ADHD Patient Intake Documentation Assignment
ADHD Patient Intake Documentation Assignment
Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s ADHD therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.
ADHD Patient Intake Documentation Assignment
Patient Profile
The Case: 8-year-old girl who was naughty
The Question: Do girls get ADHD?
The Psychopharm Dilemma: How do you treat ADHD with oppositional symptoms?
Pretest Self Assessment Question (answer at the end of the case)
What is true about oppositional symptoms in patients with ADHD
A. They can be part of the diagnostic criteria for ADHD in children
B. They can be confused with impulsive symptoms of ADHD
C. They can be part of oppositional defi ant disorder (ODD) which can be comorbid with ADHD
D. They can be part of conduct disorder (CD) which can be comorbid with ADHD
Patient Intake
• 8-year-old girl brought to her pediatrician by her 26-year-old mother
• Chief complaint: fever and sore throat
Psychiatric History
• While evaluating the patient for an upper respiratory infection, the pediatrician asks if school is going well
• The patient responds “yes” but in the background the mother shakes her head “no”
• The mother states that her daughter is negative and defi ant at home and she has similar reports, mostly of disobedience, from her teacher at school
• The patient has had temper tantrums since age 5 but these have decreased over the past 3 years, especially the past year
• Still angry and resentful since her little sister was born 6 years ago
• Academic problems
• Fights with other children, mostly arguments and harsh words with other girls at school
Social and Personal History
• Goes to public school
• Has a younger sister age 6
• Does not see her father much, lives in a nearby city
• Not many friends
• Spends most of her time with her sister and either her mother or her maternal grandmother who helps with after school supervision and baby sitting
Medical History
• None
Family History
• None known for medical or psychiatric disorders other than the father who drinks a bit too much and his father (paternal grandfather) who some think might be an alcoholic
• Mother was adopted and no family history known
Pediatrician’s Notes: Initial Evaluation
• Not enough time to do any more evaluation
• Instead, the mother is given the parent and teacher version of the Conners ADHD rating scale and is instructed to bring the completed forms to the followup visit
• A variety of rating scales are available, some without charge (see http://www.neurotransmitter.net/adhdscales.html).
• The Connors scale charges a fee but other rating scales available at this link, or listed in the Two-Minute Tute below are free.
Pediatrician’s Notes: Followup Visit Week 3
• At the followup visit, the mother admits to having been too busy to fill out the parent form
• Also admits to having forgotten to send the rating form to the teacher
• Mother acknowledges being more disorganized since her second child started school this year
• Since then it has also been extremely diffi cult to keep the patient organized and focused on school
• The mother is on the verge of tears
• “Two children are too much for a single mother”
• The pediatrician offers to send the teacher form to the school and gives the mother tips on how to remember to fi ll out her own form
• When the teacher form is sent back to the pediatrician’s office the mother will be contacted for a followup visit. ADHD Patient Intake Documentation Assignment
Pediatrician’s Notes: Followup Visit Week 6
• At the followup visit, the mother comes alone
• Teacher’s ADHD rating scale responses state that the patient has significant problems with
– Talking excessively
– Sustaining attention
– Being organized
– Being distracted
– Being forgetful
– Following instructions
– Making careless errors (except when it comes to her homework)
• The teacher also complains of the patient being more argumentative and disobedient than the other children in her class
• The mother’s responses on the ADHD rating scales are similar to the teacher’s but she endorses only fi ve symptoms as significantly impairing
• Checked “severe” for ability to listen (rated only mild by the teacher)
• Upon further questioning by the pediatrician, it becomes clear that the mother is compensating for her daughter by
– Double checking her homework
– Making sure homework is in her backpack
– Helping the patient be organized
• Eventually, symptoms that were originally determined to be “mild” by the mother are changed to “signifi cantly impairing”
• Mother confi rms that the patient argues a lot with her, especially when the mother is trying to oversee her work, and that the patient still occasionally has temper tantrums similar to when she was five years
old, but milder
Based on just what you have been told so far about this patient’s history what do you think is her diagnosis?
• ADHD
• ODD (oppositional defi ant disorder)
• CD (conduct disorder)
• ADHD comorbid with ODD
• ADHD comorbid with CD
• A child acting out again her mother’s divorce and against having to share her mother with her sister
• Other
Pediatrician’s Mental Notes: Followup Visit, Week 6, Continued
• The patient is diagnosed with ADHD, mostly inattentive type, comorbid with symptoms of oppositional defi ant disorder
– ADHD symptoms include inattention but not hyperactivity
– Some of her impulsive symptoms such as being argumentative and disobedient overlap with her ODD symptoms but the ODD symptoms seem to be willful and on purpose rather than truly thoughtlessly impulsive
• To be diagnosed with conduct disorder, the patient would need to exhibit symptoms similar to ODD plus have aggression towards animals, destruction of property, deceitfulness or theft, and serious
violations of rules, symptoms of a type and severity that neither the teacher nor the mother brought up
How would you treat her?
• Cognitive behavioral therapy
• Parent training
• d-methylphenidate XR (Focalin) 5 mg once daily in the morning titrated in 5 mg increments each week to optimization
• OROS methylphenidate (Concerta) 18 mg once daily in the morning titrated in 18 mg increments each week to optimization
• Mixed salts of amphetamine XR (Adderall XR) 10 mg once daily in the morning titrated in 10 mg increments each week to optimization
• Lisdexamfetamine (Vyvanse) 30 mg once daily in the morning titrated in 10–20 mg increments a week to optimization
• Other
Pediatrician’s Mental Notes: Followup Visit Week 6, Continued
• Mother is initially uncomfortable with the diagnosis of ADHD with ODD and is far from ready to accept medication treatment for her daughter
• Wants different options
• Pediatrician suggests cognitive behavioral therapy and parent training
• Pediatrician also offers to write a letter to the school to implement strategies to help her daughter such as
– Allowing extra time on tests and assignments
– Placing child nearest to the teacher
– Devising signals between teacher and child to redirect child’s attention without embarrassing the child
Pediatrician’s Mental Notes: Followup Visit Week 10
• Mother learns that closest CBT specialist is one-hour drive away from their home so this option falls through
• Also, while the teacher is happy to implement the strategies suggested by the pediatrician, she admits to already using them with the patient, given her experience with other ADHD students
• The lack of non-pharmacological treatment options helps the mother reconsider the risks versus the benefi ts of ADHD medications
• All the options listed as stimulants in the list above, plus some nonstimulants, are approved for the treatment of ADHD and have shown some effi cacy for ODD symptoms
• D-methylphenidate XR is chosen
Pediatrician’s Mental Notes: Followup Visits Weeks 12 and 14
• The dose of d-methylphenidate is titrated to 20 mg/day with some improvement in classroom behavior according to the teacher
• However, the patient develops problems with initial insomnia
– Sometimes the effects of stimulants later in the day can actually improve sleep, especially in hyperactive individuals who have problems slowing down for bedtime routines
– Some studies suggest that OROS methylphenidate lasts even longer (up to 12 hours) compared to d-methylphenidate XR, which seems to be more effective in the fi rst 8 hours; thus OROS methylphenidate would be a potential option in such cases
– However, this is not this patient’s presentation
– Since this patient did not have problems with sleep prior to starting d-methylphenidate XR, the initial insomnia is likely due tothe stimulant
• Also, even though classroom behavior seems to be improving according to the teacher, the patient remains defi ant with the mother, tears up some toys of her younger sister to upset her and screams
more than ever at her mother while doing homework, seeming delighted when her mother gets upset and yells back
• The mother is instructed to give the medication another month to see if the improvements in the classroom begin to be seen in the home and is instructed about sleep hygiene including
– Keeping regular schedules for going to bed and waking up
– Avoiding the patient’s favorite caffeinated sodas, especially in the late afternoon
– Providing quiet activities as part of a bedtime routine
– Having the patient leave her room to do another quiet activity if she does not fall asleep within 30 minutes. ADHD Patient Intake Documentation Assignment
Pediatrician’s Mental Notes: Followup Visit Week 18
• The mother herself is often overwhelmed and disorganized and so has a diffi cult time keeping regular schedules for going to bed and waking up, even during the week but especially on weekends
• Despite trying the behavioral approach, the initial insomnia remains a problem
• So does the defi ant behavior at home
• Also, reports last week that the patient shoved somebody who she said was crowding in line, causing her classmate to cut her knee, requiring stitches/sutures
• Was not sorry or remorseful
How would you treat her now?
• Refer to a psychiatrist for further evaluation and psychopharmacological management
• Refer to a psychologist for therapy
• Switch to dl-methylphenidate immediate release (classical Ritalin) 10 mg twice daily, then titrate to optimized dose
• Switch to the methylphenidate transdermal patch (Daytrana) starting at 10 mg, then titrate to optimized dose
• Switch to the prodrug lisdexamfetamine (Vyvanse) starting at 30 mg once in the morning, then titrate to optimized dose
• Switch to atomoxetine (Strattera) 10–18 mg per day, then titrated to optimized dose
• Switch to guanfacineXR (Intuniv) 1 mg/day, then titrated to optimized dose
• Other
Pediatrician’s Mental Notes: Followup Visit Week 18, Continued
• Each treatment option has specifi c considerations to take into account:
– In general, the active d enantiomer of methylphenidate (which the patient was originally prescribed) may be slightly more than twice as potent as racemic d,l-methylphenidate; so, if side effects persist on d-methylphenidate it may be useful to switch to immediate release d, l methylphenidate which might require a “sculpted dose” with a higher morning than afternoon dose
– The methylphenidate patch needs to have the patient and mother follow instructions and in this patient’s case, may need to remove the patch before the suggested nine-hour wear time is over, if
insomnia or other adverse events emerge; the patch should not be cut as a way to lower the dose
– Lisdexamfetamine should be titrated by increasing the dose in 10–20 mg increments each week; 10–12 hours of clinical action can be expected, so might be less favorable in patients who already have problems with insomnia
– Atomoxetine can have a longer onset of action but does not cause insomnia
– Guanfacine/guanfacineXR should start at 1 mg and titrate by 1 mg increments to a maximum of 4 mg/day but an 8 year old will not likely need or tolerate the highest dose, which may cause sedation
• The mother prefers the methylphenidate patch approach, as it seems to be the most convenient way to address the sleep problems
• Additionally, sometimes the patient refuses to swallow pills and will take the medication only if convinced to do so, or possibly if sprinkled on food. This confrontation over medications adds too much extra time to the mother’s already hectic morning schedule
• The patient likes the novelty of the patch, which reminds her of a sticker Downloaded
Continued …