Assessing and Treating Patients with ADHD Essay

Assessing and Treating Patients with ADHD Essay

Assessing and Treating Patients with ADHD

Attention deficit hyperactive disorder (ADHD) is a pervasive developmental disorder that presents with inattentiveness and hyperactivity or impulsivity. Children with ADHD have persistent inattention, hyperactivity, and impulsive behavior. ADHD interferes with a child’s developmentally appropriate functioning academically, socially, and in extracurricular activities. The purpose of this paper is to describe a scenario of a patient with ADHD and describe the treatment interventions, including ethical considerations.

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The case scenario depicts Katie, an eight-year-old Caucasian female accompanied by her parents. After seeking consultation, the parents were referred by their PCP after Katie’s teacher implied that she could be having ADHD. The “Conner’s Teacher Rating Scale-Revised” scale revealed that she is: inattentive, distracted easily, difficulties remembering things she has learned and has difficulties in reading, spelling, and arithmetic. Besides, Katie has a short attention span and only pays attention to things that interest her. Her teacher deduced that she has minimal concentration in academic work. Katie starts tasks but never finishes them, rarely follows instructions, and does not complete her school work. Her diagnosis is ADHD, predominantly inattentive presentation.

The treatment planning for Katie may be impacted by various patient factors, including tolerability to ADHD medications, presence of risk factors for cardiovascular diseases, personal or family history of cardiovascular disease, and patient preferences (Geffen & Forster, 2018). Regardless of the well-documented efficacy and safety profiles of various FDA-approved agents, some patients may have poor tolerability or lack an adequate response to treatment. Besides, some caregivers may prefer a non-pharmacological treatment approach.

Decision #1

Start Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.

Why I Selected This Decision

Ritalin was selected because it is an FDA-approved agent for treating ADHD. It is a stimulant recommended as a first-line and mainstay treatment agent for ADHD. I selected Ritalin because its efficacy has long been established and has good tolerability and overall safety compared to other psychiatric agents (Chamakalayil et al., 2021).

Why I Did Not Select the Other Two Options

The patient was not prescribed Wellbutrin because it is a non-stimulant therapy, indicated as a second-line pharmacotherapy. Geffen and Forster (2018) explain that non-stimulants effect on ADHD symptoms is not comparable to stimulants. Intuniv was not selected because it is approved as adjunctive therapy with a stimulant agent in treating ADHD (Brown et al., 2018). Besides, symptoms respond to Intuniv after 1–2 weeks of treatment, making it less ideal.

What I Was Hoping To Achieve By Making This Decision

I hoped that starting the patient on Ritalin would alleviate the ADHD symptoms, optimize the patient’s functional performance, and eliminate behavioral obstacles. Ritalin is one of the most effective and safe treatment options and the first-line treatment in national guidelines and reviews. It has been proven to alleviate ADHD symptoms, patient functioning, emotional lability, and academic/work performance (Chamakalayil et al., 2021).

Ethical Considerations That May Impact the Treatment Plan

The clinician selected the treatment option established to have the best outcomes and a good safety profile. Therefore, ethical principles of beneficence and nonmaleficence were upheld as the clinician selected medication known to promote the best outcomes with minimal harm to the patient (Bipeta, 2019).

Decision #2

Change to Ritalin LA 20 mg orally daily in the morning.

Why I Selected This Decision

Ritalin was changed from short-acting to long-acting formulation because the effects of the former formulation were not sustained the entire day. The effects of a short-acting formulation last 3 to 6 hours, which explains the patient’s daydreaming in the afternoon (Brown et al., 2018). Therefore, there was a need to give a long-acting formulation to sustain the effects the whole day. Mechler et al. (2021) explain that long-acting Ritalin formulations are connected with high compliance rates and a reduced potential of rebound effects.

Why I Did Not Select the Other Two Options

I did not continue the same Ritalin dose because the dose was only effective in the morning hours; thus, continuing the dose was not ideal. Given its shorter duration, it would need a second dose in the afternoon to sustain the effects. Besides, the option to discontinue Ritalin and start Adderall XR was not ideal because the patient’s symptoms had significantly improved with the initial agent. Besides, it is established to increase aggressive behavior in children (Brown et al., 2018).

What I Was Hoping To Achieve By Making This Decision

I was hoping that prescribing a long-acting agent would sustain the drug’s effects during the day, and thus the patient would concentrate in class the whole day. Storebø et al. (2018) explain that long-acting Ritalin formulation acts in phases to alleviate ADHD symptoms throughout the day and normally wears off in 8 to 16 hours.

Ethical Considerations That May Impact the Treatment Plan

Beneficence influenced treatment, as evidenced by the clinician changing the treatment formulation to promote better outcomes and further alleviate the patient’s symptoms (Bipeta, 2019). The clinician used the best evidence available in making treatment decisions to avoid harming the patient, promoting nonmaleficence.

Decision #3

Maintain the current Ritalin LA and re-evaluate in 4 weeks.

Why I Selected This Decision

The current Ritalin LA dose was maintained because its effects lasted throughout the school day, improving academic performance. Besides, tachycardia and palpitations had abated. Mechler et al. (2021) assert that long-acting formulations of stimulants have varying pharmacokinetic profiles with regard to the time at which peak levels are reached and go down. Thus clinicians should choose a formulation appropriate for the patient’s symptom profile and needs.

Why I Did Not Select the Other Two Options

The dose of Ritalin LA was not increased to 30 mg daily because the current dose of 20 mg lasted throughout the day and led to improved academic performance. The lowest doses of stimulant medications are recommended to minimize side effects. An EKG was not obtained because the patient had a heart rate of 92, which is normal for her age. Brown et al. (2018) explain that cardiac assessment is indicated if a patient exhibits any major unexplained chest discomfort, syncope, or symptoms indicating cardiac disease.

What I Was Hoping To Achieve By Making This Decision

I hoped that sustaining the current Ritalin LA dose would improve the ADHD symptoms resulting in better academic and social functioning and quality of life. According to Mechler et al. (2021), patients on long-acting formulations show a significant improvement in symptoms, clinical impression, and quality of life. This confirms that a single Ritalin LA morning dose has a positive treatment effect in ADHD.

Ethical Considerations That May Impact the Treatment Plan

Beneficence and nonmaleficence further influenced treatment as the clinician assessed the patient for treatment response and side effects. The treatment was maintained because the patient had an adequate response, and the side effects diminished. It was thus important to maintain the drug and dose to improve patient outcomes further.

Conclusion

Katie was diagnosed with ADHD based on impaired attention, short attention span, and easy distractibility in school. Patient factors that might influence the treatment plan include medication tolerance, risk factors for cardiovascular diseases, personal or family history of CVS and cardiovascular disease, and patient preferences. The first treatment decision entailed initiating Ritalin 10 mg orally in the morning. Ritalin was selected because of its efficacy, tolerability, and good safety profile, compared to other non-stimulants (Chamakalayil et al., 2021). Ritalin effectively improved ADHD symptoms, but its effects were not long-lasting. Besides, it had the side effect of palpitations and tachycardia.

In the second treatment, the treatment was changed to Ritalin LA 20 mg since the long-acting formulation lasts 8 to 16 hours (Storebø et al., 2018). The effects of Ritalin short-acting formulation last 3 to 6 hours, which led to the patient’s daydreaming in the afternoon (Brown et al., 2018). Changing the formulation led to improved academic performance, and the drug’s positive effects lasted the entire day. The palpitations and tachycardia also abated. In the third decision, the Ritalin LA 20 mg dose was sustained because the patient demonstrated an adequate positive response to the dose. There was no need to increase the dose to minimize the risk of side effects. Beneficence and nonmaleficence impacted treatment as the clinician had to prescribe the drug with the best possible outcomes least side effects.

References

Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19

Brown, K. A., Samuel, S., & Patel, D. R. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Translational pediatrics, 7(1), 36–47. https://doi.org/10.21037/tp.2017.08.02

Chamakalayil, S., Strasser, J., Vogel, M., Brand, S., Walter, M., & Dürsteler, K. M. (2021). Methylphenidate for Attention-Deficit and Hyperactivity Disorder in Adult Patients With Substance Use Disorders: Good Clinical Practice. Frontiers in psychiatry, 11, 540837. https://doi.org/10.3389/fpsyt.2020.540837

Geffen, J., & Forster, K. (2018). Treatment of adult ADHD: a clinical perspective. Therapeutic advances in psychopharmacology, 8(1), 25–32. https://doi.org/10.1177/2045125317734977

Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2021). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940

Storebø, O. J., Pedersen, N., Ramstad, E., Kielsholm, M. L., Nielsen, S. S., Krogh, H. B., Moreira-Maia, C. R., Magnusson, F. L., Holmskov, M., Gerner, T., Skoog, M., Rosendal, S., Groth, C., Gillies, D., Buch Rasmussen, K., Gauci, D., Zwi, M., Kirubakaran, R., Håkonsen, S. J., Aagaard, L., … Gluud, C. (2018). Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents – assessment of adverse events in non-randomized studies. The Cochrane database of systematic reviews, 5(5), CD012069. https://doi.org/10.1002/14651858.CD012069.pub2

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Assessing and Treating 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.

Attention Deficit Hyperactivity Disorder
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 (1a)
Begin Wellbutrin (bupropion) XL 150 mg orally daily
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s parents inform you that they stopped giving Katie the medication because about 2 weeks into the prescription, Katie told her parents that she was thinking about hurting herself. This scared the parents, but they didn’t want to “bother you” by calling the office, so they felt that it would be best to just stop the medication as they would be seeing you in two weeks
Decision Point One(1b)
Begin Intuniv extended release 1 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Katie’s teacher reports no change in her classroom behaviors
Katie’s parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish”
Decision Point One (1c)
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 (2a)
Continue same dose of Ritalin and re-evaluate in 4 weeks
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s academic performance is still improved, but her attention continues to worsen throughout the school day
Katie is still reporting that her heart feels “funny.” Today’s pulse rate is 122 beats per minute, regular rhythm
Decision Point Two (2b)
Discontinue Intuniv and begin Dexedrine (dextroamphetamine) 5 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are better, but that she can be a bit “hyper” at times. Katie’s parents report that Katie is sometimes too “wound up” to go to bed and bedtime has become a “difficult” time in the house
Katie’s parents are also concerned about her appetite, which has decreased since beginning the Dexedrine. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Two (2c)
Discontinue Ritalin and begin Adderall XR 15 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Katie’s academic performance is still improved, and the XR preparation has helped sustain her attention throughout the school day, however, you also learn that Katie is having tachycardia with this medication, too
Decision Point Three (1a)

Maintain current dose of medication and re-evaluate in 4 weeks
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.
Decision Point Three (1c)
Decrease to Adderall XR 10 mg orally daily
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.
Decision Point Three (1c)
Discontinue Adderall XR and begin Strattera 10 mg orally daily
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall, and may be worse because it was started at a higher dose. The PMHNP should decrease the dose to 10 mg orally daily and re-evaluate at the next office visit.

Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so maintaining the current dose of medication would not be prudent as Katie may refuse to take the medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be caused by a high starting dose of medication.

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.

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RUBRIC
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.
9 (9%) – 10 (10%)
The response accurately, clearly, and fully summarizes in detail the case for the Assignment.
The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.
Decision #1 (1–2 pages)
• 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.
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.
The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.
The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.
Examples provided fully support the decisions and responses provided.
Decision #2 (1–2 pages)
• 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.
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.
The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.
The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.
Examples provided fully support the decisions and responses provided.
Decision #3 (1–2 pages)
• 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.
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.
The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.
The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.
The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.
Examples provided fully support the decisions and responses provided.
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.
14 (14%) – 15 (15%)
The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient.
The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.