Posted: May 31st, 2023

Case Study: Julia – Diagnosis and Treatment Plan

ADHD
Julia, a 19-year-old female college student, came to a school clinic for help with academic problems. Since starting college six months earlier, she had done poorly on tests and could not manage her study schedule. Her worries about flunking out of college were causing her poor sleep, poor focus and lost hope. After a week of low grades, she returned home and told her family she should drop out of college. Her mother brought her to the clinic where she and her older brother had been treated for ADHD when they were younger. She wondered if his ADHD might be causing his problems, or whether he had outgrown it.
Julia had been to the clinic when she was 9 years old and had been diagnosed with ADHD. Notes from that evaluation showed Julia had been in trouble at school for getting out of her seat, losing things, not following instructions, not completing homework and not listening.
A psychologist also confirmed reading problems during the evaluation. Because Julia’s problems did not meet the standard for a learning disability diagnosis, she could not receive special education services. Julia’s primary care doctor had proposed medication, but her mother refused. Instead, she hired a tutor to help her daughter “with concentration and reading.”
Since starting college, Julia said he often had trouble staying focused while reading and listening to lectures. Because of his stress at school, she had trouble falling asleep, had poor energy and didn’t “have fun” like his peers.
Julia’s older brother had ADHD. Her father, who died when Julia was seven, had dyslexia (a reading disorder). Her father had dropped out of community college after one semester.
Julia was referred to a psychologist for more testing, and the doctor diagnosed her with ADHD. The report stated that Julia had certain problems with reading fluency and comprehension (reading quickly and know the correct meaning), as well as spelling and writing. When she was first assessed at age 9, the standards for ADHD required six of nine symptoms. She had been diagnosed with the combined type of ADHD, because the specialty clinic had found at least six symptoms in inattention and hyperactivity/impulsivity. With DSM-5, only five symptoms are needed for people age 17 and older. At age 19, Julia met the standards for ADHD and for a specific learning disorder. With the correct diagnosis, he was able to receive services for academic support for her college studies.
American Psychiatric Association. (2021). ADHD patient stories. Understanding Mental Disorders: Your Guide to DSM5. American Psychiatric Publishing, Inc.

What is your diagnosis and treatment plan for this case? Include the following:
Pharmacological tx
Non-pharmacological to
Patient Education
Referral to other providers
Follow-up
Use the Case Study template to show your assessment collection data as well as the thought processes for diagnosis and treatment. Support your diagnosis and treatment plan with a minimum of two reference in APA form.

Case Study: Julia – Diagnosis and Treatment Plan

Assessment Collection Data:

Julia, a 19-year-old female college student, is experiencing academic problems, poor test performance, and difficulty managing her study schedule.
She exhibits symptoms of poor sleep, poor focus, and feelings of hopelessness due to her academic struggles.
Julia has a family history of ADHD, with her older brother previously diagnosed with the disorder, and her late father had dyslexia and dropped out of college.
Previous evaluation at the age of 9 revealed symptoms of ADHD, including trouble staying seated, losing things, not following instructions, incomplete homework, and difficulties with listening.
A psychologist confirmed reading problems during the evaluation, but Julia did not meet the criteria for a learning disability diagnosis.
Thought Processes for Diagnosis and Treatment:

Based on the information provided, the following diagnosis and treatment plan is recommended:

Diagnosis:
Julia meets the criteria for ADHD according to the DSM-5, as she exhibits symptoms of both inattention and hyperactivity/impulsivity. Additionally, she also qualifies for a specific learning disorder, given her difficulties with reading fluency, comprehension, spelling, and writing.

Pharmacological Treatment:
Considering Julia’s significant academic struggles and the impact it has on her daily functioning, pharmacological intervention should be considered. Stimulant medications, such as methylphenidate or amphetamine-based medications, are commonly prescribed for ADHD and have been shown to be effective in improving attention, focus, and executive functioning in individuals with ADHD (American Academy of Pediatrics, 2019). A consultation with a psychiatrist would be appropriate to discuss medication options, potential benefits, and address any concerns or reservations that Julia or her mother may have.

Non-pharmacological Treatment:
In addition to medication, non-pharmacological interventions should be implemented to support Julia’s academic performance and overall well-being. The following strategies may be helpful:

Psychoeducation: Educate Julia and her family about ADHD, its impact on academic performance, and the potential benefits of treatment options (both pharmacological and non-pharmacological).
Cognitive Behavioral Therapy (CBT): Engage Julia in CBT to address any negative thought patterns, help develop effective coping strategies, improve time management, and enhance study skills.
Academic Support: Collaborate with the college’s academic support services to provide accommodations such as extended time for exams, note-taking assistance, and additional tutoring or study skills workshops.
Time Management and Organization: Help Julia develop strategies to improve time management, task prioritization, and organizational skills to enhance her ability to complete assignments and maintain a consistent study schedule.
Healthy Lifestyle: Encourage Julia to engage in regular exercise, practice stress-reducing techniques (e.g., mindfulness, relaxation exercises), maintain a balanced diet, and prioritize sufficient sleep to optimize overall well-being and reduce ADHD symptoms.
Patient Education:
Provide Julia and her family with comprehensive education about ADHD, its impact on academic performance and daily functioning, the benefits and potential side effects of medication, as well as the importance of implementing non-pharmacological strategies. Emphasize the need for ongoing communication and support from both home and college environments.

Referral to Other Providers:
Refer Julia to a psychiatrist for a comprehensive evaluation of medication options, dosing, and monitoring of any potential side effects. Additionally, collaborate with the college’s academic support services, tutoring programs, and counseling services to ensure coordinated care and support.

Follow-up:
Schedule regular follow-up appointments with the psychologist to monitor Julia’s progress, medication response, and the effectiveness of non-pharmacological interventions. Adjustments to the treatment plan can be made based on her response and any emerging needs or challenges.

References:
American Academy of Pediatrics. (2019). ADHD: Clinical practice guideline for the

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