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A mother brings her 9-year-old daughter into the pediatrician’s office for a follow-up appointment. The daughter had been diagnosed with attention-deficit hyperactivity disorder (ADHD) last year while repeating second grade. She has been taking methylphenidate (Ritalin) 10 mg twice a day for 7 months now. Initially, she had been started on methylphenidate (Ritalin) 10 mg three times a day, but complaints of headache and insomnia resulted in a series of changes. Initially, the last dose of the day was dropped from 10 to 5 mg at dinner time, but later, the parents stopped giving the third dose altogether, citing concerns about dependency and their desire to use a more conservative medication approach for managing the patient’s ADHD. A behavioral plan with school supports has also been in place for the past year. Although the patient had been demonstrating good progress, today the mother reports that the patient’s grades are beginning to plummet again. Earlier this school year, the patient had been earning marks of “Satisfactory (S)” and “Satisfactory Plus (S+),” but now she is getting “Satisfactory Minus (S-)” and “Needs Improvement (NI).” The mother describes the patient as being more restless and “antsy” with difficulty completing her homework and reading assignments. In reviewing the patient’s family and home environment, you discover that the patient’s father has recently left the family because of the unexpected additional stress of the mother’s two teenage nephews moving in with the family in the past 6 weeks after their mother was arrested on drug charges. The patient tells you that the two boys tease and threaten her, and she says that she is fearful of them. The mother admits that the addition of the two teenage boys to the family has been problematic because the boys have been “unruly and disrespectful.” She admits to feeling somewhat trapped and overwhelmed; however, she says the boys have “nowhere else to go,” and family should look out for family.

**How would you evaluate the effectiveness of your nursing care?****What are your suggestions to the patient's school for increasing academic performance?**

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