Not only do children and adults have different presentations for ADHD, but males and females may also have vastly different clinical presentations. Different people may also respond to medication therapies differently. For example, some ADHD medications may cause children to experience stomach pain, while others can be highly addictive for adults. In your role, as a psychiatric nurse practitioner, you must perform careful assessments and weigh the risks and benefits of medication therapies for patients across the life span. For this Assignment, you consider how you might assess and treat patients presenting with ADHD.
To prepare for this Assignment:
- Review this week’s Learning Resources, including the Medication Resources indicated for this week.
- Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with ADHD.
Examine Case Study: A Young Caucasian Girl with ADHD. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
CASE STUDY
BACKGROUND
Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.
The parents give you a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.
Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.
SUBJECTIVE
Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.”
Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.
MENTAL STATUS EXAM
The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.
Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation
RESOURCES
§ Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners’ Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
- Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)
- Which decision did you select?
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
- Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
- Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
- Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
RESOURCES:
Prince, J. B., Wilens, T. E., Spencer, T. J., & Biederman, J. (2016). Stimulants and other medications for ADHD. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 99–112). Elsevier.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/
appi.books.9780890425596
Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. https://doi.org/10.2165/
11599630-000000000-00000
Martin, L. (2020). A 5-question quiz on ADHD. Psychiatric Times.
https://cdnfiles.laureate.net/
EXPERT ANSWER AND EXPLANATION
Decision Tree for Patient with ADHD
Introduction to the Case
The patient I encountered is Katie, an 8-year-old white girl accompanied by her parents to my office after being referred to me by their PCP. The parents presented “Conner’s Teacher Rating Scale-Revised,” a document prepared by Katie’s teacher describing her mental health. The document notes that Katie is forgetful, easily distracted, and inattentive. She performs poorly in spelling, arithmetic, and reading. She is attentive only to things that are of interest to her. She hardly finishes her school work and has a short memory. However, the parents do not believe that their daughter has ADHD. According to them, she is not defiant, wild, and temperamental. Katie notes that school is “OK”, likes arts and recess. There is no big deal to her. She agrees that she sometimes wanders, an experience she finds fun.
She admits that she loves her parents and they are good to her and also denies experiences of bullying. Katie admits that sometimes does not know what is going on in her class, yet she is there. Her physical and mental development is proper, considering her age. She has clear, logical, and coherent speech. She knows where she is, who we are, and the time of the day and does not show any bad behavior, her affect is bright, and her mood is euthymic. She denies being delusional, hallucinations, and being paranoid. The attention and concentration are grossly intact, considering that she can count from 100 backward in serials of 2’s and 5’s. Her judgment is intact and denies feeling suicidal. The assessment shows that the has an inattentive category of ADHD.
Decision One
I recommended that the patient “begins Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING,” considering that she has ADHD. This medication can improve ADHD symptoms by improving the number of neurotransmitters and dopamine in the patient’s brain. Dopamine is a neurotransmitter known for improving one’s pleasure, attention, and movement. My reason for selecting this decision was that methylphenidate improves ADHD symptoms by improving the development of white matter in the brain (Bouziane et al., 2019). Bouziane et al. (2019) conducted a study and found that four-month with methylphenidate can improve the development of white matter in adolescents win ADHD. White matter is a passive tissue that affects one’s ability to learn and other brain functions. The tissue is also responsible for communicating brain parts. If one’s brain has developed white matter, the individual will have better brain function and learning capabilities.
I avoided Wellbutrin because it has a lot of side effects. According to Pi-Sunyer et al. (2019), Wellbutrin can highly impact its users’ weight. The authors did a study and found that patients using the medication experienced weight loss. According to the authors, other side effects of Wellbutrin include pharyngitis, blurred vision, tremor, gastrointestinal issues, tachycardia, suicidal thoughts in kids, adolescents, and young adults, and diaphoresis. I also avoided Intuniv because it is not a stimulant. My hope was to improve the patient’s symptoms by 25% within a month (Faraone, 2018). Faraone reports that Methylphenidate can reduce ADHD symptoms by inhibiting norepinephrine and dopamine transportation. The ethical consideration necessary for this part is autonomy. The patient’s parents have the right to allow their kid to undergo treatment or not. My ethical responsibility is to educate the parents and show them the importance and disadvantages of treatment plans for them to make informed choices.
Decision Two
The client was brought back by her parents are for weeks of using the prescribed medication. The parents said that Katie’s symptoms have improved during the mornings and worsen during afternoons. The patient often stares at the roof and daydreams during afternoons. Her heartbeat has also increased. Hence, I decided to change the medication and recommended: “Ritalin LA 20 mg orally daily in the MORNING.” This medication can work better because it can be effective for long compared to Ritalin alone. I based the decision my decision on a finding by Taş Torun et al. (2020). The authors conducted a study and found that Ritalin LA is highly effective in improving depressive symptoms. Matthijssen et al. (2019) also note that caregivers to assess the effectiveness of treatment before deciding to change or stop them. Hence, I evaluated the impact of Ritalin and found that it cannot meet my objectives, thus I changed to Ritalin LA.
Continuing the same dose was not effective, considering that the patient was complaining of irregular heartbeats and daydreaming in the afternoons. Hence, continuing the first medication was not best for the patient. I also avoided the other choice because changing medication can lead to adverse effects. A systematic review conducted by Holmskov et al. (2017) showed that short-term use of methylphenidate can lead to decreased appetite, weight loss, and pain in the abdomen among kids and teenagers with ADHD. My hope was to improve the patient’s mental state by deciding that the patient change to Ritalin LA (Taş Torun et al., 2020). Beneficence is the best ethical consideration for this case. This consideration notes that caregivers should provide treatment with more benefits than side effects, and that is why I decided to select Ritalin LA to improve the patient’s symptoms.
Decision Three
Katie was brought to the office for a check-up four weeks after the initial treatment and her parents say that she is still improving academically and the symptoms have been improved throughout the school. Her pulse rate has also reduced. Hence, I decided that the patient maintain the current dosage and then come for a check-up in four weeks for reassessment. My decision was impacted by Matthijssen et al.’s (2019)’s finding that patients should be assessed before deciding the next step of action. The current assessment shows that the patient is responding well to medication. Her academic performance has continued to increase. She is not feeling any ADHD symptoms while in school. Her heartbeat has also improved in that she says that she is no longer feeling “funny” in her heart. Nothing indicates that her medication should be altered.
I did not increase the dose for the current medication because the patient was responding well to the initial dosage. The patient assessment also shows that the patient’s heartbeat has increased. Hence, increasing the dosage might escalate Katie’s heartbeat and put her at risk of developing heart conditions. I did not obtain an EKG test on the patient’s current heart rate because as of now, her heart rate is normal. Kids aged seven to nine years’ normal heart rate is from 70-110beats/min. The ethical consideration relevant to this case is doing no harm. As healthcare professionals, nurses are required to avoid harming their patients willingly or unwillingly. My decision will not harm the patient but improve her mental health status. Maintaining the dosage is more beneficial to the patient than increasing the dosage.
Conclusion
Katie was found to have ADHD; hence her treatment plan was based on improving ADHD symptoms. The first decision was that the patient “begins Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING.” Ritalin is best for this case because it can improve ADHD symptoms by increasing neurotransmitters and dopamine presence in the brain. The neurotransmitters can improve the patient’s memory and learning. I selected the decision because Ritalin can improve the patient’s ADHD symptoms by increasing white matter development in the brain (Bouziane et al., 2019). Bouziane et al. (2019) found in their study that Ritalin increased the presence of white matter in boys with ADHD. Children will more develop white matter have better brain functions and learning. The kids’ part of the brain can also communicate better.
The second decision is that the patient change to “Ritalin LA 20 mg orally daily in the MORNING.” The initial medication improved the patient’s symptoms only in the morning. However, during the day, she experiences daydreams and stares on the roof. I recommended this medication because its effectiveness is long-term. Taş Torun et al. (2020) conducted a study and found that Ritalin LA is effective and can reduce ADHD symptoms. The third decision was maintaining the current dose and re-evaluating the patient after four weeks. She reported a positive response after using the initial response and her heartbeat had also decreased. Hence, there was no need to increase the dosage to undergo an EKG exam.
References
Bouziane, C., Filatova, O. G., Schrantee, A., Caan, M. W., Vos, F. M., & Reneman, L. (2019). White matter by diffusion MRI following methylphenidate treatment: a randomized control trial in males with attention-deficit/hyperactivity disorder. Radiology, 293(1), 186-192. https://doi.org/10.1148/radiol.2019182528
Faraone, S. V. (2018). The pharmacology of amphetamine and methylphenidate: relevance to the neurobiology of attention-deficit/hyperactivity disorder and other psychiatric comorbidities. Neuroscience & Biobehavioral Reviews, 87, 255-270. https://doi.org/10.1016/j.neubiorev.2018.02.001
Holmskov, M., Storebø, O. J., Moreira-Maia, C. R., Ramstad, E., Magnusson, F. L., Krogh, H. B., … & Simonsen, E. (2017). Gastrointestinal adverse events during methylphenidate treatment of children and adolescents with attention deficit hyperactivity disorder: A systematic review with meta-analysis and Trial Sequential Analysis of randomised clinical trials. PloS one, 12(6), e0178187. https://doi.org/10.1371/journal.pone.0178187
Matthijssen, A. F. M., Dietrich, A., Bierens, M., Kleine Deters, R., van de Loo-Neus, G. H., van den Hoofdakker, B. J., … & Hoekstra, P. J. (2019). Continued benefits of methylphenidate in ADHD after 2 years in clinical practice: a randomized placebo-controlled discontinuation study. American Journal of Psychiatry, 176(9), 754-762. https://doi.org/10.1176/appi.ajp.2019.18111296
Pi-Sunyer, X., Apovian, C. M., McElroy, S. L., Dunayevich, E., Acevedo, L. M., & Greenway, F. L. (2019). Psychiatric adverse events and effects on mood with prolonged-release naltrexone/bupropion combination therapy: a pooled analysis. International Journal of Obesity, 43(10), 2085-2094. http://doi.org/10.1038/s41366-018-0302-z
Taş Torun, Y., Işik Taner, Y., Güney, E., & İseri, E. (2020). Osmotic Release Oral System-Methylphenidate Hydrochloride (OROS-MPH) versus atomoxetine on executive function improvement and clinical effectiveness in ADHD: A randomized controlled trial. Applied Neuropsychology: Child, 1-12. https://doi.org/10.1080/21622965.2020.1796667
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