NURS6330 Assessing and Treating Patients with ADHD Assesment
NURS6330 Assessing and Treating Patients with ADHD Assesment
NURS6330 Assessing and Treating Patients with ADHD Assesment
Assessing and Treating Patients with ADHD
Introduction to the Case
Katie is an 8-year-old Caucasian female brought to the office by her parents after her teacher suggested that she may have ADHD. Her teacher filled out the “Conner’s Teacher Rating Scale-Revised,” which showed that Katie is inattentive, forgetful, easily distracted, and has poor academic performance. Her attention span is short, and she only pays attention to things she is interested in. However, Katie’s parents actively deny that she has ADHD, stating that she does not exhibit hyperactive or defiant behavior.
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During the mental status exam, Katie appears appropriately developed for her age, and her speech is clear, coherent, and logical. She is oriented to person, place, time, and event. She denies any hallucinations or delusions and has intact attention and concentration. Her insight and judgment are age-appropriate, and she denies suicidal or homicidal ideation. Based on the information gathered, Katie was diagnosed with attention deficit hyperactivity disorder, predominantly inattentive presentation.
The specific patient factors that may impact the PMHNP’s decision-making when prescribing medication for Katie include her young age, her parents’ denial of her diagnosis, and her relatively mild symptoms (Kamimura et al., 2019). Given her age, the PMHNP will need to be cautious when prescribing medication and may need to adjust the dosage based on her weight. Katie’s parents’ denial of her diagnosis may make them resistant to medication. The PMHNP will need to discuss the benefits and risks of the medication with them in a clear and empathetic manner. Katie’s relatively mild symptoms may suggest that medication is not the only appropriate treatment option. The PMHNP may need to consider non-pharmacological interventions such as behavioral therapy or changes to her academic environment.
Decision Point One:
The decision to begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning was selected for Katie. Methylphenidate is a stimulant medication widely recognized as the first-line pharmacological treatment for ADHD, particularly inattentive presentation. According to a randomized placebo-controlled discontinuation study on the benefits of methylphenidate by Matthijssen et al. (2019), methylphenidate is effective in reducing symptoms of inattention, hyperactivity, and impulsivity in children with ADHD. It should be the first-line treatment for children with moderate to severe ADHD since it has a good safety profile. As Katie’s symptoms are causing significant impairment in her academic performance, methylphenidate is an appropriate treatment option for managing these symptoms.
The other two options were not selected for several reasons. First, Wellbutrin (bupropion) XL is not FDA-approved for treating ADHD in children. While it is sometimes used off-label for this purpose, the evidence supporting its effectiveness is limited (Kweon & Kim, 2019). Second, Intuniv extended-release is a non-stimulant medication that effectively treats ADHD symptoms. However, it is typically used as an adjunct to stimulant medication rather than a first-line treatment (Mechler et al., 2021). Since methylphenidate is the first-line treatment for ADHD, starting with a non-stimulant medication is inappropriate. The decision aims to select the most appropriate treatment option for Katie’s ADHD symptoms, which are causing significant impairment in her academic performance.
Ethical considerations may impact the treatment plan and communication with patients in several ways. First, it is essential to respect Katie’s autonomy by involving her in the decision-making process to the extent possible, given her young age (Haddad & Geiger, 2022). Second, the PMHNP must ensure that the benefits of the medication outweigh the risks, particularly given Katie’s age and her parents’ resistance to medication. The PMHNP must also ensure that the treatment plan is in the patient’s best interests, considering not only the reduction of symptoms but also the potential impact on Katie’s academic and social functioning.
Decision Point Two
The selected decision is to change to Ritalin LA 20 mg orally daily in the morning because Katie’s symptoms are improving with the current dose of Ritalin chewable tablets, but they reappear in the afternoon. This suggests that the medication’s duration of action is insufficient, and switching to a long-acting formulation may provide sustained symptom relief throughout the day (Matthijssen et al., 2019). Methylphenidate is the recommended first-line medication for ADHD. The long-acting formulations of methylphenidate may be preferred over short-acting formulations because of their more prolonged duration of action and reduced potential for abuse.
The other two options were not selected because discontinuing Ritalin and switching to Adderall XR 15 mg orally daily is a significant change that should only be considered if Ritalin is ineffective or poorly tolerated. Additionally, there is limited evidence to suggest that one medication is superior to the other, and the choice should be based on individual patient factors and preferences (Steingard et al., 2019). Continuing the same dose of Ritalin and reevaluating in four weeks may be appropriate if Katie’s symptoms are stable. However, given her afternoon symptoms and reported palpitations, it is unlikely to provide adequate symptom relief.
The PMHNP must have ethical considerations by ensuring that Katie’s parents understand the risks and benefits of medication and are fully informed before consenting to treatment. The rationale for medication should be explained to address any concerns they may have (Haddad & Geiger, 2022). Finally, the treatment plan should be based on the best available evidence and tailored to Katie’s needs, considering her age, symptom severity, and treatment goals.
Decision Point Three
The decision to maintain a current dose of Ritalin LA and reevaluate in 4 weeks was selected because Katie’s symptoms are well controlled, and her side effects have gone away following the switch to a long-acting preparation. There is no indication at this point that the dose should be increased, as it is always advisable to use the lowest effective dose of stimulant medication (Matthijssen et al., 2019). Katie’s heart rate is appropriate for an 8-year-old girl, and an EKG would not be indicated based on her heart rate. Making this decision would maintain Katie’s symptom control while minimizing the risk of side effects associated with higher doses of medication.
Ethical considerations are an essential aspect of prescribing medication for children with ADHD. The PMHNP must ensure that the patient and their parents fully understand the benefits and risks of medication and that their consent is informed. Additionally, the PMHNP must ensure that they prescribe medication within their legal and ethical responsibilities (Haddad & Geiger, 2022). In this case, Katie’s parents deny her diagnosis, which may impact their willingness to consent to medication. The PMHNP must engage in an empathetic discussion with Katie’s parents to explain the rationale for medication and address any concerns they may have. The PMHNP must also comply with all relevant legal and ethical guidelines for prescribing medication to children with ADHD.
Conclusion
The case is about an 8-year-old girl named Katie, who was brought to the office by her parents after her teacher suggested that she may have ADHD. The PMHNP has diagnosed her with attention deficit hyperactivity disorder, predominantly inattentive presentation. Three treatment options are available for Katie, including Ritalin chewable tablets, Wellbutrin XL, and Intuniv extended-release. Among these, Ritalin chewable tablets of 10 mg orally in the morning are selected as the first-line treatment for Katie. It is a stimulant medication widely recognized as the first-line pharmacological treatment for ADHD, particularly inattentive presentation (Matthijssen et al., 2019). Methylphenidate effectively reduces inattention, hyperactivity, and impulsivity symptoms in children with ADHD and has a good safety profile.
The second decision is to change Ritalin to Ritalin LA 20 mg orally daily in the morning because Katie’s symptoms are improving with the current dose of Ritalin chewable tablets, but they reappear in the afternoon. This suggests that the medication’s duration of action is insufficient, and switching to a long-acting formulation may provide sustained symptom relief throughout the day (Matthijssen et al., 2019). The other two options are not selected for various reasons, such as limited evidence supporting their effectiveness or being used as adjuncts rather than first-line treatments.
The third decision involves maintaining the current dose of Ritalin LA for Katie and reevaluating her in four weeks. This decision was made because her symptoms are well-controlled, and her side effects have disappeared after switching to the long-acting preparation. There is no indication to increase the dose, and using the lowest effective dose of stimulant medication is essential. Katie’s heart rate is appropriate for her age, and an EKG is unnecessary.
The PMHNP must consider ethical considerations, such as respecting Katie’s autonomy and ensuring that the benefits of the medication outweigh the risks. The treatment plan should be based on the best available evidence and tailored to Katie’s needs, considering her age, symptom severity, and treatment goals.
References
Haddad, L. M., & Geiger, R. A. (2022). Nursing ethical considerations. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526054/
Kamimura-Nishimura, K. I., Epstein, J. N., Froehlich, T. E., Peugh, J., Brinkman, W. B., Baum, R., Gardner, W., Langberg, J. M., Lichtenstein, P., Chen, D., & Kelleher, K. J. (2019). Factors associated with attention deficit hyperactivity disorder medication use in community care settings. The Journal of Pediatrics, 213, 155-162.e1. https://doi.org/10.1016/j.jpeds.2019.06.025
Kweon, K., & Kim, H.-W. (2019). Effectiveness and safety of bupropion in children and adolescents with depressive disorders: A retrospective chart review. Clinical Psychopharmacology and Neuroscience, 17(4), 537–541. https://doi.org/10.9758/cpn.2019.17.4.537
Matthijssen, A.-F. M., Dietrich, A., Bierens, M., Kleine Deters, R., van de Loo-Neus, G. H. H., van den Hoofdakker, B. J., Buitelaar, J. K., & Hoekstra, P. J. (2019). Continued benefits of methylphenidate in ADHD after two 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
Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2021). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 230, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940
Steingard, R., Taskiran, S., Connor, D. F., Markowitz, J. S., & Stein, M. A. (2019). New formulations of stimulants: An update for clinicians. Journal of Child and Adolescent Psychopharmacology, 29(5), 324–339. https://doi.org/10.1089/cap.2019.0043
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Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD
A Young Girl With ADHD
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 the PMHNP 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
Decision Point One
Select what the PMHNP should do:
Begin Wellbutrin (bupropion) XL 150 mg orally daily
Begin Intuniv extended release 1 mg orally at BEDTIME
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
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.
Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD
A Young Girl With ADHD
Decision Point One
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute
Decision Point Two
Change to Ritalin LA 20 mg orally daily in the MORNING
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s academic performance is still improved, and the switch to the LA preparation is lasting Katie throughout the school day
Katie’s reports of her heart feeling “funny” have gone away. Pulse was 92 during today’s office visit
Decision Point Three
Maintain current dose of Ritalin LA and reevaluate in 4 weeks
Guidance to Student
At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.
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.
THE ASSIGNMENT: 5 PAGES
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.
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.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
