MY JOURNAL REFLECTION

Rewrite my assignment and replace my 2 references outside of the dsm5 reference. Apa 7th format. Avoid using formal, use more casual verbiage.

My Reflections

Last month I had the opportunity to interview a 7-year-old boy who was brought to our office by his mother for evaluation of some behavioral issues. For context, he has previously been evaluated by Dr. Ablavi; however, I had the opportunity to interview him outside of reviewing his assessment notes. He had been previously diagnosed with Disruptive Mood Dysregulation Disorder (DMDD) and Attention-Deficit/Hyperactivity Disorder (ADHD). During the time that I spoke with the patient, he was extremely irritable, could not sit for very long, and would often interrupt his mother while she was speaking. He would frequently slide his body down the chair to the floor and climb over the office ottoman throughout the duration of the forty-minute interview. His eye contact was very minimal when answering my direct questions to him. The patient would them yell over his mother stating that he was hungry and wanted to go get McDonalds after the interview. His mother repeatedly complied to his wishes and asked the patient to remain seated in which he became increasingly irritable, raising his voice and challenging his mother.

The patients diagnosis included Disruptive Mood Dysregulation Disorder (DMDD) and Attention-Deficit/Hyperactivity Disorder (ADHD), combined type. DMDD is characterized by severe recurrent temper outbursts and persistent irritability that occur across multiple settings and are inconsistent with developmental level (American Psychiatric Association [APA], 2022). ADHD is a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and impulsivity that interfere with functioning or development (Centers for Disease Control and Prevention [CDC], 2024).

Some of the observed behaviors in this patient suggested differential diagnoses. The child was fidgety, unable to remain seated for any length of time, and could not refrain from interrupting his mother or myself as we were speaking. His mother described many problems at school related to the childs poor attention span during classes and his inappropriate behavior, which often led to punishment. She reported having many tantrums at home characterized by loud yelling and crying in response to what were deemed appropriate or minor reactions by the parent, as well as hitting the childs siblings. The mother described several episodes a week occurring over the past few years. All the criteria for DMDD (APA, 2022) were met based on the childs irritability between tantrums and the impairment it caused in both the childs school and home environments.

**Use of Psychosocial Assessment Tools**

A structured psychosocial assessment tool was not administered during this portion of the interview. Utilizing standardized screening tools may also be helpful upon initial assessment. The Vanderbilt ADHD Diagnostic Rating Scale may assess the presence of ADHD symptoms in both home and school environments. The Child Behavior Checklist (CBCL) or Strengths and Difficulties Questionnaire (SDQ) can also give some sense of emotional regulation, behavioral problems and social difficulties. Use of these standardized screening tools and corroborative information from both the caregivers and teacher regarding severity of symptoms and level of impairment would provide more objective data.

There are several interventions that could be beneficial for this patient. For the management of ADHD, behavioral therapy, parent training, and school-based interventions are recommended, in conjunction with medication when appropriate (CDC, 2024). When asked, mother corroborated that the school has been supportive providing special permissions to allow the patient to be successful. I asked the mother to review special permissions with me in order to gain better understanding of what was being provided to the patient. I then asked the patient how he felt about these permissions and if he felt it allowed him to get his work done and focus. Both mother and patient agreed that the resources provided by the school were effective. Pertaining to DMDD, the recommended treatment was psychotherapy, which may include cognitive behavioral therapy (CBT), emotional regulation training, and parent management training (Roy et al., 2021). The patient is currently benefitting from community resources such as school counseling, an IEP, and behavioral therapy programs to get consistent support. I provided a follow-up question to the patient to gain understanding of his relationship with the school counselor. The patient stated, I like her, she is nice. In addition, parent education programs to help manage emotional outbursts and reward positive behavior may also be beneficial. I offered the mother community resources, she stated shed previously received this information from Dr. Ablavi, but was a busy work schedule and had not investigated any resources as of yet.

My first impression of this child was that his energy and apparent extreme reactivity was excessive and overwhelming at times. My first guess regarding his presenting hyperactivity and apparent impulsive behavior was ADHD. However, as I continued to listen to his mother talk about the extent and type of his behaviors, I realized that the childs significant emotional regulation difficulties would also need to be assessed. I also empathized with the patient as the interview took place early in the morning. Mother stated he hadnt eaten breakfast so irritability would be understandable.

I finished the interview and now feel that I understand a little better how difficult it must be to manage both ADHD and DMDD. Some of the behaviors I saw in the patient (such as becoming visibly irritated at times and being unable to articulate exactly why he was upset) may contribute to the behavior difficulties he has and that his mom has reported to me. I feel that I have a better appreciation now for the stress and challenges that a family like the patients must deal with on a daily basis.

The same patient was later re-evaluated, with feedback from school staff and mother. I reminded myself to focus on the emotional and non-hyperactive symptoms reported. Upon reviewing the interview, it is clear that there was a bias in favor of hyperactive symptoms, and that there was some delay in getting to the emotional issues. The need for a full clinical assessment to determine which symptoms to prioritize was highlighted by Dr. Ablavi. Given the parents work demands as well as sibling age gap; I fully agree that frequent therapeutic interventions would deem beneficial at this time.

The two therapeutic communication techniques that I incorporated were active listening and open-ended questions. Active listening was effective in connecting with both the patient and his mother. Maintaining the mothers gaze, nodding while she spoke and avoiding interruption allowed for a detailed account of the childs behavioral issues. Open-ended questions also helped to engage the patient and helped to further understand his feelings and perspective. Questions such as What happens when you feel very angry? encouraged the child to give his own account of what was occurring.

This was not the most effective part of the conversation. As the mom was talking about school issues, the child became fidgety and distracted. The conversation started to center more on the parent and the child lost interest. I could have used some of the simple child-friendly engagement strategies that we talked about earlier, such as using very simple language, using visual aids, or using brief activity-based open-ended questions. It also would have been helpful to use a structured behavioral screening tool in this visit, to help guide the conversation and to make sure that all of the important psychosocial information was explored.

This experience has re-enforced my need for both patient and carful assessment as well as strong communication skills when dealing with any psychiatric issues in children, especially with behavioral and mood disorders.

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.)

Centers for Disease Control and Prevention. (2024). Attention-deficit/hyperactivity disorder (ADHD).

Roy AK, Lopes V, Klein RG (2021) Disruptive mood dysregulation disorder: A new diagnostic approach to chronic irritability in youth. Am J Psychiatry, 178, 596604. DOI: 10.1176/appi.ajp.2020.20010010

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