ADHD Symptoms Checklist Paper

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. ADHD Symptoms Checklist Paper

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).

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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.

ADHD is the most common neurobehavioral condition among children with the highest comorbid psychiatric issues. The societal and social costs of unmanaged ADHD across the lifespan are immeasurable and comprise occupational and academic underachievement, safety of motor vehicles, delinquency, and difficulties with interpersonal relationships.

It is a   disorder in which children are impulsive, inattentive, and hyperactive.  Inattentive describes easily distracted children with difficulties focusing. Impulsive children behave in an inconsiderate, extremely rash, impatient, and careless manner for their age. Hyperactive refers to constantly fidgeting and restless children who cannot sit still. In its severe form, ADHD can result in major issues in a child’s life and daily routine. Since children diagnosed with ADHD    behave differently than expected, they often cause trouble thus need a lot of attention. Currently, existing evidence emphasizes the need to diagnose and manage   ADHD to prevent the symptoms from persisting to adulthood and cause other comorbid conditions. In this paper, the author discusses the pharmacotherapy of an 8-year-old Caucasia female called Katie with ADHD and ethical decisions in managing pediatric patients with ADHD.

Case Overview

This case study involves an 8-year old called Katie who was referred for a comprehensive psychiatric evaluation by her PCP for a ADHD diagnosis. The findings of the Conner’s Teacher Rating Scale by her teacher showed that she was inattentive, forgetting already learned content, easily getting distracted, poor spelling, arithmetic, and reading. She also has a short attention span, and only paid attention to things she was interested in. A MSE revealed that she was dressed appropriately for time and weather of the year, with a coherent, clear, and logical speech. She was oriented to place, person, time, and event. Katie denied paranoid or delusional thought processes, auditory and visual hallucinations. She had no noteworthy mannerisms, tics, or gestures, had a euthymic mood, and a bright affect. Her concentration and attention were grossly intact, her judgment and insight were age-appropriate. Katie also denied homicidal and suicidal ideation. The psychiatric evaluation and assessment prompted the diagnosis of ADHD with a predominantly inattentive presentation. ADHD Symptoms Checklist Paper

Decision #1

Decision Selected

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

Reason for Selecting This Decision

Ritalin is a stimulant of the central nervous system and the primary choice of drug that has also been approved by the FDA to manage ADHD in children. Ritalin is generally safe when used as per the prescription instructions. Besides, oral Ritalin has only a few adverse effects when used in therapeutic doses. Ritalin acts by blocking the reuptake of dopamine and norepinephrine neurotransmitters by presynaptic neurons. By inhibiting the transport of dopamine and norepinephrine, it increases the concentration of norepinephrine and dopamine in the synaptic cleft and produces a classic stimulant effect in the prefrontal cortex which explains its efficacy in managing ADHD (Banaschewski et al., 2016). Beginning Wellbutrin XL 150mg orally daily may be an alternative decision, but Wellbutrin is the preferred drug in off-label management of ADHD in adults and has a major side effect of suicidal ideation that can negatively impact the therapeutic relationship when not adequately addressed (Parikh & Baker, 2016). Beginning intuniv extended-release 1 mg orally at bedtime could also be an alternative since it is the preferred pharmacological agent for managing oppositional behaviors in ADHD children. However, it has a minimal therapeutic effect on improving a child’s attention, increases sluggishness, and causes sedation (Bello, 2015).

Expected Outcomes

By prescribing Ritalin, the PMHNP expected that Katie will be able to concentrate, follow rules, and maintain good relations with teachers, parents, and peers. Ritalin acts by blocking the reuptake of dopamine and norepinephrine neurotransmitters by presynaptic neurons (Huss et al., 2017). By inhibiting the transport of dopamine and norepinephrine, it increases the concentration of norepinephrine and dopamine in the synaptic cleft and produces a classic stimulant effect in the prefrontal cortex which explains its efficacy in managing ADHD.

Ethical Considerations

At this point, the most important ethical consideration is that of beneficence and autonomy whereby, the PMHNP initiates management with the best drug option with the patient’s approval. However, since this patient is a minor, Gardner, Ruest & Cummings (2016) recommends that there must be shared decision making by both the patient and parents. Therefore, before initiating treatment, the PMHNP must obtain informed consent from Katie and Katie’s parents. This includes educating Katie’s parents about the available drug options with the respective side effects.

Decision #2

Decision Selected

Change to Ritalin LA 20 mg orally daily in the MORNING

Reason for Selecting This Decision

After four weeks, the patient returned to the company of her parents who reported that, based on the teacher’s reports, Katie’s symptoms were better during the morning hours and had influenced an overall improvement in her academic performance. However, in the afternoons, she hardly concentrated. Besides, Katie also reported having a funny heart feeling despite a heart rate of 130b/min. To address the tachycardia side effect and make sure that Katie’s concentration span increased, she needed a long-acting formulation of Ritalin. According to Haertling, Mueller & Bilke-Hentsch (2015), one of the major cardiovascular effects of Ritalin is an increased heart rate, commonly referred to as tachycardia that when it worsens, should be comprehensively evaluated by a cardiac specialist. ADHD Symptoms Checklist Paper

Continuing the same dose of Ritalin and re-evaluating in 4 weeks is not the best option since Katie demonstrated a partial therapeutic response from the previous dose with complaints of difficulty concentrating in the afternoon. This implies that the desired therapeutic goals were yet to be achieved with the immediate-release form of Ritalin. Similarly, it would be inappropriate to discontinue Ritalin and begin Adderall XR 15mg orally daily since Adderall also produces the side effect of tachycardia which can worsen when started at a higher dose of 15 mg (Hennissen et al., 2017). The recommended starting dose of Adderall is 10mg orally daily and PMHNPs should increase this dosage by 5-10mg daily on weekly intervals to a maximum dosage of 30mg/day.

Expected Outcomes

The PMHNP expected that, by prescribing Ritalin LA 20 mg orally daily in the morning, Katie’s attention span will increase such that, she will be able to concentrate in the morning and afternoon, she will also be able to follow rules, and maintain good relations with teachers, parents, and peers. Ritalin LA acts by blocking the reuptake of dopamine and norepinephrine which lasts for approximately eight hours (Maia et al., 2017).

Ethical Considerations

The PMHNP must consider the ethical principle of beneficence by utilizing clinical knowledge, parental values, and current evidence to promote Katie’s safety, alleviate her suffering, and strike a balance between risks and benefits of undertreated and untreated ADHD.

Decision #3

Decision Selected

Maintain current dose of Ritalin LA and reevaluate in 4 weeks

Reasons for Selecting This Decision

After four weeks, Katie returned to the clinic in the company of her parents with reports of well-controlled symptoms. She acknowledged her ability to sustain her attention throughout the day at school and diminished side effects and Katie had an appropriate heart rate for her age. These outcomes can be attributed to the long effect duration of Ritalin whose effects last for eight or more hours. Increasing Ritalin LA to 30mg orally daily is not a good option since Caye et al., (2019) recommends that, in the pharmacological management of children with ADHD, PMHNPs should strive to utilize the lowest effective dose of stimulant drugs to obtain the desired therapeutic goals.

Since Katie demonstrates a good therapeutic response with minimal side effects and well-controlled symptoms, there is no indication to increase the dosage of Ritalin. Similarly, it would not be appropriate to obtain an EKG based on her current heart rate since her pulse rate was normal (92b/min). The American Academy of Pediatrics recommends that, for all children diagnosed with ADHD to be started on stimulant medications, PMHNPs should order an EKG before being started on stimulants, all ADHD children on stimulants who have never had an EKG, and those with a persistently elevated pulse rate to identify an unknown cardiac disease (Wolraich et al., 2019).

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Expected Outcomes

Generally, the PMHNP expected that by maintaining the current dose of Ritalin LA Katie will improve significantly on the major symptoms of ADHD; impulsivity, inattention, and hyperactivity control. Apart from Katie being able to concentrate in school throughout the day, she will be able to follow rules and sustain good relations with teachers, parents, and peers. Ritalin LA is a central nervous system stimulant whose ADHD efficacy is by increasing norepinephrine and dopamine levels at the synapse to produce a classic stimulant effect in the prefrontal cortex (Huss et al., 2017). Since it is a long-acting form of Ritalin, it has a rapid onset of action and longer action duration. ADHD Symptoms Checklist Paper

Ethical Considerations

At this point, the PMHNP must consider the child’s willingness to continue with the ADHD stimulant (Ritalin), prevention of adverse effects associated with high dosages or prolonged use of stimulants, and developmental adequate self-management of the prescribed drug.

Conclusion

ADHD (Attention Deficit-Hyperactive Disorder) is among the most prevalent neurobehavioral disorder in children with the highest comorbid psychiatric issues. It is primarily characterized by impulsivity, inattentiveness, and hyperactivity.  In this case study, the most appropriate decision for the pharmacotherapy of Katie at decision point one is beginning Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning. Ritalin is a stimulant of the central nervous system and the primary choice of drug that has also been approved by the FDA to manage ADHD in children. It acts by acts by blocking the reuptake of dopamine and norepinephrine neurotransmitters by presynaptic neurons (Banaschewski et al., 2016).  Apart from being generally safe when used as prescribed, the oral form has few adverse effects.

Indecision two, the PMHNP should change to Ritalin LA 20 mg orally daily in the morning. A long-acting formulation of Ritalin decreases the cardiovascular effects of Ritalin such as tachycardia and promotes long effect duration (Haertling, Mueller & Bilke-Hentsch, 2015). In decision three, the PMHNP should maintain the current dose of Ritalin LA and reevaluate in 4 weeks. PMHNPs must strive to prescribe the lowest effective dose of stimulant drugs required to attain specific therapeutic goals in children with ADHD who demonstrate a good response to therapy (Caye et al., 2019). Besides, since it is a long-acting form of Ritalin, Ritalin LA has a rapid onset of action and longer action duration.

References

Banaschewski, T., Buitelaar, J., Chui, C. S., Coghill, D., Cortese, S., Simonoff, E., & Wong, I. C. (2016). Methylphenidate for ADHD in children and adolescents: throwing the baby out with the bathwater. Evidence-Based Mental Health, 19(4), 97-99.

Bello, N. T. (2015). Clinical utility of guanfacine extended-release in the treatment of ADHD in children and adolescents. Patient preference and adherence, 9, 877.

Caye, A., Swanson, J. M., Coghill, D., & Rohde, L. A. (2019). Treatment strategies for ADHD: an evidence-based guide to select the optimal treatment. Molecular psychiatry, 24(3), 390-408.

Gardner, K., Ruest, S., & Cummings, B. (2016). Diagnostic Uncertainty and Ethical Dilemmas in Medically Complex Pediatric Patients and Psychiatric Boarders. Hospital Pediatrics, 6(11), 689-692.

Haertling, F., Mueller, B., & Bilke-Hentsch, O. (2015). Effectiveness and safety of a long-acting, once-daily, two-phase release formulation of methylphenidate (Ritalin® LA) in school children under daily practice conditions. ADHD Attention Deficit and Hyperactivity Disorders, 7(2), 157-164.

Hennissen, L., Bakker, M. J., Banaschewski, T., Carucci, S., Coghill, D., Danckaerts, M., … & Buitelaar, J. K. (2017). Cardiovascular effects of stimulant and non-stimulant medication for children and adolescents with ADHD: a systematic review and meta-analysis of trials of methylphenidate, amphetamines, and atomoxetine. CNS drugs, 31(3), 199-215.

Huss, M., Duhan, P., Gandhi, P., Chen, C. W., Spannhuth, C., & Kumar, V. (2017). Methylphenidate dose optimization for ADHD treatment: a review of safety, efficacy, and clinical necessity. Neuropsychiatric disease and treatment.

Maia, C. R. M., Cortese, S., Caye, A., Deakin, T. K., Polanczyk, G. V., Polanczyk, C. A., & Rohde, L. A. P. (2017). Long-term efficacy of methylphenidate immediate-release for the treatment of childhood ADHD: a systematic review and meta-analysis. Journal of attention disorders, 21(1), 3-13.

Parikh, A. R., & Baker, S. E. (2016). Adult ADHD: pharmacologic treatment in the DSM-5 era. Curr Psychiatr, 15, 18-25.

Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., … & Zurhellen, W. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4). ADHD Symptoms Checklist Paper

PLEASE INCLUDE ADDITIONAL INTRODUCTION ON  ADHD, THEN CASE STUDY INTRODUCTION AND CONCLUSION. ETHICAL CONSIDERATIONS ARE FOR EACH DECISIONS PLEASE.

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.

// Attention Deficit Hyperactivity Disorder

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 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. ADHD Symptoms Checklist Paper

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.

Decision Point One

Select what you 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 ADHD Symptoms Checklist Paper

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

Select what you should do next:

Continue same dose of Ritalin and re-evaluate in 4 weeks

Change to Ritalin LA 20 mg orally daily in the MORNING

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 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

Select what you should do next:

Maintain current dose of Ritalin LA and reevaluate in 4 weeks

Increase Ritalin LA to 30 mg orally daily

Obtain EKG based on current heart rate

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. ADHD Symptoms Checklist Paper