Respond in the following ways:
- Compare the diagnosis you provided and the process in which you reached the diagnosis with those of your colleague.
- Explain how the Z codes (other conditions that may be a focus of clinical attention) that your colleague identified may influence the client’s upcoming treatment.
My four initial diagnosis are oppositional Defiance Disorder, Autism Spectrum Disorder, Attention Deficit Disorder and Intellectual Developmental Disorder. In order to diagnose and/or rule out, it is necessary to match the symptoms with the best fitting diagnosis.
In the case of ADHD, I am not able to complete this as a diagnosis as I can only fit 6 of the 8 hyperactivity criteria. ADHD is then ruled out. In the event of ODD, Pablo does not deliberately annoy others or start arguments with his peers. He actually interacts well with this peers and is reported to be quite sociable. He also likes to be touched and/or held by his caregivers/parents. ODD is ruled out and therefore will be exploring neurodevelopmental disorders, such as Intellectual Developmental disorder and Autism Spectrum.
Autism Spectrum disorder is characterized by ongoing deficits in social communication and social interactions. This does not apply to the case of Pablo as he is the opposite and is very interactive with his peers. Also, Pablo does not have a language and/or intellectual impairment. As for the consideration of Intellectual Developmental disorder, this can impact not only the intellectual piece but the adaptives (the ability to complete routine tasks as developmentally appropriate without cues) of an individual. In Pablo’s case, there are reports about his behaviors being “immature” and demonstrating difficulty in following routines and remembering instructions as given. This also reflects at school when he is not able to be still, follow instructions and/or complete the provided task at hand. Furthermore, there is to take in account for his age, he does not know certain information such his address or home phone number, and could not print his surname.
I would give a primary diagnosis of Intellectual Developmental Disorder, mild and looks as follows:
F70 Intellectual Disability, Mild
F90.9 Other Specified Attention-Deficit/Hyperactivity Disorder, with insufficient inattention, and hyperactivity symptoms (he is still demonstrating hyperactivity in two settings, school & home)
Z55.9 Academic or educational problem
Z65.8 Other problem related to psychosocial circumstances
Z72.821 Inadequate sleep hygiene
Z81.8 Family history of other mental and behavioral disorders (grandmother was diagnosed with depression)
DSM-5 Full diagnosis of Pablo.
Morrison (2014) discusses the Roadmap for Diagnosis as building blocks of data. Informants is initial information gathered according to Morrison (2014) shedding light on possible presenting illness. Parents and teachers present Pablo’s problem characterized as; restlessness, reminders to stay on task, running around, difficulty with listening and following directions. Roadmap for diagnosis Morrinson (2014) discusses gathering mental health history. Pablo has no mental health history noted. Roadmap for diagnosis according to Morrinson (2014) collects data on personal and social background. Pablo’s personal background is he is seen as a social, enjoys spending time with his friends, invited to many activities, likes swimming, running and skating. Pablo is described as very intelligent and excels academically. He identifies well with peers his age. Parents noticed he is influenced by older kids, gets upset when he is not noticed or recognized and described as ‘socially immature” and “attention seeking behavior” by the teacher. Parents notice challenges at home with routines, recalling instructions and emotionally reactive and confrontational. Morrison (2014) describes data collection including a family history. Pablo’s parents moved to the United States from Guatemala when Pablo was 6 months old. Both parents have completed graduate schooling. No identified relatives living in the United States. Morrison (2014) roadmap includes data collection for physical symptoms. Pablo has not identified previous medical or physical symptoms although parents noted he has difficulty sleeping, often waking up for an hour or more before falling back asleep. Pablo had difficulty naming his address, phone number and writing his last name. Last collection of data mentioned in Morrison (2014) includes mental status exam. He was noted as typical in size and appearance. Pablo was seen as active, appropriate with adult interactions and easily transitioned away from parents to clinician. Speech, mood and affect were normal. No hallucinations or delusions. Judgement and insight were noted as a big challenge. Following the Roadmap to diagnosis differential diagnosis was explored below (Morrinson, 2014).
Differential Diagnosis Considered
Autism Spectrum Disorder was a considered diagnosis. Consideration for Autism Spectrum disorder initially was addressed due to difficulties with verbal communication, interactions with adults and understanding social cues. Diagnostic criteria for Autism Spectrum Disorder not met (as presenting problems did not qualify for diagnosis) as follows; 1. No mention of difficulty when maintaining conversations by parents or teacher (also note no mention of turn taking issues with clinician during assessment) 2. No motor or abnormal body language or identification of nonverbal communication delays in nonverbal communication (not mentioned by parents, teacher or identified in MSE with clinician) 3. No issues with maintaining relationships (student is highly social and several friends) (APA, 2017). Pablo does not meet diagnostic criteria for ADHD.
Social Communication Disorder was a considered diagnosis. Consideration of Social Communication disorder was initially addressed due to Pablo’s difficulties with reading social cues in class (blurting out in class) difficulty following directions and challenges with reactive behavior such as being ignored or not recognized by other students and emotional reactivity with parents such as hitting, outburst and inappropriate behavior. Diagnostic Criteria for Social Communication Disorder not met (presenting problems do not qualify for diagnosis) as follows; 1. No mention of challenges with nonverbal communication (by either parent, teacher or viewed by clinician) 2. No mention of difficulty with changing communication to different contexts such as in class or in the playground (APA, 2017). Pablo does not meet the diagnostic criteria for Social Communication Disorder.
Attention-Deficit/Hyperactivity Disorder of Combined presentation or Predominantly hyperactive/impulsive presentation. Consideration for ADHD of the combined presentation and the hyperactive/impulsive presentation was considered due to Pablo’s presenting issues and previous history. Presenting issues of restlessness, moving around all the time, challenges with listening and following instructions as mentioned by both teacher and parents. Other challenges such as following directions, impulsive behavior and behavioral concerns in preschool. Diagnostic Criteria for ADHD Predominantly hyperactive/impulsive presentation does not meet as follows; 1. No discussion of fidget like behavior with materials or clothing 2. No mention of climbing when it is inappropriate to do so 3. No mention of talking excessively 4. No mention of completing other people’s sentences and inpatient with turn taking (APA, 2017). Pablo does not meet the diagnostic criteria for ADHD of hyperactive/impulse presentation therefore he does not meet the ADHD of Combined presentation criteria either.
Pablos Symptoms match Specific Diagnostic Criteria
Pablos symptoms match with attention-deficit/hyperactivity disorder of the inattentive type due to his current presenting problems identified by both parents and the teacher. He has maintained a pattern of inattention that is interfering with his social and academic activities (APA, 2017). He has persistently had issues as discussed by current teachers ( past teachers) and parents that qualify for 6 months or more of persistent behavior to qualify (APA, 2017). He does not identify as having a developmental delay as he is academically successful. Diagnostic criteria was met for Pablo’s diagnosis as;
F90.0 Predominantly inattentive presentation, mild (provisional), Z60.9 unspecified problem related to social environment. (APA, 2017).
Diagnostic Criteria characterized and qualified by meeting the following 6 or more criteria; 1. Difficulty holding attention and difficulty with details (the presenting problem by both parents and teacher and clinician notes challenges with details like address and phone number recall) 2. Has difficulty holding attention (noted by teacher) 3. Inability to follow simple instructions and duties (as noted at school and home by parents and teacher) 4. Difficulty organized tasks and activities (inability to follow directions/getting up and moving around) 5. Avoids or reluctant to engage in tasks with long mental effort needed (able to hyperfocus on preferred activities only and nonpreferred are difficult) 6. Easily distracted (difficulty doing routines or completing instructions at home and school) 7. Forgetful in daily activities (inability to complete routines and recall instructions)
Due to Pablos presenting problems and meeting the diagnostic criteria for ADHD of the inattentive type he qualifies for this diagnosis. Pablo is mild in presentation and symptoms presented only qualify him for ‘mild’ as he does not meet the criteria in excess (APA, 2017).
Eliminated obvious neurodevelopmental spectrum disorders as follows; intellectual disability (Pablo excelled academically and socially), language disorder (speech was normal for developmental age), speech sound disorder (speech was normal for developmental age), Stuttering (normal speech), Specific Learning Disorder (excelled academically), Motor Disorders (motor movements normal), Tic Disorders (no involuntary movements).
Pablos prior diagnosis
No previous diagnosis was noted in his intake performed in May, 2020. Only behavioral issues as noted by Preschool teachers with disruptive behavior,
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Morrison, J. (2014). Diagnosis made easier (2nd ed.). New York, NY: Guilford Press.