Assessment and Diagnosis of Tommy: Exploring Neurodevelopmental and Disruptive Disorders

QUESTION

Tommy has recently turned nine years old and has been brought in for a psychological evaluation in the middle of third grade.

He lives with his mother and younger sister, age 6. His parents divorced three years ago. At first his dad visited him and his sister every month, but now he only comes to see them once or twice a year, even though he only lives and hour or so away.

Tommy’s mom describes him as angry and states that at home he has a great deal of trouble following instructions. He leaves his toys all over the house and he is constantly running around. He often does not seem to listen no matter how much his mother tells him to be careful. He sprained his wrist a year ago when he attempted to climb up the stairs using the banister instead of the stairs. He typically resists all direction and guidance in that he often yells and screams in response to being asked to complete even the most basic tasks such as brushing his teeth or putting on his shoes. He also often fights with his younger sister, occasionally to the point of injuring her. His mother reports that timeouts are ineffectual, because he rarely sits still long enough to be in them. She finds herself becoming easily frustrated with Tommy, and she admits that sometimes she raises her voice with him. She states that he often yells and swears at her in return. She has to work long hours to financially support her children, and she often does not pick them up from their after school program until 6 o’clock in the evening. Once when she was extremely late picking them up, Tommy poured an entire bottle of nail polish in her purse later that evening.

Tommy’s third grade teacher finds him incredibly difficult to teach. He often gets up out of his seat during class, blurts out answers, and has trouble taking turns. During class he seems to not listen to her instructions, and he is often disorganized in his work. He also very easily loses track of what he’s working on, and his teacher finds it very hard to keep him on task. When he does attempt to complete his work, he rushes through it and makes mistakes that he could easily avoid making if he took his time on the assignment. Tommy is quick to become frustrated and angry when he does not get what he wants, and for that reason he has great difficulty making or keeping friends among his classmates. At one time when arguing with another student over his place in line, he jabbed the other boy with a pencil and was sent home from school.

In his after-school program, he prefers the unstructured, outdoor activities where he can do a lot of running around. He has a much harder time when he has to be inside and sit still for snacks, stories, or songs. Instead of singing the song everyone else is singing, he often tries to sing a different one. One day another child told him to stop and he bit her. He blamed the other child for biting him first, yet none of the staff or children in the room saw that child bite him. Tommy did have any bite marks or physical injuries like the other child did. His mother was given a warning that if he again injures another child, he risks being removed from the program permanently.

During the evaluation Tommy squirmed in his seat incessantly. He verbalized few emotions, but he appeared visibly angry when asked about the absence of his father, his lack of friends, and his difficulty at school and home. He stated that the interview was “dumb” and was minimally cooperative. The psychologist had to incentivize his participation by allowing him to earn minutes of playtime for a fun video game that she had in her office for just such occasions. While he did engage with her more in order to earn video game time, he would not keep working on a task for very long and seemed to lose focus easily. When she asked him to complete a sequence of steps for a task, he could only complete one or two before stopping due to forgetting the remaining steps. When he spoke, he often provided incorrect or opposite answers to obvious questions. For example, when asked the opposite of cold, he stated, “colder.” When he was asked to draw a picture of his life, he just quickly rushed to draw scribbles in red crayon all over the paper. He frequently expressed a desire to go home. When asked what he would like to do when he got home, he stated, “fight with my sister.”

CASE DISCUSSION QUESTIONS

Use the DSM-5 and information from the case study to answer the following questions in your discussion on neurodevelopmental and disruptive and impulse control disorders.

Identify and discuss three similarities and differences between attention deficit hyperactivity disorder and oppositional defiant disorder.

Formulate a diagnostic impression for Tommy with coding and specifiers from the DSM-5. Explain your answer in terms of how he meets diagnostic criteria for the disorder or disorders that you gave.

What are one or two differential diagnoses that you considered for Tommy and what helped you to rule them out?

What diagnosis or diagnoses would you diagnose Tommy with? Discuss your diagnosis or diagnoses by specifically detailing how his behavioral and cognitive symptoms for each diagnosis meet the diagnostic criteria.

Why is it important to refer clients to a psychiatrist or nurse practitioner for a medication evaluation instead of making one yourself?

Using 1-2 scholarly sources, how would Tommy’s behavior be responded to in a school setting depending on his racial identity?

If you were a therapist in this case, what therapeutic modality would you use to treat his disorder, such as psychodynamic, cognitive, behavioral, cognitive-behavioral, systems, person-centered? Use 1-2 scholarly sources to support your answer.  If you have not taken a theories course, choose one theory from the above list and summary the articles.

ANSWER

Assessment and Diagnosis of Tommy: Exploring Neurodevelopmental and Disruptive Disorders

Introduction

This case study revolves around Tommy, a nine-year-old boy presenting with challenging behaviors and difficulties in various settings. Using the DSM-5 diagnostic criteria and information provided, this essay aims to analyze and discuss the similarities and differences between Attention Deficit Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD). It will also formulate a diagnostic impression for Tommy, consider differential diagnoses, and discuss the importance of referral for a medication evaluation. Furthermore, we will explore how Tommy’s behavior may be influenced by his racial identity in a school setting and identify an appropriate therapeutic modality for his treatment.

 Similarities and Differences between ADHD and ODD

Similarities

 Impulsivity: Both ADHD and ODD may involve impulsive behaviors, such as Tommy’s difficulty following instructions and frequent outbursts.
 Emotional Dysregulation: Both disorders can manifest with emotional dysregulation, as seen in Tommy’s anger, frustration, and difficulties managing emotions.
Interpersonal Difficulties: Both ADHD and ODD may lead to challenges in interpersonal relationships, as observed in Tommy’s conflicts with his mother, sister, and peers.

 Differences

Attention and Hyperactivity: ADHD primarily involves attention deficits and hyperactivity, while ODD is characterized by oppositional and defiant behaviors.
Rule Violation: ODD specifically includes a pattern of negative, defiant, and hostile behaviors towards authority figures, whereas ADHD focuses more on inattentiveness and hyperactivity.
 Persistence of Symptoms: ODD tends to be more persistent over time, whereas ADHD symptoms may fluctuate or change with age.

Diagnostic Impression for Tommy

Based on the provided information, a preliminary diagnostic impression for Tommy is Oppositional Defiant Disorder (ODD) with comorbid symptoms of ADHD. This diagnosis is supported by his chronic patterns of defiance, aggression, and difficulty following instructions, which align with the DSM-5 criteria for ODD. Additionally, his impulsivity, inattentiveness, and hyperactive behaviors are suggestive of comorbid ADHD.

Differential Diagnoses

Two differential diagnoses that could be considered for Tommy are Conduct Disorder (CD) and Disruptive Mood Dysregulation Disorder (DMDD). However, CD is ruled out as Tommy’s behaviors do not involve significant violations of basic rights or aggression towards people or animals. DMDD is unlikely as Tommy does not exhibit chronic irritability and temper outbursts as required for the diagnosis.

Diagnosis for Tommy

Tommy’s diagnosis would include:
Oppositional Defiant Disorder (ODD) (DSM-5 code: 313.81): He exhibits a pattern of angry, irritable, and defiant behaviors towards authority figures.
 Attention-Deficit/Hyperactivity Disorder (Combined Presentation) (DSM-5 code: 314.01): Tommy’s impulsivity, hyperactivity, and inattentiveness align with ADHD criteria.

Importance of Referral for Medication Evaluation

Referring clients to a psychiatrist or nurse practitioner for a medication evaluation is crucial because they are specialized in psychopharmacology and can assess the need for medication intervention. Professionals in this field have the expertise to evaluate the potential benefits, risks, and appropriate dosage of medications, ensuring comprehensive treatment planning for individuals like Tommy.

Response to Tommy’s Behavior in a School Setting and Racial Identity

In a school setting, responses to Tommy’s behavior should be equitable and unbiased, regardless of his racial identity. School personnel should prioritize understanding and addressing the underlying behavioral challenges rather than making assumptions based on race. Culturally responsive interventions and practices should be employed to promote inclusivity and address the unique needs of individuals from diverse backgrounds.

Therapeutic Modality for Treatment

Cognitive-Behavioral Therapy (CBT) would be an appropriate therapeutic modality for Tommy’s treatment. CBT can help him recognize and modify maladaptive thought patterns, develop problem-solving skills, manage emotions, and improve impulse control. Additionally, CBT can address the underlying cognitive and behavioral factors contributing to his difficulties, empowering him to make positive changes in his interactions and overall functioning.

Conclusion

Tommy’s case highlights the complex nature of neurodevelopmental and disruptive disorders. By considering the similarities and differences between ADHD and ODD, formulating a diagnostic impression, exploring differential diagnoses, and understanding the importance of referral for medication evaluation, professionals can provide comprehensive assessments and interventions. By promoting cultural sensitivity in school settings and utilizing appropriate therapeutic modalities such as CBT, Tommy’s behavioral challenges can be addressed effectively, enhancing his overall well-being and functioning.