The presenting concern is that Ayna is easily distracted

The presenting concern is that Ayna is easily distracted, Ayna is easily distracted, relies on her family has trouble making decision, and eats less. Ayna fells overwhelmed and anxious, tens and moody. She also has repetitive behaviors, compulsions, fear, and distress associated with obsessions. In the case of Ayna there is no surgeries, accidents, illnesses or pregnancies. Ayna has a long history of poor school performance due to numerous challenges. Despite extensive private tutoring and accommodations from her school, she has failed to succeed academically. The contributing factors include poor school work, possible attention and learning problems, and complex family dynamics. The reason for the referral assessment is Ayna’s decreased need for sleep, distractibility, being overly restless, not being tired, and having an unrealistic belief in her abilities. Ayna is also genetically predisposed to Bipolar disorder which tends to run in families. Ayna has not been hospitalized for counseling, but she is under intensive psychological treatment. Ayna’s present circumstance is that she is failing school, but still attending. Ayna is active in playing tennis but isolate herself from family and friends. Her family is her social support. She is good in artistic projects.
Ayna at age three she was diagnosed as oppositional defiant disorder which has been applied, no treatment was given but Ayna was referred for evaluation. At age four Ayna experienced problem with asthma, sinus infection and frequently complained of being cold and tired. Night terrors, is regular occurrence by the time she become five and she had difficult time making friends, this was implicated to the parent pending divorce but then the divorce become official, Ayna’s father become sole custodian. Ayna paternal grandparents parent took care of Ayna .they were ill to deal with Ayna behavioral issue.
Ayna was first diagnosed as having ADHD at age of 7 in second grade Methylphenidate was prescribed and give to her the impression was that it was quite helpful, although the does frequently needed to be increased in order to maintain its success.in the other hand Obsessive-compulsive disorder (OCD) indications also became more apparent during this time, there was a significant and unreasonable distractions present. Ayna father and the stepmother were concerned that the behaviors that Ayna represents are something more than just ADHD, they attributed with developmental delays to family and life stressors.
Ayna experience hallucinations, Ayna frequently seemed to have difficulty engaging in meaningful conversation. Despite have what seemed to appear to be an above average intelligence, Ayna had problems with concentration which continued to hinder her ability to complete homework assignments. Ayna denies any suicidal or homicidal ideation. Ayna is small but well nourished, her hygiene is adequate; she looks younger that her stated age. She is cooperative and reliable for this evaluation. Ayna mood was anxious, her thought processing was not focused, She seemed confused, her thoughts were not content, and there is little auditory or visual expression. There were some auditory and visual delusions. She complains of chronic poor sleep. As for cognition, she was alert and fully oriented. Her gross memory functions were intact but slow in processing. Her IQ appeared to be above average, and her insights and judgment appeared to be intact.
Behavior observations: Ayna has established rapport and was open and forthcoming about the struggles she had. Ayna was evaluated over a period of two hours. She is motivated to perform tasks and she fails to show signs of resistance, but she is hyperactive, distractible, has physical fatigue, emotional hallucinations and cognitive problems. She struggles to carry conversations even though Ayna has an above average intelligence.
Ayna is an 11-year-old girl who enjoys art activities, and tennis, she does not like cooking or large crowds. She likes art activities and has a good sense of humor, but she can also be irritable. She is fearful around new people and may become quiet and more reserved in those situations. Her parents and teachers talk her through exposure to new people. Ayna is highly verbal and speaks in sentences. Ayna is above her grade level in reading. She enjoys reading, and her favorite books are Greek Mythology. According to Ayna, she dislikes writing. Most of her writing is simple sentences, which has a great deal of grammatical errors and little detail. She also struggles with math, which she is approximately at a second grade level. She has recently learned how to play tennis with her left hand. Ayna has a medical diagnosis of childhood-onset bipolar disorder and an educational classification of severe emotional and behavioral disorder. She takes medication for bipolar disorder on a daily basis. She is currently on a new medication because of her increasing erratic behavior. Ayna has a new baby brother who is five months old.
Ayna is behavior has been increasingly disruptive the past few months. She has verbal outbursts and pushes classroom materials onto the floor after being given an academic task during quiet work time. Her verbal outbursts include yelling that she is not doing the assignment, telling a student to shut up, using profanity, and calling student names. Her teachers feel that they spend about an hour per day dealing with the behavior, and they usually respond to Ayna’s behavior by cautioning her or by initiating an office referral. Ayna attends a regular K-5 public elementary school. Ayna is new to the school. Ayna is in the 5th grade. There are nineteen students in her classroom. Ayna has two segments in a resource track running class with five other students. Ayna also has one co-teaching segment for math. Her teacher is very organized and structured. She is loving and understanding with regards to Ayna’s needs. Ayna has attended the school for two months now. Initially, she seemed to adjust to the new school well. However, things have gotten more difficult for her lately. Ayna’s teacher set up some rewards for her to earn if she does not engage in the disruptive behavior. Her behavior has not improved, and it has been difficult for her team to identify why she is engaging in such behavior. There is not a consensus among her team that the rewards are an appropriate intervention for her disruptive behavior. Her team agreed that they should conduct an Functional Behavior Assessment (FBA) and develop a Behavioral intervention Plan (BIP).
Ayna was born by cesarean section at approximately 36 weeks’ gestation with a birth weight of 6 lb 2 oz. Although her mother had adequate prenatal care, it is possible that Ayna was exposed to alcohol, marijuana, narcotics, and/or benzodiazepines in utero. Little family history is know on the mother side, but it is known that both Ayna’s mother and maternal grandmother were diagnosed with bipolar disorder. Prior to and after Ayna’s birth, her mother had been on and off treatment with multiple medications and struggled with substance abuse, severe depression, and suicidal ideation. For the first five years of her life, Ayna lived with both of her biological parents, who were involved in a strained relationship. Her mother’s refusal to take medication during this time, the relationship has been coupled with a labile personality led to inappropriate behaviors, many of them perhaps witnessed and subsequently mimicked by Ayna. As early as eighteen months of age, Ayna’s pediatrician noted her to be “difficult to discipline.” She was being raised primarily at that time by her paternal grandparents, who described her behavior as “hyper” and noted an erratic sleep pattern. By the time Ayna was three years old, the diagnosis of oppositional defiant disorder had been applied, although no medications were prescribed, and the patient was not referred for psychiatric evaluation. Ayna has not done drugs and Ayna is not doing drugs at his time. She neither uses tobacco nor caffeine.
So far, the information given on Ayna’s aunt and her maternal grandmother is that they have been diagnosed with bipolar disorder. Ayna’s birth mother had been on and off treatment with numerous prescriptions drugs and problems with substance abuse, difficult depression and has had a suicidal attempt. The parents struggle to deal constructively with Ayna’s behavior at home during this time period, which demanded a significant investment of time, energy, and economic incomes. Ayna older stepsisters assisted in regular after-school care in order to continue the arrangement vital for her to finish her school work. Ayna’s father decide to suspended an advancement with his company in order not to move to a new place, and her stepmother took off time away from work with no pay using the Family and Medical Leave Act to participate in regularly meeting with Ayna’s teachers and on some medical visits.
Children with a family history of bipolar disorder are about twice as likely as others to develop the illness, and a family history of early onset suggests an even greater risk. Earlier age at onset of mood disorders in general has been associated with an increased likelihood of switching from childhood major depressive disorder to mania. In DSM-V, Attention-Deficit/Hyperactivity Disorder and a Manic Episode are both characterized by excessive activity, impulsive behavior, poor judgment, and denial of problems. ADHD is described, however, as being chronic rather than episodic and more consistent in presentation over time. While ADHD is said to appear an earlier age at onset than bipolar disorder, there is evidence to suggest that ADHD may lower the age at onset for comorbid bipolar disorder. Given the variability and lack of specificity regarding symptom patterns for childhood bipolar disorder, it has been suggested that the core feature of bipolar disorder in this population is mood lability or fluctuation in mode state.
It is hard to diagnosis adolescents for bipolar. The common signs of childhood bipolar disorder are often concealed symptoms. The diagnosis in psychiatry is often challenging. Lab test is not available for adolescent, and the experience of each person with illness is different. Doctors trust self-reporting data on symptoms reported by clients, family history, the clinical progression of the disorder, and observable behavior. The American Psychiatric Association (APA) has recognized and defined the maximum diagnostic criteria in the fifth edition of The Diagnostic and Statistical Manual of Mental Disorder, commonly referred to as the DSM- V. The DSM- V is still under development, is and aimed to coordinating the diagnoses of mental disorders. The DSM-IV and DSM -V has divided mood disorders into depressive disorder and bipolar disorder. While children are not mentioned, they are basically still diagnosed according to the criteria for adults, and this can be where part of the problem in receiving a correct diagnosis begins.
The two diagnostics manuals are DSM- V and ICD-10 which are the framework diagnostic criteria’s as for bipolar disorder; however, the two criteria sets are not the same. For a diagnosis of bipolar I disorder, it is essential to meet the following criteria for a manic episode. The manic episode may have been perceived by hypomanic or major depressive episodes. Both a manic and a hypomanic are episode contain three or more symptoms of these episode. Irritable mood with high level energy, racing thoughts, pressure communication (fast, unnecessary, hyperactive speaking), declined need for sleep are the symptoms of bipolar. Major depressive disorder has five or more symptoms that have been presented throughout the same two-week phase. One of symptoms is also depressed mood, loss of interest or pleasure. This does not involve symptoms that are evidently due to another medical condition.
7Ayna’ s first visit to the office at the age of 9, session with psychiatry was recommended, which resulted in medication adjustment was made from short temporary methylphenidate to a longer temporary invention and a diagnosis of bipolar disorder, ADHD and OCD. The first trial of oxcarbazepine has resulted in no clear benefit. Following the application of risperidone in mixture with ongoing use of long substitute methylphenidate was reasonably effective in subsiding the mood brake down, improving attention span, and improving Ayna ability to initiate and to keep proper peer relationships. The hormone levels increasing just four after month among others was a concern, however, methylphenidate was substitute for the summer between the fifth and sixth grades. At the time Ayna started sixth grade, her psychiatrist ordered additional aripiprazole to her continuing use of extended the methylphenidate. Aripiprazole appeared useful in modifying mood swing but resulted in a somewhat depressed state. The strength to succeed in depression by adding sertraline resulted in fast and major development of hypomania. Following sertraline termination, Ayna ‘s irritable mood was not resolved somewhat, yet her mood continued” high drive,’ valproate was recommended the side effect was also kept in mind, in addition to ongoing use of aripiprazole and long temporary use of methylphenidate, seems to be helping to resolve this predestine problem while also is to improving overall mood stability, the goal at this point is to consider possible, future discontinuation of aripiprazole if continuing use of valproic acid can be safely and effectively regulated. Ayna is bipolar but the medication was not working for her and was changed recently. Now there is a waiting time to see if the new medication is working.
When Ayna started sixth grade in the fall at the age of eleven, her psychiatrist added aripiprazole to her ongoing use of long-acting methylphenidate. Aripiprazole seemed helpful in modifying mood swings, but resulted in a somewhat depressed state. Efforts to manage the depression by adding sertraline resulted in rapid and significant development of hypomania. Following sertraline discontinuation, Ayna’s hypomania resolved somewhat, yet her mood remained “high energy.” Initiation of valproic acid, in addition to ongoing use of aripiprazole and long-acting methylphenidate, seems to be helping to resolve this residual hypomania while also improving overall mood stability. The goal at this point is to consider possible future discontinuation of aripiprazole if ongoing use of valproic acid can be safely and effectively regulated.
Summary and recommendation
Ayna is a 11-year-old (not her name) is who was seen in our office almost three years ago for concerns was raised by her stepmother regarding progressive behavioral problems in the four five years prior to the visit, multiple mental health evaluations and treatment had been undertaken. However, little clinical improvement has been noticed. At the first visit to our office, Ayna’s medication was methylphenidate for ADHD. Both Ayna and her stepmother agreed that methylphenidate is helping somewhat with schoolwork, while the compulsive behaviors for instant repeatedly sharpening pencils down to the easer, extreme mood swings, and impulsive behavior seemed to be increasing. Ayna’s stepmother stated that she was not aware of Ayna hallucinations of any kind, but she notices that Ayna frequently seemed to have difficulty engaging in meaningful conversation. Despite having what appeared to be above average intelligence, Ayna had problems with concentration that continued to hinder her ability to complete her work assignments. Ayna symptom pattern overlap with other mood disorders and attention deficit/hyperactivity disorder. Assessment need to done determine her mood disorders, attention deficit/hyperactivity disorder, cognitive, and emotional status to make recommendations regarding a treatment plan. Ayna has had trouble with motivation and attention in school. There is concern that her attention deficit disorder might have been added at her previous visit and there is also a history of bipolar disorder on her mother and aunt’s side (who is the father’s sister). An evaluation of her early development, cognitive capability, emotional status and academic achievement resulted in a determination of a complex set of characteristics that are contributing to her difficulties. Ayna performed at an average range of cognitive functioning with no notable differences between verbal and nonverbal functions. However, there were many variations in her basic processing of information. Excellent abstract cognitive capability was noted for abstract thinking in both verbal and nonverbal visual spatial modalities. These good capabilities are reflected by her outstanding ability with reasoning and verbal comprehension. Most likely the underlying with bipolar disorder can be difficult to identify mood, impulsive behavior and depression. Any treatment must consider the interaction of these co-morbid conditions.