Case Studies – Attention Deficit Hyperactivity Disorder

Case Studies – Attention Deficit Hyperactivity Disorder 

The patient, Katie, is a Caucasian female aged eight years. Her parents bring her for psychiatric review. According to her parents, Katie’s teacher implied that their daughter may have attention deficit hyperactivity disorder (ADHD). As such, their primary care provider referred them to a psychiatric-mental health nurse practitioner. Katie’s teacher completed Conner’s Teacher Rating Scale-Revised. This is a questionnaire completed by a child’s teacher. It is an essential component of the workup in the diagnosis of ADHD.

According to the teacher’s evaluation, Katie has a short attention span, is forgetful and distracted, and performs dismally in spelling tests, reading, and mathematics. She has a short attention span and is known to focus on only the things that interest her. According to the teacher, she lacks enthusiasm for schoolwork and is easily sidetracked. Katie is known for starting tasks but never finishing them, not always doing as she is told, and not completing her assignments. According to Katie, she fails to understand the cause of the alarm. She reports that school is okay and that she enjoys art and recess. According to her, other subjects do not intrigue her. She admits to having a short attention span. Additionally, she denies abuse, bullying, suicidal ideations, hallucinations, delusions, or paranoia.

In this context, relevant patient factors that affect the prescription decision-making process include the patient’s age, medical history, and absence of comorbidities. The patient is aged eight years. Children have poorly developed metabolic pathways (Aldin Sharifnia et al., 2018). Therefore, this necessitates accurate dose calculation and appropriate drug selection. In the context of medical history, the patient has never received treatment for ADHD. In addition, she is not on any other medication. This eliminates the likelihood of polypharmacy or drug interactions (Peugh et al., 2020). Furthermore, the patient lacks any comorbidity that may lead to contraindications of specific treatment options.

Decision 1

The first decision is to begin Ritalin (methylphenidate) chewable tablets of 10 mg orally in the morning. My decision was guided by the guidelines of the American Academy of Pediatrics for the management of ADHD. According to these guidelines, FDA-approved medications should be prescribed for ADHD in children aged above six years (Wolraich et al., 2019). Methylphenidate is the first-line FDA-approved treatment of choice for managing children with ADHD aged six years and above (Wolraich et al., 2019). Methylphenidate is ideal for Katie because she is aged eight years. Additionally, there is no known hypersensitivity to methylphenidate that could contraindicate its use.

Medical history reveals that the patient is not on medications such as monoamine oxidase inhibitors that would warrant contraindication. Additionally, the patient lacks comorbidities such as hypertension, tachycardia, or other cardiovascular problems that may contraindicate the use of methylphenidate (Wilens et al., 2022). Examination revealed that the patient is appropriately developed for her age. As such, the need to use methylphenidate (a stimulant) with caution is eliminated. The risk of abuse is minimal because the patient is under the custody of her parents. Therefore, the patient is an ideal candidate for a low dose of methylphenidate.

The other options are initiating Ritalin LA 20 mg orally daily in the morning and maintaining this dose (20mg) for four more weeks. I did not select these options because they are initiated at a higher dose. This is undesirable because higher doses are associated with a higher risk of adverse effects (Storebø et al., 2018). By selecting Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning, I was hoping to evaluate the toxicity profile of the drug. This includes hypersensitivity reactions, adverse events, and response to treatment (Storebø et al., 2018). Ethical considerations can impact my interactions with the patient and her family. For example, autonomy requires involving the patient’s parents in clinical decision-making (McDermott-Levy et al., 2018).

Decision 2

The second decision is to change the medication to Ritalin LA 20 mg orally daily in the morning. I selected this option after reviewing the patient. Four weeks after initiating 10 mg of Ritalin every morning, follow-up indicates that the patient’s symptoms have improved in the morning. However, the symptom recurs in the afternoon. This finding reveals that the immediate-release formulation of Ritalin 10 mg does not provide a sustained therapeutic effect to last the whole day. This necessitates the selection of an extended-release formulation (Wolraich et al., 2019). As such, Ritalin LA 20 mg is chosen. Extended-release formulations provide a prolonged effect of about 10 hours because the drug is released slowly into the bloodstream (Wilens et al., 2022). Additionally, extended-release formulations are associated with a low adverse effects profile because the drug is released slowly over a long period (Wilens et al., 2022). As such, Ritalin LA 20 mg will avert the adverse effect of elevated pulse rate reported by Katie.

I did not select the other two options because they would have worsened the patient’s condition. Initially, I had initiated Ritalin (methylphenidate) chewable tablets of 10 mg orally in the morning. Maintaining this option implies that the patient would not control the symptoms that occur in the afternoon. Furthermore, it would worsen the drug’s adverse effect (elevated pulse rate of approximately 130 beats per minute). The third option is to maintain the dose of Ritalin LA at 20 mg and review after four weeks. This option is not feasible because I had not initiated this regimen.

The principles of healthcare ethics would impact my treatment plan and communication with the patient and her family. Non-maleficence and beneficence require healthcare providers to engage in practices that do not harm the patient and those that benefit the patient, respectively (McDermott-Levy et al., 2018). In this context, the first clinical decision was associated with an adverse effect and suboptimal outcomes. As such, modifying the regimen to an extended-release formulation ensures that the patient benefits from treatment.

Decision 3

The third decision is to maintain the current dose of Ritalin LA (20 mg) and reevaluate in four weeks. This is relevant because this dose yielded positive results. Before initiating Ritalin LA 20 mg orally daily, the patient’s pulse rate was elevated. Furthermore, her symptoms were not adequately controlled, as evidenced by daydreaming in the afternoon. After initiating this treatment, the patient’s symptoms improved significantly, and she no longer had episodes in the afternoon. Additionally, her pulse rate stabilized, as evidenced by a decrease from 130 to 92 beats per minute. Therefore, the current dose of Ritalin LA (20 mg) should be maintained, and the patient should be reviewed after four weeks.

I did not select the other two options because they would have worsened the patient’s condition. As aforementioned, 10 mg of Ritalin was associated with suboptimal clinical outcomes and adverse effects. This is evidenced by the recurrence of the symptom in the afternoon and an elevated pulse rate (Wilens et al., 2022). This implies that this option would not benefit the patient. The other option is changing the drug to Ritalin LA 20 mg orally daily in the morning. This is not applicable in this context (decision 3) because this intervention had already been initiated.

Ethical considerations relevant to this decision-making process are autonomy, beneficence, and non-maleficence. The patient and her parents should be actively involved in the decision-making process. This includes addressing issues such as potential adverse events and compliance issues. On the other hand, healthcare providers should ensure that all clinical decisions are evidence-based and benefit the patient (McDermott-Levy et al., 2018). The healthcare provider should also assess the patient’s safety and responses to treatment by conducting monthly reviews.

Conclusion

The recommended treatment option for this patient is methylphenidate. The FDA-approved treatment of choice for ADHD in children aged six years and above is methylphenidate (Wolraich et al., 2019). Methylphenidate is used frequently and is variable in different formulations, such as immediate-, delayed, and sustained-release formulations. In this context, the patient presents with manifestations of ADHD. This necessitates treatment initiation. The first decision is to initiate a low dose of immediate-release methylphenidate. Accordingly, I started Ritalin (methylphenidate) chewable tablets of 10 mg orally in the morning. The exact mechanism of action of this drug is unknown. However, it may inhibit the reuptake of dopamine and noradrenaline in the presynaptic neurons (Wilens et al., 2022).

Furthermore, it may activate the cerebral cortex and other cortical structures (Storebø et al., 2018). After initiating this dosage of Ritalin, the patient’s follow-ups revealed that the clinical outcomes were suboptimal, as evidenced by the occurrence of symptoms in the afternoons. Additionally, this formulation affected the patient by elevating her pulse rate.

The initiation of Ritalin LA 20 mg orally daily in the morning significantly improved patient outcomes. As aforementioned, extended-release formulations provide a prolonged effect of about 10 hours because the drug is released slowly into the bloodstream (Wilens et al., 2022). Additionally, extended-release formulations are associated with a low adverse effects profile because the drug is released slowly over a long period (Wilens et al., 2022). The patient review revealed that her symptoms were adequately controlled by Ritalin LA 20 mg. This formed the basis of the third clinical decision to maintain the current dose and review the patient after four weeks.

References

aldin Sharifnia, S. H., Mohammadzadeh, M., Arzani, G., Salamzadeh, J., Abolfazli, S. A., Zali, A., & Khoshdel, A. R. (2018). Main factors affecting physicians’ prescribing decisions: the Iranian experience. Iranian Journal of Pharmaceutical Research, 17(3), 1105–1115. http://ijpr.sbmu.ac.ir/article_2260_75dd1e768b0ed39071953fb25e634907.pdf%0Ahttp://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emexa&NEWS=N&AN=623038325

McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical Principles and Guidelines of Global Health Nursing Practice. Nursing Outlook, 66(5), 473–481. https://doi.org/10.1016/j.outlook.2018.06.013

Peugh, J., Brinkman, W. B., Baum, R., & Kelleher, K. J. (2020). Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings. 155–162. https://doi.org/10.1016/j.jpeds.2019.06.025.

Storebø, O. J., Pedersen, N., Ramstad, E., Kielsholm, M. L., Nielsen, S. S., Krogh, H. B., & Gluud, C. (2018). Methylphenidate for attention deficit hyperactivity disorder (ADHD) in children and adolescents–assessment of adverse events in non-randomized studies. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012069.pub2/full

Wilens, T. E., Faraone, S. V., Hammerness, P. G., Pliszka, S. R., Uchida, C. L., DeSousa, N. J., Sallee, F. R., Incledon, B., & Newcorn, J. H. (2022). Clinically Meaningful Improvements in Early Morning and Late Afternoon/Evening Functional Impairment in Children with ADHD Treated with Delayed-Release and Extended-Release Methylphenidate. Journal of Attention Disorders, 26(5), 696–705. https://doi.org/10.1177/10870547211020073

Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., & Zurhellen, W. (2019). Clinical practice guideline for diagnosing, evaluating, and treating attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4). https://doi.org/10.1542/peds.2019-2528

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Case Studies – Attention Deficit Hyperactivity Disorder

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. Consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
You should evaluate all options at each decision point before deciding and moving throughout the exercise. Before making your decision, ensure that you have researched each option and considered the decision you will select. Be sure to research each option using the primary literature.

Attention Deficit Hyperactivity Disorder Case Study

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 suggestions 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 reasoning, it will not count toward the resource requirement. It would be best if you were utilizing the primary and secondary literature.