ask her what she likes to do. "Nothing," she tells you. You mention that you heard that she is a talented artist. "Yeah," she says. "I'm good." You ask what her favorite media is. "Drawing and painting," she replies, dryly. You wait. "I haven't been doing it much, lately." You ask why. "I just don't feel like it. I don't feel like doing anything. Just the computer, and that just gets me into trouble so I don't know why I even bother trying to use it." You recall she said she lost a lot of friends. You ask if there is anyone with whom she still does things. "My brother," she says. "We hang out in the basement sometimes. I don't like his friends very much, though. They're jerks and they pick on me." You ask how long she has not felt like doing the things she normally enjoys. She thinks for a while then responds, "I don't know. Maybe a year. Maybe more. Maybe less."
You ask her what her biggest worries are. She puts her head back down and shifts in her chair. "I guess school," she tells you. "Or maybe they're going to send me off someplace to get rid of me." She wipes her eyes on her sweatpants and then lets out a wail that begins softly and then picks up volume. You wait. You note that she does not seem to be crying. She stops suddenly. "Can I go now?" As the session is over, you agree.
Given what you know about this patient, what is your differential diagnosis? +2 points are given for correct answers, and −2 points for incorrect answers.
In adolescent females, a diagnosis of ADHD has been shown in several studies to be a significant risk factor for which of the following (+2 points are given for correct answers and −2 points for incorrect answers):
|D1.||Long-term psychosocial impairment|
|D7.||Oppositional defiant disorder|
|D9.||Illicit drug use/abuse|
If you conclude that comorbid ADHD, major depressive disorder, and cannabis abuse can be diagnosed in this patient, what would be the best approach to treatment, from both psychopharmacological and psychotherapeutic modalities? Points awarded for correct and incorrect answers are scaled from best (+5) to unhelpful but not harmful (0) to dangerous (−5).
|E1.||Treat the substance abuse first, then the major depressive disorder, and then the ADHD.|
|E2.||Treat the major depressive disorder first. This will probably reveal that the patient has been using marijuana to self-medicate and should have an easier time abstaining from its use. Use fluoxetine, the best studied selective serotonin reuptake inhibitor (SSRI) for adolescents, to treat the major depressive disorder. The ADHD will probably resolve as it was most likely the result of being "stoned" all the time and therefore leaving the patient unable to concentrate and suffering from amotivational syndrome.|
|E3.||Treat the ADHD first. Her subsequent demoralization and difficulties in school most likely were the etiology of the major depressive disorder and the substance abuse. If she continues to have symptoms once the ADHD is controlled, then treat the major depressive disorder and substance abuse concurrently.|
|E4.||Use the regular formulation of methylphenidate or amphetamine to treat the ADHD as this is the most likely therapy to help the patient's ADHD symptoms. It will also lift her mood as she will have more energy and not feel the need to self-medicate with marijuana.|
|E5.||Once the substance abuse has been treated, begin with either long-acting methylphenidate or amphetamine as these are not easily abused. Alternatively begin with bupropion which, although considered a third-line treatment for ADHD, will also help with depressive symptoms.|
|A1.||−5 Although the diagnosis of ADHD may be correct, this patient has symptoms that suggest a variety of other diagnoses (see Decision Point C). The patient's story is complicated, and she is only mildly cooperative during the interview. Because of their patients' developmental age and minor status, child and adolescent psychiatrists must make every effort to gather collateral information in addition to further exploration of the patient's psychiatric, developmental, academic, familial, medical, social, and personal histories. This would not be good practice with an adult who presented in such a fashion.|
|A2.||−3 Although the diagnosis of ADHD may be correct and your thoughts about a presumptive diagnosis of depression may represent a greater perspective than that suggested by answer A1, the mood symptoms may be related to other factors. In addition, because of their patients' developmental age and minor status, child and adolescent psychiatrists must also make every effort to gather collateral information in addition to further exploration of the patient's psychiatric, developmental, academic, familial, medical, social, and personal histories.|
|A3.||+3 Although you are not skeptical about the diagnosis of ADHD given the prior diagnosis at age 10, her positive response to ADHD medication, and a strong likelihood of familial genetic loading for ADHD, this answer suggests that your thinking has some basis in evidence. Numerous studies are highly suggestive of a heritable component to ADHD. However, ADHD is a clinical diagnosis, and it is not wise to base a diagnosis upon response to a specific treatment. You do note the possibility of a substance abuse issue by asking for a urine toxicology screen, and you are searching for any possible medical reasons for her symptoms. You have not made up your mind about other possible diagnoses, and ask the father to return for further evaluation. However, it is imperative to get collaborative reports of the patient's behaviors and symptoms from other stakeholders given the poor cooperation of the patient and only the father's perspective on a family situation that is clearly chaotic and may be, at the very least, exacerbating her symptoms, especially because she mentions her own anger concerning her father's decision to invite his girlfriend to live in the family home while the biological mother lived upstairs.|
|A4.||+3 By being skeptical about the prior diagnosis of ADHD, considering a mood disorder, and seeking to further verify these diagnoses by obtaining collateral information from parents and teachers, including the use of metrics, your evaluation is proceeding in a more appropriate and effective manner. However, this answer does not include other important aspects of a full diagnostic evaluation, such as the patient's psychiatric, developmental, academic, familial, medical, social, and personal histories.|
|A5.||+5 You remain skeptical about all diagnoses and make efforts to obtain further information, both from the patient, her father, and other stakeholders. You also ask for metrics to help assess the overall picture and create a baseline measurement to which you can later compare results once treatment is initiated. Finally, you attempt to rule out medical causes of her symptoms as well as laboratory proof of substance abuse. This is the most thorough of the choices offered.|
Generally, studies have repeatedly demonstrated that the greatest likelihood of success for the individual patient in the treatment of substance abuse disorders is seen when family and peers are involved. Of concern, of course, is maintaining the therapeutic alliance with the patient so that there is trust and open communication between patient and doctor. In this particular patient, you have not yet determined whether there is a significant substance abuse problem. As a result, clinicians are divided regarding whether to share this sensitive information immediately with the patient's caregivers or to wait until it is determined whether the substance abuse is significant enough to warrant specific treatment. Many worry that if the therapeutic alliance is broken so easily and quickly before the substance abuse issue is substantiated, any treatment will be compromised, whether it is for the alleged substance abuse, major depressive disorder, ADHD, or other diagnoses. On the other hand, it can be argued that "nipping it in the bud" by addressing the potential for substance abuse with involvement of the family immediately will yield a greater degree of patient safety, as well as treatment of the comorbidities.
Regarding drug-testing of minors, laws can differ from state to state. For the past 50 years, laws have been changed to allow for minors to obtain treatment without parental consent for specific concerns such as sexually transmitted diseases, alcohol and substance abuse treatment, mental health care, and contraception. The clinician should clarify the limits of these rights as some states mandate reporting, whereas others prohibit it. Some states allow for treatment of alcohol-related disorders while insisting on parental consent for other substances.
|B1.||−1 As stated above, many clinicians will feel obligated to involve the family from the start, even if the substance abuse has not been substantiated, because of the risks involved. However, given that you just met this patient, it would be wise to establish a better rapport with the patient to pave the way for her acceptance of your "need" to break this confidence.|
|B2.||−1 For the same reasons as stated in answer B1, if you wish to involve the patient's family immediately, the rapport described in the vignette thus far is not sufficient given the unsubstantiated and unexplored diagnosis of actual substance abuse.|
|B3.||−5 This is not true. Although most information shared in the doctor-patient relationship may not be disclosed, specific concerns are not considered confidential. For example, if the patient admits to engaging in dangerous behaviors, threatening suicide or homicide, she is a minor, and her parents should be informed. If she is threatening homicide, you have a "duty to protect" the intended victim according to the Tarasoff ruling.|
|B4.||+3 Although this is true, because she is a minor, dangerous behaviors should be shared with her parents to help with treatment. This point should be explained in a way that does not prompt the patient to deliberately withhold information for fear of parental or legal reprisals. As stated in the first two answers in Decision Point B, the establishment of a strong therapeutic alliance and solid rapport will aide in delivering this information without compromising the patient's likelihood of sharing sensitive material.|
|B5.||+3 Given that you do not yet know the extent of her substance abuse, further exploration of her use of illicit substances will help you develop a clearer clinical picture and give the 15-year-old patient incentive to maintain abstinence before you share the information with her parents. This approach may prove therapeutic and allow for the clinician to maintain the alliance should the patient prove unable to maintain abstinence per their agreement In some parts of the country, especially in California, there is a movement toward a harm reduction approach, in which the clinician meets the patient where he or she is in terms of the abuse and uses motivational interviewing techniques to help him or her see the substance abuse as a problem.|
|B6.||+1 Further evaluation of the substance use will determine the severity of the problem. If the patient's abuse of substances is significant, this constitutes risky and dangerous behavior. It is then up to the clinician to decide whether to break confidence and involve the family or to allow the patient to volunteer for treatment. Two important caveats are as follows. The particular state that the patient lives in may allow for her to seek treatment for substance abuse without prior parental consent, so breaking this confidence could undermine any further treatment for her possible comorbid diagnoses. Depending on the patient's domestic situation, involvement of the family in the treatment of substance abuse has been demonstrated to be more effective than allowing the patient to manage this problem on her own.|
|B7.||+5 This answer allows the patient to feel as though she is collaborating with you to maintain sobriety. The approach is amenable to further development of a solid rapport and therapeutic relationship but leaves open the possibility that her parents may become involved specifically in the issue of her substance abuse if she is unable to address the problem on her own. It also includes useful psycho-education about the potential benefits of involving her family in this treatment. Your discussions with her school faculty have been focused on her behavior and academic performance.|
Attention Deficit-Hyperactivity Disorder, Inattentive Type: +2.
This patient is disorganized, is unable to sustain attention, does not seem to listen when spoken to directly, is not completing her academic work, often either leaves her book bag at home or forgets to take it home from school, refuses to participate in academic activities that require attention, seems internally preoccupied, and is often forgetful in daily activity. She subsequently meets the criteria for the inattentive aspect of ADHD at school, and her father's reports suggest similar impairments at home.
Attention Deficit-Hyperactivity Disorder, Combined Type: -2.
She does not meet criteria for hyperactivity or impulsivity. Her disruptive behaviors are more likely explained by oppositional defiant disorder.
Depressive Disorder, Not Otherwise Specified: +2.
The patient endorses anhedonia, sleep disturbance, difficulty with concentration, and irritability. Subsequently, at this early stage in your evaluation, she does not meet the criteria for a major depressive disorder or episode. Some of her answers are ambivalent, leaving open the question of whether she has a dysthymic disorder or suffered a major depressive episode 1 year ago when she ingested 8—10 headache tablets. Further evaluation may help establish one or both of these diagnoses.
As stated in the explanation for Depressive D/O, NOS, further evaluation of the patient's symptoms and time course will help determine whether she meets criteria for a Dysthymic D/O. She may have had a Major Depressive Episode on top of a preexisting Dysthymia, when considering her intentional ingestion of Tylenol one year ago. For children and adolescents, the criteria requires symptoms lasting at least one year, instead of the two years required for this diagnosis in adults.
Oppositional Defiant Disorder: +2.
Information from teacher and school psychologist, reports from her father, and her behavior in your office all suggest a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which she often loses her temper, argues with adults, refuses to comply with adults' requests or rules, blames others for her mistakes or misbehavior, is easily annoyed by others, seems irritable, and is angry and resentful. These behaviors have caused her to be close to expulsion by her school despite her ability to perform academically, and it is not apparent that these criteria were met specifically during a mood disorder.
This patient does not meet the criteria for conduct disorder, which requires three or more of the following criteria in the past 12 month with at least 1 criterion present in the past 6 months: aggression to people and animals; destruction of property; deceitfulness or theft; or serious violations of rules.
Rule out Cannabis Abuse: -2.
The patient has intimated that she may have used marijuana by asking if you intend to tell her father. She has not admitted to using marijuana and you do not have results of a urine toxicology screen. Both ADHD and depression both have strong links to comorbid substance abuse, so this issue requires further evaluation.
Rule out Substance-Induced Mood Disorder: +2.
Until you have established the severity of the patient's cannabis use, you must entertain the possibility that her current symptoms are subsequent to this use. This patient certainly has severe psychosocial stressors, including the possibility of her expulsion from school, interpersonal conflicts with family members, loss of friendships, and a chaotic home environment. However, given the limited history you have obtained thus far, it is difficult to determine how resilient this patient may be to the psychosocial stressors versus the effects of a possible substance abuse problem. Determining this will affect your treatment strategy.
Rule out Bipolar Disorder: +2.
This patient exhibits an irritable mood and mild grandiosity, belittling her classmates and teachers as not being as intelligent as she is. However, her self-esteem does not appear to be overly inflated, especially as she is known to be intelligent and talented and since the first grade been in gifted academic programs. She does not describe a decreased need for sleep, but a reversal of her days and nights. She easily falls asleep in your office, the waiting room, and in school. The cardinal symptoms of pediatric mania, as described by researchers, including Robins, Guze, and Staton et al., in an attempt to differentiate true mania from ADHD by looking past the more nonspecific symptom of irritability, focus more on extreme forms of grandiosity, elation, and racing thoughts. This patient does not describe racing thoughts, nor does she describe any of the other bipolar disorder-specific symptoms. She is easily distracted, but her symptoms seem more related to ADHD and depressive symptoms. However, a link between ADHD as a risk factor for mania has been suggested by several researchers so ruling this out by taking further history, especially from collateral informants, is important. If you do determine she has mood bipolarity, this will affect your choice of pharmacotherapy.
Major Depressive Disorder: -2.
Given the ambivalence of the patient's description of her mood, the reference to an intentional ingestion of 8—10 headache tablets in the context of a fight with her mother, and your suspicion that she has at least four of the five criteria currently for a major depressive disorder, you may find she qualifies for major depressive episode, severe without psychotic features, in full remission. Currently, however, she does not meet the criteria as explained above under depressive disorder, not otherwise specified.
Rule out Anxiety Disorder, Not Otherwise Specified: -2.
Although a link between ADHD and anxiety disorders has been demonstrated in the literature, this patient does not describe nor exhibit symptoms of panic disorder, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, acute stress disorder, or generalized anxiety disorder. Unless you uncover symptoms of any of these anxiety disorders during further evaluation, at this point in she does not qualify even for a rule-out diagnosis.
To meet the criteria for an adjustment disorder, this patient must have developed her symptoms within 3 months of the onset of a stressor. According to the patient's father, she learned only in the past 2 weeks of the possibility of her expulsion from school. Other psychosocial stressors that have been described by both the father and the patient have been ongoing.
Strong Cluster B Traits: -2.
The difference between "traits" and a "disorder" typically implies an enduring character-logic pattern that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Diagnosing a personality disorder in an adolescent or child is fraught with controversy and can cause irreparable damage to the patient by virtue of labeling, both from the patient's personal experience and by the preconceived notions of others including clinicians. According to the DSM IV TR's strict criteria, personality disorder categories may be applied to children or adolescents in those relatively unusual instances in which the individuals particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular axis I illness. To diagnose a personality disorder in an individual under age 18, the features must have been present for at least one year. All people have personalities, and many have specific traits that can be understood as the individual's adaptive or maladaptive behavioral patterns. This patient exhibits some traits that are nonspecific but tied to a personality disorder, such as impulsivity and irritability in antisocial personality disorder. However, she clearly does not meet the criteria for this much more serious disorder, which is the one personality disorder that cannot be diagnosed until age 18.
Rule out Borderline Personality Disorder: -2.
She describes losing her friends or being picked on, which may suggest a pattern of unstable interpersonal relationships. She continues to engage in self-injurious behavior, namely cutting. Her affect during your interviews features a rapid movement from what seems like an isolation of affect to marked reactivity, suggestive of borderline personality disorder, although these mood shifts are very transient, not meeting the criterion of lasting a few hours to a few days. Additionally, this patient's maladaptive coping strategies may be more temporary, related primarily to Axis I diagnoses plus living in a dysfunctional family environmental and being part of a highly demanding academic setting. According to strict DSM-IV-TR criteria, it is considered premature to ascribe personality disorders to adolescents as their personalities or character structures are still undergoing major, dynamic evolution.
Rule out Histrionic Personality Disorder: -2.
She dresses in an inimical style that she may use to attract attention to herself, suggesting a histrionic personality disorder; however, she is also known to be artistic, and the style is not considered provocative or sexually seductive.
Rule-Out Narcissistic Personality Disorder: -2.
Her admissions that she is smart and talented, more so than her peers or teachers, that no one understands her, and that she may behave as she likes despite the rules of the school suggesting a sense of entitlement, plus her arrogant, haughty behaviors indicate a narcissistic personality disorder. However these behaviors and attitudes may also be at least partially explained by oppositional defiant disorder at this stage in her development. Therefore, although it may be true this patient is developing the maladaptive aspects of a narcissistic personality structure, it is too early to make such a diagnosis or even a rule out.
Rule out Schizoid Personality Disorder: -2.
She has not described any sexual interests, but you have not explored this area yet. She does not have friends but has had friends in the past. If she felt better, it is likely that she would wish for more social interaction. She chooses solitary activities, but this choice is better described by depressive symptoms than by a personality disorder. Finally, although she admits to being anhedonic, this is not the same as the criterion of taking pleasure in few, if any, activities associated with schizoid personality disorder.
|D1.___||+2 Long-term psychosocial impairment. Studies have demonstrated an increased occurrence of impaired functioning in work, social, and family life.|
|D2.___||+2 Suicide. Clinical outcomes of patients with adolescent-onset major depressive disorder into adulthood compared with control subjects without psychiatric illness include a high rate of suicide (7.7%), a fivefold increased risk for first suicide attempt, and a twofold increased risk of major depressive disorder.|
|D3.___||+2 Psychiatric hospitalization. Studies have demonstrated an increased occurrence of psychiatric and medical hospitalization.|
|D4.___||+2 Chronic course. Given the high risk of comorbidity between ADHD and major depressive disorder and the significant impairments associated with each individual disorder, the severity of the major depressive disorder in the context of ADHD has a higher likelihood of ongoing morbidity and disability, as well as poor long-term prognosis.|
|D5.___||+2 Major depression. Recent studies have demonstrated a range of a 2- to 5.1-fold increase in the development of major depressive disorder compared with that for control subjects, after controlling for comorbid conditions. This finding is considered to be of greater significance in adolescent than in adult females. The major depressive disorder was found to be more severe, causing greater impairment and increased suicidality.|
|D6.___||+2 Mania. Several new studies have documented robust associations between ADHD, bipolar disorder, and conduct disorder in this population.|
|D7.___||+2 Oppositional defiant disorder. Continuity from one diagnosis to another (heterotypic) has been shown to be significant from depression to anxiety and anxiety to depression, from ADHD to oppositional defiant disorder, and from anxiety and conduct disorder to substance abuse. Girls are overrepresented in the heterotypic subset compared with boys.|
|D8.___||+2 Conduct disorder. ADHD in adolescent females has been associated with significant increase in risk for conduct disorder, independent of major depressive disorder.|
|D9.___||+2 Illicit drug use/abuse. Adolescents with major depressive disorder and untreated ADHD have been shown by several studies to have a greater risk of developing substance abuse disorders and, more significantly, alcohol-related disorders. However, it should be noted that one new study (Biederman, et al) demonstrated that there is no evidence of psychostimulant treatment for ADHD having a protective effect against the development of substance abuse disorders into adulthood. Subsequently, more studies are warranted, especially those that examine female youth, before we conclude there is no protective effect.|
|D10.___||+2 Anxiety disorders. Newer studies have demonstrated a significant association between major depressive disorder and increased risk for anxiety disorders. Continuity from one diagnosis to another (heterotypic) has been shown to be significant from depression to anxiety and anxiety to depression, from ADHD to oppositional defiant disorder, and from anxiety and conduct disorder to substance abuse. Girls are overrepresented in the heterotypic subset compared with boys.|
In general, before you can begin treating the ADHD or the major depressive disorder, you must first determine the severity of this patient's use or abuse of cannabis. You also need to further explore the magnitude and extent of the patient's mood symptoms and reevaluate the patient's diagnosis of ADHD. Given that there are multiple layers of pathological conditions in this patient, including a presumptive diagnosis of ADHD, it is necessary to further evaluate possible risky behaviors or abuse of other substances. Although the patient presents with some neurovegetative symptoms of depression such as anhedonia, sleep disturbance, appetite disturbance, and irritability (specific symptoms for depression in children and adolescents), these symptoms may also be explained by the abuse of marijuana or the diagnosis of ADHD. Address the abuse of marijuana using motivational interviewing (MI), cognitive behavioral therapy, and, if possible, family therapy (FT). MI has been shown to be very effective in helping patients overcome any ambivalence they may have about their substance use and is used to help foment a determination by patients to overcome the abuse or addiction. CBT, especially in combination with SSRIs has been shown to have the most significant impact upon more severe forms of depression if added after the SSRI is initiated during the acute phase. Patients were less able to benefit from psychotherapy while suffering from the worst of the depressive symptoms.
FT is typically underused in treatments because of difficulties in initiating such treatment with families and ongoing compliance if treatment has started or because the family itself is so fragmented and/or chaotic that bringing members in for treatment of the "identified patient" seems impossible. However, it has been demonstrated that a child's presentation is heavily influenced by environmental factors, specifically those within the family. From a diagnostic perspective, simply having the opportunity to explore the variety of family factors, including parental styles, patterns of interaction, and family dynamics, through direct observation will yield a more comprehensive and valuable understanding of the etiology of the child's presentation. Moreover, the opportunity to help the family reorganize what may be (and in the case of this child is) a maladaptive and dysfunctional multipersonal system that is focused on the individual patient will enable the family to reduce as much as possible the variety of individual systems whose function worsens the individual patient's psychopathology and reinforces negative and impaired familial function. In other words, helping the child to overcome his or her illness is of limited utility if he or she returns to the toxic environment that helped create or exacerbate it. In this particular case, family therapy could prove to be immensely challenging but possibly have the greatest impact if the family agrees to enter into this therapy.
If one wishes to initiate treatment of the ADHD, use of a long-acting stimulant formulation of methylphenidate, which cannot be abused owing to its unique pill construction, or the extended release formulations of amphetamine or methylphenidate, which have a lower potential likelihood of abuse, is recommended. Alternatively, if the patient does not have a seizure disorder, a history of clinically significant head trauma, or an eating disorder, a trial of bupropion because it treats the ADHD as well as depressive symptoms or atomoxetine because of its low potential for abuse may be useful.
Subsequently, numerous options are possible, including approaching each problem simultaneously. It is often difficult to sequence treatments in patients such as this one. In this particular patient, because we are still missing a lot of significant information that will influence treatment, we can attempt to parse out our approach according to what we do know, as follows:
|E1.||+3 Treat the substance abuse first, then the major depressive disorder, and then the ADHD.|
|E2.||+3 Although sobriety may not be a useful endpoint, the patient's substance abuse is probably contributing to her mood symptoms. If the mood symptoms did not precede the substance abuse and in this patient this is unlikely, initiation of fluoxetine, the best studied SSRI for adolescents to treat the major depressive disorder is a good first step. Concurrent treatment of the ADHD while a patient is actively abusing marijuana has been demonstrated to have little impact on either the addiction or the ADHD unless the addiction is addressed first. Once the substance use has been addressed, rapid commencement of treatment of the ADHD is more effective. Whether the ADHD will probably resolve as it was most likely the result of being "stoned" all the time and therefore leaving the patient unable to concentrate and suffering from amotivational syndrome is a questionable assumption.|
|E3.||+3 If the ADHD is shown to be the cause of demoralization, academic failure, or other reasons for "self-medication," concurrent treatment of both the substance abuse and the ADHD may be most effective. Use of pharmacological agents without strong abuse potential for the treatment of ADHD, such as bupropion (assuming no history of significant head trauma or seizure disorder) or atomoxetine, is typically well tolerated, even in the context of abuse of marijuana. Bupropion has been demonstrated to be effective in the treatment of ADHD in adolescents with ADHD and depression or mood disorders and substance abuse. Another more recent pharmacological intervention is the use of modafinil, although the literature on the use of this agent is lacking.|
|E4.||−5 The regular formulations of psychostimulants, including methylphenidate and amphetamine, are easily and commonly crushed, snorted, or otherwise ingested with the intention of substance abuse. In a patient with a substance abuse disorder, this will only contribute to the problem.|
|E5.||+3 For the same reasons as described above, these treatments are acceptable.|