Although AC has agreed to take her Abilify, she may change her mind. What are some ways to get teenagers to take their medications when they refuse? This seems to be problematic as I have had many parents report this.
Pediatrician is no longer willing to manage psychiatric medications due to complexity of case.
HISTORY OF PRESENT ILLNESS:
AC is a 15-year-old biracial girl who presents with her maternal grandparents to establish care. AC reports she has not been in school for the last five to six weeks, because she was “kicked out.” Grandparents report AC had been at Headway Day Treatment since November 2017, but she was dismissed on 2/7/2018 due to disruptive and uncooperative behaviors. Prior to November, she was a sophomore at Champlin High School.
Headway recommended residential treatment, and AC is on the waiting list at several facilities. In the meantime, her grandparents are waiting to hear if she has been accepted into the day treatment program at Options. AC’s grandparents are at their “wits end” and state the police have been to their home 18 times since January 2017.
AC is no longer taking Abilify 5 mg daily, because “I don’t need it!” Last week, she was rummaging through her grandmother’s dresser drawers, and her grandfather asked her to stop. She refused and punched him in the face. AC states “the police came and told me they would take me to juvy next time.” AC said she doesn’t remember hitting her grandfather. “He hit me first.”
Grandparents would like for AC to resume Abilify or obtain a prescription for another medication to help with her anger and disruptive behaviors.
PAST PSYCHIATRIC HISTORY:
AC has diagnoses of ODD, PTSD, reactive attachment disorder and ADHD (inattentive type). When AC was 10-years-old, she expressed suicidal ideations and a desire to cut her wrists. She was seen in the Emergency Department (ED) and placed on a 72-hour hold. When she was 11-years old, AC was upset she had to leave her mother’s home and repeatedly tried to jump out of her grandparent’s moving car. She was seen in the ED and received a medication to calm down. Then, she was released to her grandparents.
SUBSTANCE ABUSE HISTORY:
- Drinks caffeinated beverages including soda and tea once or twice a day.
- No energy drinks.
- Denies history of tobacco, alcohol, marijuana or other drugs.
PSYCHOSOCIAL HISTORY:
Education Level: She is a sophomore in high school with a long history of academic struggles across subjects, ongoing difficulty organizing assignments and completing homework assignments.
Marital Status: Single. Never married.
Children: No.
Current living arrangement: AC has been living with her maternal grandparents for the last 5 years. They received permanent custody in May 2015. Her biological 10-year-old twin sisters live there as well.
Social Support: Although AC does not like her maternal grandparents and wants to go live with her mom, they are her only social supports. Grandparents report AC does not have any friends. She has difficulty making and keeping friends, because “it’s her way or the highway!” Grandparents are exhausted and in need of respite. Grandmother reports they have a large family. However, “no one will keep her for even two hours for fear of what she will accuse them of doing.”
Employment Status/History: Since she is not in school, grandmother states “I can’t get her to move off the couch.”
Religious Affiliation: AC attends a Lutheran Church with her grandparents. Grandparents lead two missionary trips to Haiti each year. AC has been to Haiti multiple times.
Legal History: In September 2013, Child Protective Services became involved with AC, and she was placed in foster care with her maternal grandparents who were granted permanent custody in May 2015. Biological mother previously had supervised visitation, but she decided she couldn’t afford to continue them. AC’s mother is now seeking unsupervised visitation. Grandparents do not feel this is a good idea.
Current Violence: No violence against patient. Last week, AC punched her grandfather in the face when he asked her to stop rummaging through her grandmother’s drawers. AC does not admit to doing this. She claims to not remember.
Past Violence/Trauma: Prior to age 10, AC was exposed to a chaotic living environment due to her mother’s neglect, physical and verbal abuse. She experienced multiple changes of address and primary caregiver changes. AC was sexually assaulted at the age of 8 by an intoxicated adult female friend of the family which involved fondling. She witnessed domestic violence involving her parents as well as parental relationship distress. AC’s mother often sold drugs out of the family mini-van and committed home invasions while AC and her sisters waited in the car. AC saw her mother arrested. AC’s father was in and out of her life until she was two-years-old. She does not have contact with him.
GROWTH AND DEVELOPMENT:
Grandparents are unsure of what drugs AC was exposed to during utero. However, they do know AC’s mother drank alcohol and smoked cigarettes when she was pregnant. They also report AC’s mother was “totally disengaged” in caring for her. AC had delayed social skill development and difficulty getting along with other children. She achieved all other milestones on time. As a toddler, she had nightmares and displayed sensory integration difficulties including excessive reaction to unexpected and loud noises.
MEDICAL HISTORY:
Family Medical/Psychiatric History:
- Mother has a history of depression, bipolar disorder, anxiety, narcissistic and borderline personality disorders. She also has a history of polysubstance abuse/addiction and sexual addiction.
- Maternal cousin committed suicide at age 17 (prior to AC’s birth).
- Maternal uncle has a history of alcoholism.
- Maternal aunt with command hallucinations and anxiety.
- Paternal side of family with history of chemical use.
Patient Medical History:
- Exercise-induced asthma.
Biopsychosocial stressors:
AC reports she does not like her grandparents and wants to live with her mother. Grandparents report AC’s mother is a significant stressor in her life.
ALLERGIES:
No drug or food allergies.
MEDICATIONS:
She is not on any medications at this time. In the past, she has been on methylphenidate for ADHD and fluoxetine for mood. She has also taken prazosin for nightmares.
REVIEW OF SYSTEMS:
General: Negative for chills, fever, fatigue or weight gain.
HEENT: Adequate hearing and vision. Denies headache, nasal congestion or sore throat.
CV: Denies chest pain or lower extremity edema.
Resp: Denies shortness of breath. She has an albuterol inhaler she uses if needed.
GI: Denies nausea, vomiting, diarrhea or constipation.
GU: No urinary frequency or burning.
Skin: Dry. Denies lacerations or bruises.
Hematologic: Denies.
Musculoskeletal: No joint pain or range of motion problems.
Neurologic: AC reports she sometimes does not remember things. For example, she says she was told she hit her grandfather but says she doesn’t remember it. Grandparents report AC claims to have blackouts and not remember things. However, they think she is being manipulative.
Immunologic: Negative.
Endocrine: No thyroid issues.
Sleep: Sleeps 6 to 8 hours a night per grandparents.
MENTAL STATUS EXAM:
Appearance: Well-groomed, clean clothing. Appears older than stated age. Average weight and height.
Motor Activity: Gait normal. Cranial nerves grossly intact. No tics, tremors or mannerisms.
Attitude: Cooperative.
Speech: Normal rate and volume. Spontaneous.
Affect: Appropriate to situation, congruent to thought content.
Mood: When asked about her mood, AC reported “It’s okay.”
Thought Processes: Normal.
Thought Content: Normal.
Perceptions: No outward evidence of perceptual disturbances.
Suicidal Ideation: Denies.
Self-injurious behavior: Denies.
Homicidal Ideation: Denies.
Cognition: Adequate concentration.
Orientation: Alert and oriented to self, place, date, and situation.
Memory: Good.
Concentration: Fair.
Insight: Poor.
Judgement: Poor.
DSM-5 DIAGNOSES:
- Oppositional defiant disorder (ODD)
- Post-traumatic stress disorder (PTSD)
- Attention deficit/hyperactivity disorder (inattentive type)
PLAN/INTERVENTIONS:
- Patient is agreeable to restart Abilify. Will start at 2.5 mg for 7 days, then increase to 5 mg daily.
- Return to clinic in 2 weeks for follow up.
- Case manager to continue working on placement in an intensive outpatient program (IOP) while waiting for opening at residential treatment facility.
- If patient unable to be placed in an intensive outpatient program in the next day or two, patient should make an appointment for individual therapy with previous therapist. AC stopped going to her individual therapist when she was admitted to Headway in November 2017.
I chose this case for several reasons. First, I see many grandparents raising their grandchildren when they should be planning for retirement. I emphasized with this couple. Second, AC’s mother carries diagnoses of both borderline personality disorder and bipolar disorder. I verified this with the grandparents, and AC’s mother was diagnosed with both disorders when she was a teenager. Borderline personality disorder was diagnosed during a hospitalization and bipolar disorder was diagnosed by her outpatient psychiatrist. Even though she was diagnosed with both, I question whether or not she was misdiagnosed. Third, I wonder what the chances are AC will develop one or both of these disorders. Lastly, AC has been refusing to take her medication which caused me to start thinking about ways to get teenagers to take their meds.
Questions:
- Can a person have both bipolar disorder and borderline personality disorder? What are some risk factors and the likelihood AC will be diagnosed with one or both of these disorders?
- Although AC has agreed to take her Abilify, she may change her mind. What are some ways to get teenagers to take their medications when they refuse? This seems to be problematic as I have had many parents report this.