PDF(Pubmed)
Abstract：
Layla is a 6.7-year-old girl diagnosed with attention-deficit/hyperactivity disorder (ADHD)-predominantly hyperactive/impulsive type-delayed adaptive skills, enuresis, unspecified malnutrition, and feeding difficulties. She presented to developmental-behavioral pediatrics (DBP) in January 2022 due to caregiver concerns for autism spectrum disorder (ASD).Layla lives in a polyamorous family with her biological mother and father, mother\'s partner whom Layla refers to as her uncle, and her 2 half-siblings. There is a maternal history of special education services, schizoaffective disorder, bipolar disorder, multiple sclerosis, Wolff-Parkinson-White syndrome, and ADHD. Layla\'s father is a veteran diagnosed with post-traumatic stress disorder. Layla\'s siblings, aged 5 and 9 years, have established diagnoses of ADHD, ASD, global developmental delays, behavioral concerns, and poor sleep. There is a history of adverse childhood experiences, including parental mental health, poverty, and involvement with child protective services. Acknowledgement and inclusion of all members of this diverse family structure, as well as consistent validation from the DBP and social worker, allowed a strong treatment alliance to form and the mother continued to contact the DBP clinic, even for those questions related to other specialties. A social worker received weekly calls from the mother sharing grievances related to feeling misunderstood and spoke about the assumptions she felt external providers made about her family, culture, and parenting styles. For example, she recalls the pediatrician commenting about their family structure being \"confusing for the children\" and describing their home as \"chaotic,\" assumptions that may not have been made of nuclear family structures. Behavioral therapies were a repeated recommendation, but the mother verbalized not being interested in these options as she had participated in parent management training several years earlier and felt that the strategies taught were not applicable to her unique family structure, to which the clinician replied, \"this is the standard recommendation for all children this age with disruptive behaviors.\" Although the mother was initially hesitant to trial medications, she eventually agreed that Layla\'s symptoms were negatively affecting her school performance, and the DBP initiated a stimulant medication.Layla\'s initial evaluation included a developmental history, behavioral observations, and standardized testing. The results from developmental testing demonstrated age equivalents between 4 and 6 years across gross motor, adaptive, visual motor, and speech-language domains.On observation, Layla was extremely active. During the visit, she walked over to her mother, made eye contact, and showed her the picture that she had drawn. She engaged in imaginary play, reciprocal conversation, and responded to social bids. The mother felt strongly that Layla had ASD and reported symptoms such as motor stereotypies (hand flapping), covering ears with certain noises/sounds, and rigidity when it came to things being a certain way or a certain color. These behaviors did not occur in the initial or subsequent clinic visits with DBP, her general pediatrician, or during other outside evaluations the mother pursued. The DBP felt strongly that Layla was mimicking her siblings\' symptoms and provided ongoing education regarding ADHD symptomology.In terms of behavior management, the mother did not attempt to redirect Layla\'s behaviors during the initial clinic visit and in subsequent visits, and both adult men yelled loudly, clapped, and hit their hands on the table as a form of redirection. The mother continued to voice her diagnostic disagreement with the DBP and the pediatrician and insisted that Layla met the criteria for ASD. When the mother reviewed the report, a statement insinuating that Layla\'s behaviors were \"understandable given parental inconsistency and complicated family structure\" upset her.What factors would you consider when thinking about caregiver disagreement with the diagnosis and treatment plan? Does diagnostic overshadowing apply here?
摘要：
方法：Layla是一名6.7岁的女孩，被诊断患有注意力缺陷/多动障碍（ADHD）-主要是多动/冲动型延迟适应技能，遗尿症,未指明的营养不良，和喂养困难。由于护理人员对自闭症谱系障碍（ASD）的担忧，她于2022年1月向发育行为儿科（DBP）提出了建议。Layla和她的亲生母亲和父亲生活在一个多情的家庭中，母亲的伴侣，莱拉称之为她的叔叔，还有她的两个同父异母的兄弟姐妹.有特殊教育服务的母亲历史，分裂情感障碍,双相情感障碍,多发性硬化症,Wolff-Parkinson-White综合征,和ADHD。Layla的父亲是一名被诊断患有创伤后应激障碍的退伍军人。Layla的兄弟姐妹,5岁和9岁，已经确定了多动症的诊断，ASD,全球发展迟缓，行为关注，和可怜的睡眠。有一段不良童年经历的历史，包括父母的心理健康，贫穷,并参与儿童保护服务。承认和包容这个多样化家庭结构的所有成员，以及DBP和社会工作者的一致验证，允许形成强大的治疗联盟，母亲继续联系DBP诊所，即使是与其他专业相关的问题。一名社会工作者每周接到母亲的电话，分享与被误解有关的不满，并谈到了她认为外部提供者对她的家庭所做的假设，文化,和育儿方式。例如,她回忆起儿科医生评论他们的家庭结构“让孩子们感到困惑”，并将他们的家庭描述为“混乱”，“可能没有对核心家庭结构做出假设。行为疗法是一个重复的建议，但是母亲说对这些选择不感兴趣，因为她几年前参加了父母管理培训，并认为所教授的策略不适用于她独特的家庭结构，临床医生回答说，“这是所有这个年龄段有破坏性行为的儿童的标准建议。“尽管母亲最初对试验药物犹豫不决，她最终同意Layla的症状对她的学习成绩有负面影响,DBP启动了兴奋剂药物治疗。Layla的初步评估包括发展历史，行为观察，标准化测试。发育测试的结果表明，粗大运动的年龄在4到6岁之间，适应性，视觉运动，和语音语言领域。根据观察,莱拉非常活跃。访问期间,她走到她母亲身边,眼神接触，给她看了她画的画.她从事虚构的游戏，互惠对话，并回应社会出价。母亲强烈感到Layla患有ASD，并报告了诸如运动刻板印象（拍手）等症状，用某些噪音/声音覆盖耳朵，当涉及到某种方式或某种颜色时，它是刚性的。这些行为在最初或随后的DBP临床就诊中没有发生，她的普通儿科医生,或在母亲追求的其他外部评估中。DBP强烈认为Layla正在模仿她的兄弟姐妹的症状，并提供有关ADHD症状学的持续教育。在行为管理方面,母亲在初次就诊和随后的就诊中没有试图改变Layla的行为,两个成年男子都大声喊道，鼓掌,把手放在桌子上作为重定向的一种形式。母亲继续表达对DBP和儿科医生的诊断分歧，并坚持认为Layla符合ASD的标准。当母亲审查报告时，一份声明暗示Layla的行为是“可以理解的，因为父母的不一致和复杂的家庭结构”让她心烦。在考虑护理人员对诊断和治疗计划的分歧时，您会考虑哪些因素？诊断阴影是否适用于此？
