Assignment: Assessing and Treating Patients With ADHD

Assignment: Assessing and Treating Patients With ADHD

Assignment: Assessing and Treating Patients With ADHD

Assessing and Treating Patients with ADHD
This case study is about Katie, an 8-year-old Caucasian female that has been brought to the office for assessment by her parents. Their primary care provider referred Katie for psychiatric evaluation, as she felt that she might have ADHD. The parents submit the Conner’s Teacher Rating Scale-Revised that shows that Katie’s teacher reported Katie to be inattentive, easily distracted, forgets things easily, and poor in spelling, arithmetic and reading. She also has short attention span, lacked interest in schoolwork, and rarely follows instructions or starts things but never finishes them. Katie’s parents denied that their daughter has ADHD, as she has not demonstrated abnormal behaviors. Katie acknowledged that she finds other subjects besides arts and recess boring. She also reported feeling lost, her mind wandering, and distracted in class activities. Mental status examination revealed Katie having grossly intact attention and concentration with euthymic mood and absence of delusions, hallucinations or suicidal thoughts.

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The patient factors that would influence decisions made when prescribing medications for Katie are varied. One of them is age. Age influences the pharmacokinetics and pharmacotherapy of medications, hence, selective prescription when dealing with children and the elderly. The other factor is the Conner’s Teachers Rating Scale-Revised score. The aim will be to improve to score, as way of enhancing Katie’s behaviors and functioning in social and academic activities. Therefore, the aim of the treatment in this case study would be to improve the Conner’s Teacher Rating Scale-Revised, as it will indicate an improvement in Katie’s cognitive and behavioral functioning. The treatment seeks to improve aspects such as attention span and Katie’s ability to engage in complex tasks as well as complete assigned tasks and follow instructions.
Decision Point One
Selected Decision
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.
Reason for Selection
Ritalin is a central nervous system stimulant recommended for use in treating ADHD in children. It exerts its effects on the dopaminergic system in the prefrontal complex to cause inhibitory control of the limbic system (Tarrant et al., 2018). The findings in the study by Pertermann et al., (2019) informed the decision to administer Ritalin. Besides it being the recommended drug for children with ADHD aged above 6 years according to the study by Tarrant et al. (2018), Ritalin also modulates the neural noise that contribute to the cognitive and behavioral symptoms associated with ADHD in children (Pertermann et al., 2019).
Why the Other Options Were Not Selected
I did not select the option to begin Wellbutrin (bupropion) XL 150 mg orally daily because it is recommended for use in treating ADHD in adults (Deang et al., 2019). The findings by Xiang (2017) also do not recommend the use of Wellbutrin in children, as they found that Wellbutrin has smaller effect sizes when compared to Ritalin. I also did not select the decision to begin Intuniv extended release 1 mg orally at bedtime because it is only indicated for use in cases where patients cannot tolerate stimulants such as Ritalin. It is also indicated in cases where stimulants have been found ineffective (Webb, 2019). The effectiveness of other stimulants has not been established, hence, the decision not to administer Intuniv.
What I Was Hoping to Achieve
I was hoping to achieve improvement in the attention span of Katie with the administration of Ritalin. I was also hoping to witness improvement in her cognitive skills, as evidenced by improved engagement in complex tasks and following instructions due to modulation of neural noise contributing to ADHD symptoms (Pertermann et al., 2019).
Ethical Consideration
While Ritalin has comparable effectiveness to that of Wellbutrin in treating ADHD in children, its large effect size influenced the adopted decision. The decision is also despite the fact that the prevalence of side effects such as headache is high in the use of Ritalin when compared to Wellbutrin (Xiang, 2017). However, the fact that Ritalin produces sustained, long-term effectiveness in managing the symptoms of ADHD informed the decision (Matthijssen et al., 2019). Therefore, it shows the ethical dilemma of balancing between safety of treatment and promotion of patient autonomy.
Decision Point Two
Selected Decision
Change Ritalin to LA 20 mg orally daily in the morning.
Reason for the Selection
Katie returned to the office four weeks later with symptom improvement. However, the teacher noted her staring into space and daydreaming by the afternoon. The implication is that the therapeutic effect of Ritalin wore off by the afternoon. According to the recommendations by the American Academic of Pediatrics, Ritalin dosage can be titrated for maximum benefit and minimum adverse effects. Sources of evidence-based data also recommend the titration of Ritalin to optimal doses to achieve the desired effect in symptom improvement (Ching et al., 2019). Safety issues such as seizures and abuse potential should be monitored with titrations (Cortese et al., 2021). Therefore, the above data informed the decision to increase dosage of Ritalin.
Reason For Not Selecting The Other Options
The decision to continue the same dose of Ritalin and re-evaluate in 4 weeks was not selected because it could not have contributed to the realization of the required treatment objectives. According to Ching et al., (2019), titrating Ritalin to optimum dose that produces the desired treatment outcomes can result in enhanced self-esteem, academic achievement and social functioning in children with ADHD. Continuing the current treatment may not lead to the above outcomes. Discontinuing Ritalin and beginning Adderrall XR 15 mg orally daily was not selected because of its lack of stronger evidence supporting its use over Ritalin (Chan, 2021).
What I Was Hoping To Achieve
I was hoping to achieve sustained improvement in symptoms of ADHD. Increasing the dosage of Ritalin would have led to improvement in social functioning, academic performance, and attention span of Katie due to increase in the therapeutic effect of the drug (Ching et al., 2019).
Ethical Consideration
Adderrall is may be used for treating ADHD for children aged 3 years and above. This makes it the desired drug for use in dealing with pediatrics. However, Adderrall being an older drug with weak evidence on its efficacy, Ritalin was considered due to adept of evidence supporting its use in ADHD (Ching et al., 2019). Therefore, I applied the ethical principle of ensuring benevolence safety and quality in making the above decision.
Decision Point Three
Selected Decision
Maintain the current dose of Ritalin LA and reevaluate in 4 weeks.
Reason for the Selection
I selected the above decision because the desired treatment objectives had been achieved. The teacher reports that Katie’s academic performance is still improved. The switch in medication lasts Katie throughout the day. The side effect of palpitation is no longer being experienced. According to Ching et al., (2019), Ritalin should be titrated until the optimum treatment outcomes, as long as patients report minimal or no side effects with titration or switch in medications.
Why The Other Options Were Not Selected
The decision to increase the dosage of Ritalin LA to 30 mg orally daily was not selected since high doses of Ritalin may predispose the patient to seizures and stimulate dependence (Cortese et al., 2021). Besides, treatment outcomes have been achieved. The decision to obtain EKG was not selected because the pulse rate is within the normal range.
What I Was Expecting To Achieve
I was expecting to achieve sustained improvement in symptoms. I was also hoping to ensure that the client tolerates the current dosage of Ritalin.
Ethical Considerations
The decision to increase the dosage of Ritalin to 30 mg orally daily may appear appropriate to cause further improvement in the symptoms of ADHD. However, evidence-based data and guidelines recommend the titration of dose until the set treatment objectives have been achieved. Similarly, guidelines assert that higher doses increase the risk of adverse side effects such as seizures and drug dependence (Ching et al., 2019; Cortese et al., 2021). Therefore, it informed the decision to ensure benevolence and non-maleficence in Katie’s treatment.
Conclusion
The aim of treatment in this case study was to improve the social and cognitive functioning of Katie. The score of Conner’s Teachers Rating Scale-Revised guided the evaluation of the effectiveness of the adopted treatment. It included a focus on treatment outcomes such as changes in the attention span of Katie, her ability to engage in complex task, follow instructions, and engage in social activities.
The adopted treatments were effective in improving the symptoms of ADHD that Katie experienced. The decision to initiate Katie on Ritalin was appropriate, as it led to minimal improvements in the symptoms of ADHD. The improvements could not be sustained throughout the day due to the short acting form of the Ritalin that was administered. Ritalin is the recommended first-line drug for ADHD in children, hence, the consideration in the phase. The decision to administer Wellbutrin was not considered because it is used in treating ADHD in adults. It also has smaller effect size on ADHD symptoms when compared to Ritalin (Cortese et al., 2021). The decision to administer Intuniv was not considered since the effectiveness of the other stimulants had not been explored (Webb, 2019). Therefore, I aimed at ensuring safety and optimum outcomes in treatment by selecting Ritalin in this stage.
The second step entailed the administration of extended release Ritalin, which was effective in symptom management. I did not select the decision to continue with the earlier dose of Ritalin, as it has short-lived effectiveness in symptom management. The third decision entails the continued use of the extended form of Ritalin, 20 mg, as the desired treatment objectives had been achieved (Chan, 2021). Therefore, I believe that the adopted interventions were effective in managing the symptoms of ADHD that Katie experienced.

References
Chan, C. (2021). A2As or stimulants: Which is better for treatment of ADHD in young children? Pharmacy Today, 27(8), 25. https://doi.org/10.1016/j.ptdy.2021.07.010
Ching, C., Eslick, G. D., & Poulton, A. S. (2019). Evaluation of Methylphenidate Safety and Maximum-Dose Titration Rationale in Attention-Deficit/Hyperactivity Disorder: A Meta-analysis. JAMA Pediatrics, 173(7), 630–639. https://doi.org/10.1001/jamapediatrics.2019.0905
Cortese, S., Newcorn, J. H., & Coghill, D. (2021). A Practical, Evidence-informed Approach to Managing Stimulant-Refractory Attention Deficit Hyperactivity Disorder (ADHD). CNS Drugs, 35(10), 1035–1051. https://doi.org/10.1007/s40263-021-00848-3
Deang, K. T., Sidi, H., Zakaria, H., Adam, R. L., Das, S., Hatta, N. H., Hatta, M. H., & Wee, K. W. (2019). The Novelty of Bupropion As a Dopaminergic Antidepressant for the Treatment of Adult Attention Deficit Hyperactive Disorder. Current Drug Targets, 20(2), 210–219. https://doi.org/10.2174/1389450118666170511145628
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
Pertermann, M., Bluschke, A., Roessner, V., & Beste, C. (2019). The Modulation of Neural Noise Underlies the Effectiveness of Methylphenidate Treatment in Attention-Deficit/Hyperactivity Disorder. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 4(8), 743–750. https://doi.org/10.1016/j.bpsc.2019.03.011
Tarrant, N., Roy, M., Deb, S., Odedra, S., Retzer, A., & Roy, A. (2018). The effectiveness of methylphenidate in the management of Attention Deficit Hyperactivity Disorder (ADHD) in people with intellectual disabilities: A systematic review. Research in Developmental Disabilities, 83, 217–232. https://doi.org/10.1016/j.ridd.2018.08.017
Webb, L. (2019). P039 Consideration of guanfacine for addition to the ADHD pathway following review of effectiveness. Archives of Disease in Childhood, 104(7), e2–e2. https://doi.org/10.1136/archdischild-2019-nppc.49
Xiang, N. (2017). A Systematic Review of the Use of Bupropion for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Journal of Child and Adolescent Psychopharmacology. https://doi.org/10.1089/cap.2016.0124

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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.

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 outbursts” adds her father.

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 has dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. The 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 attendance at the clinical interview and her ability to count backward 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