Assessing and Treating Patients with Attention Deficit Hyperactivity Disorder Decision

Attention Deficit Hyperactive Disorder (ADHD) is a common psychiatric diagnosis. Persons with the disorder display patterns of developmentally inappropriate levels of hyperactivity and inattentiveness. The fifth manual of the Diagnostic and Statistical Manual for Mental Health Disorders (DSM-V) recognizes these disorders and clusters them into predominantly hyperactive, predominantly inattentive, and combined types.

The case presented is of an 8-year-old girl referred to the clinic by her primary care provider (PCP) for the management of ADHD. Collaborative findings revealed that the client was positive for inattentiveness, easy distractibility, forgetfulness, and poor arithmetic, spelling, and reading, as demonstrated by the Conner’s Teacher Rating Scale-Revised. Her attention span is also reportedly short. Also, she only pays attention to things she is interested in. The reports further indicated that she lacks interest in schoolwork, has difficulties completing tasks and following instructions, and does not finish her schoolwork.

Subjective findings revealed that the client states that she is okay and that she doesn’t understand where the big deal is. Her favorite subjects are art and “recess”; she finds other subjects boring and sometimes hard. As per the client’s reports, she sometimes feels “lost” in the hard subjects. The client admitted that sometimes, her mind wanders during class. She recognizes the kindness of her parents and reports that she loves them. She denies any bullying or abuse at school.

A mental status examination revealed that the client is an 8-year-old Caucasian appearing developmentally appropriate for her age. She is well-oriented to time, event, person, and place. Her speech is goal-directed, coherent, and logical. She is also well-groomed and dressed appropriately for events and weather. Her mood is euthymic, and her affect is bright. She denies any visual or auditory hallucinations, delusional thoughts, or paranoia. Her attention and concentration during the examination are intact, and her insight and judgment are appropriate. She denies having any suicidal ideation or tendencies.

Decision#1: Ritalin 10mg chewable tablet

The first decision point is to start the client on Ritalin 10mg chewable tablet. Ritalin, methylphenidate, is a stimulant medication that is FDA-approved for the management of ADHD. It maintains effectiveness in alleviating ADHD symptoms and is tolerated in children (Jaeschke et al., 2021). This medication helps lessen hyperactivity and impulsivity that characterize ADHD and are apparent in the case presented. The child, in this case, could benefit from this intervention.

The decision point was aimed at reducing impulsivity while enhancing the client’s focus on low-interest activities and concentration. Ritalin reduced impulsivity and improved the general clinical outcomes in the client’s case presented. It acts by increasing the levels of norepinephrine and dopamine in the central nervous system. This enhances the client’s concentration and diminishes their hyperactive behavior (Jaeschke et al., 2021). For the management of ADHD in children, chewable tablets are recommended due to their palatability. At a starting dose of 10mg, this medication maintains effectiveness in managing ADHD. This explains why the client was started on the 10mg strength.

The ethical concern that comes into play when communicating with the client is beneficence. The caregiver, in this respect, is obligated to act in the best interest of the client. This includes making decisions that will better guarantee their wellness. Being a minor, informed consent may also be required from the parents before initiating therapy.

Decision Point#2: Ritalin LA 20mg

The second decision point is to switch to a long-acting dosage form and double the dose. This dose increments and switch to the long-acting formulation were necessitated by the partial response to the 10mg dose. As evident in the case, the effects of the medications were mostly felt in the morning but weaned through the afternoon, with manifestations such as daydreaming and staring off into space being apparent. Matthijssen et al. (2019) note that extended-release formulations of methylphenidate guarantee better symptomatic control over time. Their long duration of action allows for once-daily dosing with a greater assurance of symptomatic relief throughout the day. Doubling the dose was necessitated due to the partial response to Ritalin. Doubling the dose helps in optimizing the clinical responses to the medications and is warranted where clinical responses to methylphenidate are suboptimal (Drechsler et al., 2020). These findings justified the need to switch to Ritalin 20mg LA.

This decision point was aimed at optimizing the clinical responses to Ritalin. As evident in the case, the client achieved suboptimal symptom control after being started on Ritalin 10mg. Doubling the dose and switching to the long-acting formulation may be beneficial in optimizing the clinical responses to the medication (Matthijssen et al., 2019). This informed this decision point.

The ethical concern that comes into play in this decision point is beneficence. In this respect, caregivers maintain the obligation to ensure the welfare of their clients by selecting care approaches that optimize their client’s clinical outcomes. Switching to Ritalin 20mg LA served to optimize the clinical response of the client in the case.

Decision Point#3: Maintain Current Dose and Reevaluate in 4 weeks

The third decision point was to maintain the current dose of Ritalin 20mg LA and reevaluate the client after four weeks. This decision point proceeded to the attainment of optimal control of ADHD as demonstrated by sustained attention in school and the tolerability of the medication. At this point, there was no concern about side effects, increasing the dose, or switching to other medication. During the comprehensive management of ADHD, caregiver-patient interactions are necessary for the optimization of therapy. Kolko et al. (2020) note that pharmacotherapy in ADHD can only be optimized in the presence of continuous interactions between the patient and their caregivers. This warrants timely follow-up appointments for all clients under medication management for ADHD. The client, in this case, is set to be reevaluated after four weeks.

This decision point was aimed at maintaining an optimized response to the selected interventions. Maintaining the dose of methylphenidate was necessary as the disease control was optimal, and the side effects of the medication were well tolerated. Reevaluation was also necessary as it helps guarantee optimal ADHD control in the long term. Continuous reevaluation helps in improving client-caregiver interactions thereby optimizing pharmacotherapy for ADHD (Kolko et al., 2020). The client in the case presented may benefit from such follow-up appointments.

An ethical concern that comes into play during this decision point is centered around the principles of beneficence and autonomy. Beneficence puts much emphasis on the caregiver’s role in bettering the health of their clients. In this respect, caregivers involved in the management of the client must make the best choices that ensure improved clinical outcomes for their client. Likewise, the principle of autonomy works towards improving the clinical outcomes of the client. However, autonomy requires the client to make independent decisions on healthcare interventions targeted at them. This includes decisions on clinical visitations. Caregivers, in this respect, are expected to help their clients make informed decisions by educating them on the need for such follow-up visits.

Conclusions

The case presented was of an 8-year-old Caucasian girl referred to the clinic with suspicions of ADHD. Subjective and collaborative findings revealed symptoms consistent with those of ADHD. ADHD is a psychiatric disorder characterized by hyperactivity and inattentiveness. Persons with this disorder will manifest symptoms such as inattentiveness, forgetfulness, easy distractibility, difficulty completing tasks, difficulty concentrating, disorganization, and ease of losing things. Per the DSM-5 criteria for ADHD, a positive diagnosis of the disorder is made in the presence of these symptoms, in which the symptoms persist for over six months and occur in two or more settings (DSM-5-TR, 2022). In the case presented, the findings were consistent with the DSM description of ADHD, affirming the ADHD diagnosis.

Comprehensive management of ADHD utilizes psychotherapies and pharmacotherapeutic modalities. Pharmacotherapy is the mainstay modality for managing ADHD. Medications utilized to manage these conditions can be classified into stimulants and non-stimulant medications. Stimulant medications include amphetamine and methylphenidate. These medications act by increasing the levels of dopamine and norepinephrine in the CNS and are effective in diminishing impulsivity and increasing attentiveness and concentration.

Methylphenidate is FDA-approved in the management of ADHD. Initiated at low doses, this medication is effective in alleviating ADHD symptoms. The course of treatment with methylphenidate often depends on the clinical response of the patients. The extended-release formulations are the mainstay in the maintenance phase of the disease. They allow flexibility in dosing and provide a better guarantee of all-fay relief of symptoms. Patients can thus benefit from these extended-release formulations. In the case presented, Ritalin 20mg long-acting formulation was used.

References

Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current concepts and treatments in children and adolescents. Neuropediatrics, 51(05), 315–335. https://doi.org/10.1055/s-0040-1701658

DSM-5-TR. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR. American Psychiatric Association Publishing.

Jaeschke, R. R., Sujkowska, E., & Sowa-Kućma, M. (2021). Methylphenidate for attention-deficit/hyperactivity disorder in adults: A narrative review. Psychopharmacology, 238(10), 2667–2691. https://doi.org/10.1007/s00213-021-05946-0

Kolko, D. J., Hart, J. A., Campo, J., Sakolsky, D., Rounds, J., Wolraich, M. L., & Wisniewski, S. R. (2020). Effects of collaborative care for comorbid attention deficit hyperactivity disorder among children with behavior problems in Pediatric Primary Care. Clinical Pediatrics, 59(8), 787–800. https://doi.org/10.1177/0009922820920013

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 2 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

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

Question

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.

Assessing and Treating Patients with Attention Deficit Hyperactivity Disorder Decision

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)

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.

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. The effect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backward from 100 by serial 2s 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 #1
Ritalin 10mg chewable
RESULTS OF DECISION POINT ONE
• Client returns to the 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 # 2
Ritalin LA 20mg
RESULTS OF DECISION POINT TWO
• Client returns to the 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

DECSION #3
Maintain current dose and reevaluate in 4 weeks

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 the 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 HR.

Assessing and Treating Patients with Attention Deficit Hyperactivity Disorder Decision