Assessing and Treating a Patient with Attention Deficit Hyperactivity Disorder

Assessing and Treating a Patient with Attention Deficit Hyperactivity Disorder

Katie, a Caucasian 8-year-old girl, is brought to the office by her parents after her teacher suspected that she could have ADHD. They were sent to the office for further evaluation by their PCP, who brought along a “Conner’s Teacher Rating Scale-Revised” form that Katie’s teacher had completed. The form highlights Katie’s difficulties with spelling, reading, and math, as well as her lack of focus, distractibility, and forgetfulness. The teacher also mentioned Katie’s short attention span, lack of interest in schoolwork, complete lack of ability to follow instructions, and beginning projects that she never finishes. Katie’s parents say she doesn’t have ADHD since she is not hyperactive, rebellious, or short-tempered.

Katie, during the assessment, says that she feels okay and there is nothing wrong with her. She notes art and recess are her favorite topics and claims that the other subjects are boring, difficult, and unsettling. She freely admits to daydreaming about activities she thinks are fun during class. She adds that she adores her parents and has no issues at home. She says she’s never been mistreated or bullied and has no additional worries.

According to Katie’s mental status examination, she is physically and verbally well-developed for her age. She is dressed appropriately for the weather and is aware of persons, places, times, and events. She is in a cheerful, euthymic mood with no indications of hallucinations, delusions, or paranoid thinking. She can do activities requiring serial counting without trouble, and her attention and focus are grossly intact. She denies having any suicidal or homicidal ideation, and her insight and judgment are age-appropriate. Katie is diagnosed with predominantly inattentive attention deficit hyperactivity disorder.

Decision Point #1

The first decision in managing Katie’s condition is to begin Wellbutrin (Bupropion) XL 150 mg orally daily. This decision is made because Katie’s primary presentation is predominantly inattentive, a type of ADHD. This shows her brain has trouble focusing, organizing, and remembering information or actions. Wellbutrin is a norepinephrine reuptake inhibitor (NRI). The decision to use Wellbutrin (Bupropion) XL 150 mg is supported by evidence as research has shown that Bupropion has proven to be effective and safe in managing children, adolescents, and adult populations with depressive and ADHD-I symptoms (Kweon & Kim, 2019; Ng, 2017).

The other two options, Intuniv extended release 1 mg and Ritalin (methylphenidate) chewable tablets 10 mg were not selected for various reasons. For instance, although Intuniv extended release 1 mg is effective in managing ADHD, it focuses on addressing factors of hyperactivity and impulsivity, which Katie does not present. On the other hand, although Ritalin (methylphenidate) chewable tablets 10 mg is a stimulant and first-line choice to address predominantly inattentive-type ADHD, it is not selected due to considerations of tolerability and potential side effects of stimulant medications on Katie, who is only 8-years-old. Additionally, stimulants risk worsening comorbid mental issues such as lack of sleep, mood, and anxiety disorders (Ng, 2017).

Selecting Wellbutrin (Bupropion) XL 150 mg as the first choice for Katie aims at her inattention and related symptoms such as distractibility and forgetfulness. It will also reduce the risk of hyperactivity, impulsivity, and other side effects associated with the other stimulant options (Ng, 2017). Ethical considerations will guide decisions and communication with Katie and her parents. For instance, ethical considerations such as safety and beneficence guide medication choices, such as the need to avoid side effects and associated risks. Additionally, since Katie cannot make her own decisions, autonomy is considered in decisions as her parents are informed of the possible choices and their benefits and risks and are involved in the selection of the medications. Top of Form

Decision Point #2

The second decision was to educate Katie’s parents that Bupropion sometimes causes suicidal ideation in children and that they needed to restart administering the drug at the previous dose. Educating Katie’s parents on the side effects of Bupropion and why they needed to continue with the medication was to address their fears and risks of discontinuing the medication. Sometimes, the parent’s and child’s beliefs, attitudes, and concerns affect the adherence to pharmacological treatment of ADHD (McCarthy, 2014). Non-adherence to medication treatment is associated with costly wastage of medications as well as a risk factor for increased ill health (While 2020).

The other choices, discontinuing Wellbutrin and beginning on either Strattera (atomoxetine) 10 mg or Adderall (amphetamine d, l) extended-release 5 mg, were not selected for reasons specific to each drug. For instance, Strattera (atomoxetine) 10 mg has major side effects, which would be concerning for an 8-year-old as it increases the risk of suicidal ideation and suicide behaviors in ADHD patients (Kim et al., 2023). In the case of Adderall (amphetamine d, l) extended-release 5 mg, it was not an option as it is a stimulant, and simulants risk altering Katie’s moods and exacerbating her current suicidal ideation.

Educating Katie’s parents on the side effects of Bupropion and the need to restart the drug at the previous dose aims to address the parents’ concerns and risks of not administering the medication to Katie. It also aims to improve adherence to the treatment as evidence from a randomized controlled trial of educating rheumatoid arthritis patients showed improved adherence to medication after the education (Taibanguay et al., 2019). Ethics will influence communication with Katie’s parents by focusing on the principles of safety, justice, and informed consent. The education must consider the severity of Katie’s suicidal behaviors, the safety concerns associated with discontinuing her current medication and starting a new regimen, and her parent’s concerns and what they need to know. Top of Form

Decision Point #3

On the third visit to the clinic, the decision for Katie’s care was to refer the parents to a pediatric psychologist who could use behavioral therapy to treat Katie’s ADHD. The reason for this decision is based on their complaints that Kate’s suicidal behaviors have worsened, considering that she now has dreams of herself being dead. This shows that Katie cannot tolerate Wellbutrin (Bupropion) XL 150 mg. As Wellbutrin (Bupropion) XL 150 mg is the only option among the available medications to help manage Katie’s predominantly inattentive ADHD, it is important to now consider alternative treatment options. Pharmacological interventions for ADHD are associated with an increased risk of intolerable side effects in preschool children and adolescents (Young et al., 2021). Discontinuation of pharmacological interventions is advised, and behavioral interventions are recommended in such cases (Ogundele & Ayyash, 2023).

The other options to do nothing and explain to the parents that Katie’s ADHD will most likely improve with age as her prefrontal cortex grows and matures and to discuss the use of a medication such as Adderall and its evidence for treating ADHD were not selected. I hope that Katie’s symptoms will improve as she ages. She is unprofessional and is not proactive in managing Katie’s condition and risks future complications. Additionally, the other option, Adderall, is not an option at the moment due to safety and suicidal ideation concerns.

Referring the parents to a pediatric psychologist will provide non-pharmacological options for Katie. Psychologists can apply behavioral therapy to treat Katie’s ADHD. Options such as Behavioral therapy (BT), Cognitive behavior therapy (CBT), and group-based parental Psychoeducation can benefit Katie and her parents, too (Ogundele & Ayyash, 2023). Ethical considerations at this point are on Katie’s safety, beneficence, and privacy. The most beneficial alternative to reduce Katie’s risks needs to be considered. The communication must also consider Katie’s and her parents’ privacy and willingness to transfer to a new care provider.

Conclusion

Katie, based on her presented symptoms, has predominantly inattentive ADHD. Various treatments have been made. Firstly, despite the available effective options for managing ADHD, Wellbutrin (Bupropion) XL 150 mg is the best option, considering the patient’s safety based on her age. Wellbutrin (Bupropion) is the first option and recommended medication due to its efficacy in addressing symptoms related to predominantly inattentive ADHD (Kweon & Kim, 2019). Other options, such as the available stimulants, although effective in managing ADHD, are not an option due to her age and concerns over the risk of leading to and exacerbating sleep, anxiety, and mood disorders (Ng, 2017). The other recommendation, to take Katie to a pediatric psychologist for behavioral therapy to treat Katie’s ADHD, is based on the consideration of the pediatric psychologist’s understanding of pediatric neurodevelopmental disorders and options for non-pharmacological therapies for ADHD and managing suicidal ideation in young children. The pediatric psychologist can develop behavioral therapy interventions for both Katie and her parents, such as CBT and group-based parental Psychoeducation. CBT is provided as group therapy alongside other Psychoeducation and pharmacological interventions to improve coping and organizational skills and techniques to manage her attention and focus, as well as caregivers’ mental health (Haugan et al., 2022). Notably,  all decisions made, including the use and discontinuation of the treatment using Wellbutrin (Bupropion) and the recommendation to seek the help of a pediatric psychologist in the care for Katie, are justifiable as the focus is on improving Katie’s ADHD symptoms, reduce the risks of side effects, and to improving her coping abilities.

References

Haugan, A. L. J., Sund, A. M., Young, S., Thomsen, P. H., Lydersen, S., & Nøvik, T. S. (2022). Cognitive behavioural group therapy as addition to Psychoeducation and pharmacological treatment for adolescents with ADHD symptoms and related impairments: A randomised controlled trial. BMC Psychiatry, 22(1). https://doi.org/10.1186/s12888-022-04019-6

Kim, J. H., Park, S., & Lee, Y. J. (2023). Systematic Review of Suicidal Behaviors Related to Methylphenidate and Atomoxetine in Patients With Attention Deficit Hyperactivity Disorder. Journal of the Korean Academy of Child and Adolescent Psychiatry, 34(2), 125. https://doi.org/10.5765/JKACAP.220040

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. https://doi.org/10.9758/CPN.2019.17.4.537

McCarthy, S. (2014). Pharmacological interventions for ADHD: How do adolescent and adult patient beliefs and attitudes impact treatment adherence? In Patient Preference and Adherence (Vol. 8). https://doi.org/10.2147/PPA.S42145

Ng, Q. X. (2017). A Systematic Review of the Use of Bupropion for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Journal of Child and Adolescent Psychopharmacology, 27(2), 112–116. https://doi.org/10.1089/CAP.2016.0124

Ogundele, M. O., & Ayyash, H. F. (2023). ADHD in children and adolescents: Review of the current practice of non-pharmacological and behavioral management. AIMS Public Health, 10(1), 35. https://doi.org/10.3934/PUBLICHEALTH.2023004

Taibanguay, N., Chaiamnuay, S., Asavatanabodee, P., & Narongroeknawin, P. (2019). Effect of patient education on medication adherence of patients with rheumatoid arthritis: a randomized controlled trial. Patient Preference and Adherence, 13, 119–129. https://doi.org/10.2147/PPA.S192008

While, A. (2020). Medication adherence: understanding the issues and finding solutions. British Journal of Community Nursing, 25(10), 474–479. https://doi.org/10.12968/BJCN.2020.25.10.474

Young, J. R., Yanagihara, A., Dew, R., & Kollins, S. H. (2021). Pharmacotherapy for Preschool Children with Attention Deficit Hyperactivity Disorder (ADHD): Current Status and Future Directions. CNS Drugs, 35(4), 403–424. https://doi.org/10.1007/S40263-021-00806-Z/

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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.

Assessing and Treating a Patient with Attention Deficit Hyperactivity Disorder

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.