ASSESSING AND TREATING PATIENTS WITH ADHD

Walden University ASSESSING AND TREATING PATIENTS WITH ADHD-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University  ASSESSING AND TREATING PATIENTS WITH ADHD  assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for  ASSESSING AND TREATING PATIENTS WITH ADHD

Whether one passes or fails an academic assignment such as the Walden University   ASSESSING AND TREATING PATIENTS WITH ADHD depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for  ASSESSING AND TREATING PATIENTS WITH ADHD

The introduction for the Walden University   ASSESSING AND TREATING PATIENTS WITH ADHD is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for  ASSESSING AND TREATING PATIENTS WITH ADHD 

After the introduction, move into the main part of the  ASSESSING AND TREATING PATIENTS WITH ADHD assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for  ASSESSING AND TREATING PATIENTS WITH ADHD

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for  ASSESSING AND TREATING PATIENTS WITH ADHD

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Attention deficit hyperactive disorder (ADHD) is a disorder that affects a significant percentage of the population globally. The diagnosis of ADHD is largely made during the early childhood stage based on the observed behaviors and learning difficulties that children demonstrate. Therefore, this essay focuses on Katie’s case study. Katie has ADHD, which was diagnosed following her primary care provider’s recommendation for her psychiatric review.

Katie’s teacher completed the Conner’s Teacher Rating Scale-Revised, which shows that Katie has symptoms of ADHD. They include her lack of attention, being distracted easily, forgetting things, and being poor in arithmetic reading, and spelling. Katie also has a short attention span, does not pay attention to things she dislikes, is disinterested in schoolwork, fails to complete tasks, and does not follow through with instructions. Based on these symptoms, Katie was diagnosed with attention deficit hyperactive disorder, predominantly inattentive presentation.

This essay makes three treatment decisions for Katie. It also examines the basis for not selecting the other options and ethical considerations that guided the decisions. The patient-specific factors influencing treatment decisions made in the case study include Katie’s age, presenting symptoms, and experiences with the selected decisions.

Decision 1

Selected Decision

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning

Why the Decision Was Selected

Methylphenidate was chosen because FDA has approved its use for ADHD in children. Clinical studies also support methylphenidate use in treating ADHD to improve functioning and academic performance. According to Sugaya et al., (2022), methylphenidate effectively reduces the core symptoms of ADHD as well as improves children’s and adolescents’ quality of life. Methylphenidate is also more effective than other treatments such as behavioral training for ADHD. Sugaya et al., (2022) found out that methylphenidate improved teachers’ and parents’ composite scores on the Swanson, Nolan, and Pelham-IV scale, the Children’s Global Assessment Scale, and the Clinical Global Impressions Severity Scale. The improvements translated into enhanced functioning among children with ADHD, unlike the use of behavioral training alone. The study by de Faria et al., (2022) found improved academic performance while Matthijssen et al., (2019) found the long-term effectiveness of methylphenidate use in ADHD children.

Reasons for not Selecting the Other Options

Katie was not started on Wellbutrin (bupropion) XL 150 mg orally daily since it is not an evidence-based treatment for ADHD. Bupropion is recommended for use by patients intending to quit smoking. Katie was not administered Intuniv extended release 1 mg orally at bedtime due to its safety concerns such as hypotension, syncope, and electrocardiography changes(Iwanami et al., 2020).

Intended Outcomes

Methylphenidate improves patient’s functioning and academic performance. As a result, I hoped Katie’s academic and social performance would be better. I expected Katie’s parents and teacher to report positive improvements in Katie’s performance in arithmetic, reading, spelling, and attention and socialization skills(Iwanami et al., 2020).

How Ethical Considerations May AffectMy Treatment Plan

Katie is a minor. Her parents make decisions on the care that she needs. The parents have the authority to accept or reject ADHD-recommended treatments. PMHNP should provide adequate information about the benefits, risks, and alternatives for Katie’s parents to make informed decisions about their daughter’s treatment(Buka, 2020).

Decision 2

Adopted Decision

Change to Ritalin LA 20 mg orally daily in the morning

Reasons for the Decision

Katie was brought to the clinic after a month with evidence of improved ADHD symptoms. There were reports that Katie’s teacher noticed that her symptoms improved in the morning, resulting in enhanced performance in her academics. However, Katie seems lost and daydreams by the afternoon hours. Katie’s parents are concerned about their daughter’s heart as it feels funny. Katie’s pulse is around 130 bpm. The above information demonstrates mild improvements in Katie’s symptoms with the current methylphenidate 10 mg tablets. The desired therapeutic dose of methylphenidate was inadequate to last throughout the day. An effective solution would be changing the treatment to another form of methylphenidate. The long-acting methylphenidate with an increased dosage would increase the drug’s plasma concentration and effect to produce improved symptoms throughout the day(de Faria et al., 2022; Matthijssen et al., 2019). Methylphenidate is associated with a side effect of palpitations and increased heart rate, which improves as the patient tolerates treatment.

Why the Other Alternatives Were not Selected  

I did not continue with the same dose of Ritalin and re-evaluated in 4 weeks. This is because Katie showed minor improvement in ADHD symptoms. The initial dosage would not lead to improved functioning and performance. Discontinuation of Ritalin and starting Adderall XR 15 mg orally daily was not considered because of the increased risk of symptom relapse with a sudden change in the medications(Merrill et al., 2021). Katie has also not shown adverse reactions, which do not necessitate a need for a change in treatment.

What I was hoping to Achieve

Long-acting methylphenidate produces more sustained benefits than normal methylphenidate when used in ADHD. The increased dosage would also enhance performance and functioning. Therefore, I was hoping Katie’s seeming to be lost and daydreaming would resolve(Sugaya et al., 2022). I hoped that she would tolerate the current dosage, as evidenced by her normal heart rate.

How Ethical Considerations May Affect My Treatment Plan

PMHNP adopt evidence-based practices to minimize the risk of harm while promoting safety, quality, and efficiency in the care process. The existing evidence-based data supports the use of methylphenidate as the first-line drug for ADHD. Its use does not predispose Katie to any form of harm due to its high safety and efficacy profile(Matthijssen et al., 2019). This decision promotes non-maleficence and beneficence in treating Katie.

Decision 3

Adopted Decision

Maintain the current dose of Ritalin LA and reevaluate in 4 weeks

Reasons for the Decision

Katie came to the facility after a month. The data obtained shows sustained improved performance. The switch to the LA produces effects that last Katie throughout the school day. The funny feeling of the heart also resolved with the current pulse being 92. The data shows that the use of Ritalin LA has been effective. There has been sustained improvement in ADHD symptoms. Katie functions optimally in her academic activities. There is no evidence of adverse effects(Matthijssen et al., 2019). As a result, an appropriate decision would be sustaining the current Ritalin LA dose and reevaluating in a month’s time.

Reasons for not Selecting the Alternatives

I did not increase Ritalin LA to 30 mg orally daily. This was because the projected treatment outcomes have been achieved. Increasing the dosage could predispose Katie to adverse effects such as insomnia, dry mouth, headache, and depression(Matthijssen et al., 2019). I did not request for an EKG based on the current heart rate because Katie’s heart rate normal.

Intended Outcomes

The desired optimum plasma concentration of Ritalin has been achieved. This means that the improvements should be maintained. As a result, I was hoping that maintaining the dosage would ensure sustained improvements, in functioning, and academic performance(Quintero et al., 2022).

How Ethical Considerations May Affect My Treatment Plan

PMHNP implements interventions that address disparities in access to and utilization of mental health services. Factors such as cost and having medical insurance coverage influence the utilization of mental health services. The PMHNP has the ethical responsibility of assessing and addressing any potential barriers to healthcare for Katie’s family(Buka, 2020). The practitioner advocates the adoption of policies that eliminate issues such as cost barriers for optimum mental health for all.

Conclusion

In summary, the use of methylphenidate to treat Katie in this case study was effective. Evidence-based data informed the selection of methylphenidate as the first drug of choice in the case study. Methylphenidate improves functioning, academic performance, and attention among children with ADHD. The alternatives given in the first step were not selected because of safety concerns and bupropion being the drug of choice for smoking cessation. The use of Ritalin LA in the second step was effective. The LA form of Ritalin was effective in producing the desired effects throughout the day. This meant sustaining Katie’s functioning and academic performance. The decision to change medications in the second step was inappropriate because of the increased risk of safety concerns(Merrill et al., 2021; Quintero et al., 2022). The last step to maintain the dosage of Ritalin was appropriate since moderate improvements in symptoms had been achieved.

Ethical and legal considerations informed the case study’s treatment decisions. The psychiatric nurse ensured that Katie’s family was actively involved and adequately informed about the treatment options for their autonomous decision-making. Evidence-based data was used to make decisions that would minimize any risks of harm to Katie in the treatment process. The consideration ensured non-maleficence and beneficence(Buka, 2020). PMHNP must address barriers to mental health to ensure Katie receives the high-quality care she deserves for optimum symptom management.

References

Buka, P. (2020). Essential Law and Ethics in Nursing: Patients, Rights and Decision-Making. Taylor & Francis Group.

de Faria, J. C. M., Duarte, L. J. R., Ferreira, L. de A., da Silveira, V. T., Menezes de Pádua, C., & Perini, E. (2022). “Real-world” effectiveness of methylphenidate in improving the academic achievement of Attention-Deficit Hyperactivity Disorder diagnosed students—A systematic review. Journal of Clinical Pharmacy and Therapeutics, 47(1), 6–23. https://doi.org/10.1111/jcpt.13486

Iwanami, A., Saito, K., Fujiwara, M., Okutsu, D., & Ichikawa, H. (2020). Efficacy and Safety of Guanfacine Extended-Release in the Treatment of Attention-Deficit/Hyperactivity Disorder in Adults: Results of a Randomized, Double-Blind, Placebo-Controlled Study. The Journal of Clinical Psychiatry, 81(3), 7891. https://doi.org/10.4088/JCP.19m12979

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

Merrill, B. M., Raiker, J. S., Evans, S. W., Gnagy, E. M., & Pelham, W. E. (2021). Cognitive mechanisms of methylphenidate in ADHD: Do improvements in sustained attention mediate behavioral improvements in the natural environment? Child Neuropsychology, 27(4), 425–446. https://doi.org/10.1080/09297049.2020.1862074

Quintero, J., Gutiérrez-Casares, J. R., &Álamo, C. (2022). Molecular Characterisation of the Mechanism of Action of Stimulant Drugs Lisdexamfetamine and Methylphenidate on ADHD Neurobiology: A Review. Neurology and Therapy, 11(4), 1489–1517. https://doi.org/10.1007/s40120-022-00392-2

Sugaya, L. S., Salum, G. A., Gurgel, W. de S., Morais, E. M. de, Prette, G. D., Pilatti, C. D., Dalmaso, B. B., Leibenluft, E., Rohde, L. A., &Polanczyk, G. V. (2022). Efficacy and safety of methylphenidate and behavioural parent training for children aged 3–5 years with attention-deficit hyperactivity disorder: A randomised, double-blind, placebo-controlled, and sham behavioural parent training-controlled trial. The Lancet Child & Adolescent Health, 6(12), 845–856. https://doi.org/10.1016/S2352-4642(22)00279-6

Not only do children and adults have different presentations for ADHD, but males and females may also have vastly different clinical presentations. Different people may also respond to medication therapies differently. For example, some ADHD medications may cause children to experience stomach pain, while others can be highly addictive for adults. In your role, as a psychiatric nurse practitioner, you must perform careful assessments and weigh the risks and benefits of medication therapies for patients across the life span. For this Assignment, you consider how you might assess and treat patients presenting with ADHD.

To prepare

• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with ADHD.

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.

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.

note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Extras

Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD

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. 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.

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

RESOURCES

• 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.

Decision Point One

Begin Wellbutrin (bupropion) XL 150 mg orally daily

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Katie’s parents inform you that they stopped giving Katie the medication because about 2 weeks into the prescription, Katie told her parents that she was thinking about hurting herself. This scared the parents, but they didn’t want to “bother you” by calling the office, so they felt that it would be best to just stop the medication as they would be seeing you in two weeks

Decision Point Two

Educate the parents that Bupropion sometimes causes suicidal ideation in children and that this is normal, and re-start the drug at the previous dose

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Katie’s parents again report that after about a week of treatment with the Bupropion, Katie began telling her parents that she wanted to hurt herself and began having dreams about being dead. This scared her parents and they stopped giving her the medication

At this point, they are quite upset with the results of their daughter’s treatment and are convinced that medication is not the answer

Decision Point Three

Refer the parents to a pediatric psychologist who can use behavioral therapy to treat Katie’s ADHD

Guidance to Student

Bupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.

At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.

In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.

The PMHNP should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow the PMHNP to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.

Decision Point One

Begin Intuniv extended release 1 mg orally at BEDTIME.

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• Katie’s teacher reports no change in her classroom behaviors
• Katie’s parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish.”

Decision Point Two

Increase Intuniv to 2 mg orally at BEDTIME

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Katie’s parents report that Katie is even more sedate and has been refusing to get out of bed in the morning. Her teacher reports that she has gone from being a “daydreamer” in class to being on the “verge of falling asleep.”

Katie’s parents state that there were two instances where Katie fell asleep on the school bus on her way to school in the morning prompting the school nurse to call Katie’s parents

Decision Point Three

Maintain current dose of Intuniv

Guidance to Student

Intuniv is a nonstimulant medication used in the treatment of ADHD. It is generally used to treat the oppositional behaviors associated with ADHD. Although less sedating that clonidine, Intuniv can be quite sedating. Whereas the PMHNP can definitely improve symptoms by decreasing the dose, it is clear that after 4 weeks of therapy Katie is experiencing sedation with no real improvement in attention. However, decreasing the drug to 1 mg at bedtime and evaluating the effect may be considered. Clearly, the current dose of Intuniv cannot be maintained as it is having a negative impact on Katie’s academic performance and quality of life.

Although Strattera a second-line agent, the most appropriate course of action would be to discontinue Intuniv at this point and begin Strattera 10 mg orally daily, as this drug primarily targets attention span and concentration and is not associated with the same levels of sedation as Intuniv.

Decision Point One

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

RESULTS OF DECISION POINT ONE

• Client returns to 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 Point Two

Continue same dose of Ritalin and re-evaluate in 4 weeks

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Katie’s academic performance is still improved, but her attention continues to worsen throughout the school day

Katie is still reporting that her heart feels “funny.” Today’s pulse rate is 122 beats per minute, regular rhythm

Decision Point Three

Change to Ritalin LA 20 mg orally daily in the morning+

Guidance to Student

Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.

Decision Point One

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

RESULTS OF DECISION POINT ONE

• Client returns to 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 Point Two

Continue same dose of Ritalin and re-evaluate in 4 weeks

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Katie’s academic performance is still improved, but her attention continues to worsen throughout the school day

Katie is still reporting that her heart feels “funny.” Today’s pulse rate is 122 beats per minute, regular rhythm

Decision Point Three

Change to Ritalin LA 20 mg orally daily in the morning

Guidance to Student

Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent disorders in child psychiatry with the prevalence increasing over the years. It is characterized by inattention, hyperactivity, and impulsivity. It has a male predilection with a male to female ratio of 2:1. The hyperactive and impulsive subtype is the most prevalent. The inattentive subtype occurs in 18.3% of the condition and mostly affects females (Magnus et al., 2020). ADHD is diagnosed before the age of 12 years. It affects an individual’s ability to form and maintain close social ties.

This week’s case study focuses on Katie an 8-year-old Caucasian female brought into the office by her parents following a referral. She is referred for a psychiatry assessment to determine if she has ADHD. From the Conner’s Teacher Rating Scale-Revised, Katie is inattentive, easily distracted, forgets things already learned, and poor in spelling, reading, and arithmetic. Of note is that she has a short attention span, lacks interest in school work, is easily distracted, starts things but never finishes them, seldom follows through on instructions, and fails to finish her school work. She has no open defiance or temper outbursts. In subjective history, her favorite subjects are art and recess. She finds other subjects hard and boring. She admits her mind wanders off from class most of the time. There is no history of abuse or bullying at school. She reports that her home life is fine and her parents are good to her. The Mental State Exam is normal. She is appropriately developed for her age. She has a clear, coherent, and logical speech. She is oriented to time, place, person, and event. She has no mannerisms or tics. Her subjective mood is euthymic with a bright affect. She has no hallucinations, delusions, or abnormalities of thought. Attention and concentration are intact. Insight and judgment are age appropriate. Her diagnosis is ADHD, predominantly inattentive presentation. Decision-making in the prescription of ADHD medication is influenced by the patient’s gender, the subtype of ADHD displayed, level of academic impairment, age, and the parent’s socioeconomic status (Kamimura-Nishimura et al., 2019). These factors act together to influence the drug to be used, the dosage, and the duration of therapy. The purpose of this paper is to discuss the decision points on the treatment of this patient in regards to the choice of drug, the expectations post initiation of therapy, and the ethical considerations.

Decision 1

Chewable Methylphenidate tablets 10mg orally in the morning

Reason for Selection

Methylphenidate is considered the first-line drug therapy for childhood, adolescent, and adult ADHD (Cortese et al., 2021). The American Academy of Pediatrics recommends parent training in behavior management, and classroom training, along with medications. Methylphenidate is highly efficacious in the resolution of emotional dysregulation, and propensity to violent behavior and increases susceptibility to learning and rehabilitation of social skills (Asherson et al., 2019). The availability of methylphenidate also influences its wide use.

The few Randomized Control Studies done show that Bupropion is considered as effective as Methylphenidate in the treatment of ADHD. It also has fewer adverse symptoms compared to methylphenidate. For therapy, several trials agree that there is still a need for a further trial of the medication. Some serious adverse effects like paresthesia, agitation, and palpitations were marked in bupropion (Pozzi et al., 2020). For this reason, its suitability for treatment is reduced especially in children and adolescents.

In trials of Intuniv, there was significant symptomatology improvement in inattention, hyperactivity, and impulsivity. Intuniv is however associated with severe side effects such as polydipsia, hypotension, nasopharyngitis, and hypersomnolence (Iwanami et al., 2020). This limits its use despite having a decent efficacy.

Expectation

There is an expected beginning of the resolution of symptomatology within a few days of therapy. These changes include an enhanced concentration with a slightly increased concentration span, improved attention, reduced distractibility, and a reduction in antisocial behaviors like violence and breaking of school rules (Jaeschke et al., 2021). These changes must be supported by both classroom and parent training.

Ethical Considerations

The ethical considerations are hinged on the four principles of justice, do no harm, beneficence, and respect for autonomy. Considering the best treatment for the child’s condition is approved through research findings. The autonomy of children is an important factor. A child’s flexibility in preference is important in character development. A small room for guided autonomy is associated with better outcomes. For this reason, the parents act in the best interest of the child. Informed consent is key. Informed consent in children is proven to strengthen the morals and structure of the child by improving esteem and social interactions (Díaz-Pérez et al., 2020). Providing adequate information and education regarding the condition is n important tenet. Providing top-notch care in the best interest of the child through offering follow-up is vital.

Decision 2

Change to Ritalin LA 20mg orally daily in the morning

Reason for Selection

The slow-release long-acting Ritalin is considered effective in controlling symptoms of inattention and hyperactivity (Karahmadi et al., 2020). The long-acting Ritalin has increased compliance with medication. Although the adverse effects of the long-acting and short-acting Ritalin are comparatively the same, Ritalin LA could be responsible for a reduction in side effects as it causes a maintained plasma concentration of the drug over time.

Arrhythmias and increased systolic blood pressure are common adverse effects of Ritalin (Liang et al., 2018). Continuation with the same dose of Ritalin could cause further development in other side effects of cardiovascular disease such as stroke which would be detrimental (Nauman et al., 2021). Adderall has a very high potential for abuse and dependence. In women, Adderall can cause infertility. Sudden stoppage of the drug also comes with severe withdrawal effects such as suicidal ideas, delusions, and psychosis. These side effects occur in both the short term and the long term.

Expectations

Due to a change to Ritalin LA, there is expected maintenance in improved concentration and consequently a good performance. Resolution of the daydreaming in the afternoon. There is also an expected decrease in the presenting side effects like high heart rate; there is an expected reduction in heart rate.

Ethical Considerations.

Informed consent to the change of drug is important with adequate education on the dosage. Autonomy of the child should be guided by the parents as at the same time the child is allowed to express their preference (Díaz-Pérez et al., 2020). Continuous counseling of the family on how best to handle and train the child. A cordial patient-doctor relationship is very vital for this particular case as it eases subsequent clinic visits for follow-up.

Decision 3

Maintain current dose of Ritalin LA and reevaluate in 4 weeks

Reason for Selection

At this point, the current dose is effective in perfectly controlling the symptoms and the side effects have vanished. It is advised that in drug usage, the lowest effective dose is indicated. Here heart rate of 92 beats per minute falls in the range appropriate for her age. For this reason, maintaining the current dosage is the most plausible option. Increasing Ritalin LA  to higher doses is not advisable firstly because the symptoms are well controlled without any adverse effects. Secondly higher doses are associated with increased side effects (Karahmadi et al., 2020). Obtaining an EKG based on her heart rate is futile. The heart rate of 92 beats per minute is normal for her age.

Expectations

The current dose of Ritalin in conjunction with the psychosocial treatments should be able to abate the symptoms. There should be a net effect of improved concentration and learning. The girl should be able to get better grades. There will be improved interest in school work and not easily distractible. There will be minimal side effects of the drug as it is set at the lowest effective dose.

Ethical Considerations

The mere fact of not doing any harm and providing recommended drug treatment at the minimal effective dose is not enough. Respectful handling of the patient in a child-friendly manner and her parents by the healthcare provider is an essential part of treatment as it builds patient confidentiality and trust (Díaz-Pérez et al., 2020). The success of long-term follow-up is also greatly dependent on this relationship. Sound patient education on the side effects and dosage of the drug is key.

Conclusion

ADHD is a common encounter in child psychiatry. It is mostly overdiagnosed even in patients who show a few symptoms but don’t meet the diagnostic criteria (Magnus et al., 2020).  It is characterized by reduced attention, hyperactivity, and impulsivity. These symptoms have to occur for no less than 6 months and the patient less than 12 years for a primary diagnosis to be made. Although ADHD is more common in boys, the inattention subtype is common in girls. This case study provides a perfect example of the inattention subtype. It involves an 8-years-old Caucasian girl who displays markedly reduced attention in class, easy distractibility, and poor academic performance but does not have violent properties. There is no demarcated precipitating factor for her condition. Methylphenidate is the first-line drug used in the management of ADHD in all age groups (Cortese et al., 2021). Methylphenidate is highly efficacious in the resolution of emotional dysregulation, and violent behavior and increases susceptibility to learning and rehabilitation of social skills (Asherson et al., 2019). The availability of methylphenidate also influences its wide use. Studies show that Bupropion is as effective as Methylphenidate in the treatment of ADHD. For therapy, several trials agree that there is still a need for a further trial of the medication. Intuniv use is marred by adverse effects such as increased thirst, nasopharyngitis, and somnolence which makes its use unpopular  (Iwanami et al., 2020). Studies comparing the efficacies of Ritalin LA and the short-acting Ritalin show only a minimal difference in their profiles. The slow release of Ritalin reduces the dosing interval hence improving medication adherence. In the dissolution of symptoms, there is no major difference although clinically, Ritalin LA is associated with reduced side effects (Karahmadi et al., 2020). The principle of monotherapy and usage of the lowest effective dose is a key facet in the treatment of ADHD. The drug choice is influenced by the pharmacokinetic profile of the drug, availability, age of the patient, symptomatology, level of academic and social impairment, subtype of ADHD, gender, and the socio-economic status of the patient (Kamimura-Nishimura et al., 2019). Ethical considerations include informed consent, guided autonomy, providing the best treatment possible, formation of meaningful patient and healthcare provider relationships that improve treatment, and constant counseling and education of the patient concerning the different aspects of management.

References

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