NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology

Week 9

Attention Deficit Hyperactivity Disorder: A Young Girl With ADHD

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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. Attention Deficit Hyperactivity Disorder: A Young Girl With ADHD Essay. 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.

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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. Attention Deficit Hyperactivity Disorder: A Young Girl With ADHD Essay.

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

For each decisions point answer the following

Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision Point One
Select what the PMHNP 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
Decision Point Two
Select what the PMHNP should do next:
Increase Intuniv to 2 mg orally at BEDTIME
Discontinue Intuniv and begin Dexedrine (dextroamphetamine) 5 mg orally daily
Discontinue Intuniv and begin Focalin (dexmethylphenidate) XR 10 mg orally daily
Decision Point Three
Select what the PMHNP should do next:
Maintain current dose of Focalin XR and re-evaluate at next clinic visit in 4 weeks
Increase Focalin XR to 20 mg orally daily
Discontinue Focalin XR and begin Strattera (atomoxetine) 10 mg orally daily

References
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.
Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. doi:10.2165/11599630-000000000-00000
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Clients, including children, are diagnosed with various mental and psychiatric conditions. This paper focuses on diagnosing and treating an 8-year-old girl presented with school difficulties. The client has diagnosed with Attention deficit hyperactivity disorder, predominantly inattentive presentation. Three significant decisions will be made to treat the presented symptoms.

Decision Point One

The Selected Decision

This client will first be administered with Intuniv extended-release 1 mg orally at bedtime.

Reason for Selecting this Decision

This medication was selected due to its efficacy and safety in treating ADHD in children. Psychotherapists use this medication together with psychological, social, and education initiatives to develop a complete treatment plan for children struggling with ADHD. Attention Deficit Hyperactivity Disorder: A Young Girl With ADHD Essay. FDA approved the use of extended-release of Intuniv in treating the symptoms of ADHD among adolescents and children aged 6 to 17 years (Joseph et al., 2017). Additionally, this drug is preferred to manage ADHD symptoms in children since it is not a stimulant (Huss et al., 2018). Its working mechanism involves the receptors found in the brain, thus strengthening working memory. This move, in turn, lowers the level of distraction and boosts the control of attention and impulse.

Expected Results

The medication was expected to reduce ADHD symptoms, including inattentiveness, high distraction, forgetfulness, poor spelling, and inability to read and complete the arithmetic computation.

Difference between the Expected and Achieved Results

The achieved results differed from the expected outcomes. Although Katie’s parents reported some differences when they returned to the clinic after four weeks, the results did not meet the expectations. Specifically, she portrayed improvement in the symptoms in the morning. For instance, she was attentive in the morning and was not easily distracted. However,

Katie demonstrated some symptoms of ADHD in the afternoon, disrupting her academic performance. Also, Katie’s heartbeat was relatively high (130 beats per minute). Consequently, decision point 2 was necessary to improve the presented symptoms.

Decision Point Two

The Selected Decision

            Secondly, the PMHNP selected to discontinue Intuniv and begin Focalin (dexmethylphenidate) XR 10 mg orally daily.

Reasons for Selecting this Decision

            The PMHNP selected due to its effectiveness in managing ADHD symptoms in children. Dexmethylphenidate and methylphenidate are effective in treating the symptoms of ADHD in children (Luan et al., 2017). Nonetheless, dexmethylphenidate has a long-lasting impact. Children should initially be administered a dose of dexmethylphenidate, which is 50% of the methylphenidate. Although both medications have a similar half-life, dexmethylphenidate’s clinical efficacy is relatively longer than that of methylphenidate (Brown, 2018). Also, the use of methylphenidate in managing the symptoms of ADHD is limited due to its wide range of side effects (Victor, 2016). Therefore, individuals taking dexmethylphenidate do not need midday dosage. Attention Deficit Hyperactivity Disorder: A Young Girl With ADHD Essay.

Expected Results

The PMHNP expected dexmethylphenidate 10 mg orally daily to reduce ADHD symptoms portrayed by Kattie, including inattentiveness, distraction, forgetting what she had learned in class, poor spelling, and being attentive to what she was interested in only.

Difference between the Expected and Achieved Results

            No difference was reported between the achieved and the expected results upon returning to the clinic after four weeks. Katie’s parents reported a significant improvement in her academic performance. Additionally, her heartbeat had reduced from approximately 130 to 92 beats per minute. At this point, the PMHNP made decision point three.

Decision Point Three

The Selected Decision

The PMHNP decided to continue with the current dose of Focalin XR and re-evaluate the client at the next clinic visit after four weeks.

Reason for the Selected Decision

This decision was based on the effectiveness of the current dosage in managing the reported symptoms of ADHD. In the previous visit, Kattie’s parent reported a significant improvement in her academic performance, indicating Focalin’s effectiveness (dexmethylphenidate) XR 10 mg orally daily in managing the symptoms of this condition. Therefore, further improvements would be reported upon continuing with the current medication. Additionally, this dosage of dexmethylphenidate is not associated with any side effects.

Expected Results

Dexmethylphenidate 10 mg treat the presented symptoms of ADHD. Therefore, Kattie’s teacher would not report any inattentiveness, distraction, forgetfulness, and poor spelling. More, so Kattie would start being attentive in all class activities rather than what she was interested in only.

Difference between the Expected and Achieved Results

The was no difference between the achieved and the expected results. All the symptoms of ADHD presented by Katie were well controlled. Thus, the client should be advised to continue with the current dosage of dexmethylphenidate since one should strive to maintain the minimum dosage of the described medication.

In conclusion, various medications are used to manage the symptoms of ADHD in children. Examples of these medications include Intuniv extended-release 1 mg taken orally at the bedtime and Focalin XR 10 mg taken orally daily. The PMHNP begins with a particular medication, and another decision is made based on the results of the first one. An alternative medication is prescribed if the first one is ineffective or is associated with many side effects that the client cannot tolerate. However, the client is advised to continue taking the current medication if it effectively manages the presented symptoms.

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References

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.

Huss, M., Dirks, B., Gu, J., Robertson, B., Newcorn, J. H., & Ramos-Quiroga, J. A. (2018). Long-term safety and efficacy of guanfacine extended-release in children and adolescents with ADHD. European child & adolescent psychiatry, 27(10), 1283-1294.

Joseph, A., Ayyagari, R., Xie, M., Cai, S., Xie, J., Huss, M., & Sikirica, V. (2017). Comparative efficacy and safety of attention-deficit/hyperactivity disorder pharmacotherapies, including guanfacine and extended-release, are a mixed treatment comparison. European child & adolescent psychiatry, 26(8), 875-897.

Luan, R., Mu, Z., Yue, F., & He, S. (2017). Efficacy and tolerability of different interventions in children and adolescents with attention deficit hyperactivity disorder. Frontiers in Psychiatry, 8, 229.

Victor R. P. (2016). Neuropathology of Drug Addictions and Substance Misuse: General Processes and Mechanisms, Prescription Medications, Caffeine and Areca, Polydrug Misuse, Emerging Addictions, and Non-Drug Addictions. London: King’s College London. Attention Deficit Hyperactivity Disorder: A Young Girl With ADHD Essay.