NURS 6630 The Management of Attention Deficit Hyperactivity Disorder (ADHD)
The management of attention deficit hyperactivity disorder (ADHD) in children is difficult due to a lack of evidence supporting the safety of several recommended drugs for this disorder. The case of an 8-year-old Caucasian female has been provided to further illustrate the management of ADHD. The patient exhibits ADHD symptoms as identified by her teacher, who completed the Conner’s Teacher Rating Scale-Revised. Her teacher claims that the patient is frequently forgetful and easily distracted, with a short attention span. The patient also has poor language, spelling, and arithmetic skills, which negatively impact her overall school performance. The teacher also stated that the patient has recently been failing to follow instructions, resulting in incomplete homework. Despite her parents’ denial that their daughter has ADHD, the patient reports that she is bored most of the time at school and has little interest in her schoolwork. She, on the other hand, denies any kind of bullying at school and has a positive home life experience. The patient was diagnosed with Attention deficit hyperactivity disorder, predominantly inattentive presentation, based on the findings of the conducted mental status examination and the Conner’s Teacher Rating Scale-Revised.
Several factors were considered when deciding on the specific pharmacological agent and dosage to prescribe in the patient’s condition management. Such factors include the patient’s young age, Caucasian race, ADHD diagnosis, and reported symptoms. The completed Conner’s Teacher Rating Scale-Revised can also assist in determining the severity of the patient’s condition, which is important in determining the dosage of the chosen drug. As such, the purpose of this discussion is to devise the most effective treatment plan for the 8-year-old patient’s ADHD management, with a rationale for each decision made.
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 get ready for this Task:
Review the Learning Resources for this week, as well as the Medication Resources for this week.
Think about what kinds of psychopharmacological treatments you might suggest for evaluating and treating people with ADHD.
The Task: Five pages
Check out the Case Study: A Young White Girl with ADHD.
You will be asked to decide on three different medications to give to this patient. Make sure to think about things that could affect the pharmacokinetic and pharmacodynamic processes of the patient.
At each decision point, you should think about all of your choices before making a choice and moving on. Before you make a choice, make sure you’ve looked into each option and thought carefully about the one you’ll choose. Make sure to look into each choice using the primary sources.
The beginning of the case (1 page)
Explain and sum up the case for this Assignment in a few words. When writing a prescription for this patient, make sure to list the specific patient factors that may affect your choice.
Choice No. 1 (1 page)
Which choice did you choose?
Why did you choose this path? Be specific and back up your answer with resources that are clinically relevant and specific to the patient, such as the primary literature.
Why didn’t you choose either of the other two choices in the exercise? Be specific and back up your answer with resources that are clinically relevant and specific to the patient, such as the primary literature.
What did you want to happen when you made this choice? Use evidence and references to the Learning Resources to back up your answer (including the primary literature).
Explain how your treatment plan and how you talk to patients may be affected by ethical issues. Give examples and be specific.
Choice No. 2 (1 page)
Why did you choose this path? Be specific and back up your answer with resources that are clinically relevant and specific to the patient, such as
- primary literature.Why didn’t you choose either of the other two choices in the exercise? Be specific and back up your answer with resources that are clinically relevant and specific to the patient, such as the primary literature.
What did you want to happen when you made this choice? Use evidence and references to the Learning Resources to back up your answer (including the primary literature).
Explain how your treatment plan and how you talk to patients may be affected by ethical issues. Give examples and be specific.
Read Also: Assignment: Assessing and Treating Clients With ADHD NURS6630
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Choice No. 3 (1 page)
Why did you choose this path? Be specific and back up your answer with resources that are clinically relevant and specific to the patient, such as the primary literature.
Why didn’t you choose either of the other two choices in the exercise? Be specific and back up your answer with resources that are clinically relevant and specific to the patient, such as the primary literature.
What did you want to happen when you made this choice? Use evidence and references to the Learning Resources to back up your answer (including the primary literature).
Explain how your treatment plan and how you talk to patients may be affected by ethical issues. Be specific and provide examples.
In the end (1 page)
Summarize the treatment options you chose for this patient and what you think should be done. Make sure to back up your recommendations and answer with resources that are relevant to the patient and clinically useful, such as the primary literature.
Note: Use at least five academic sources to back up your reasoning. You can use the course text to back up your reasoning, but it won’t count as one of the resources you need. You should use both first-hand and second-hand sources.
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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
Asherson, P., Johansson, L., Holland, R., Fahy, T., Forester, A., Howitt, S., Lawrie, S., Strang, J., Young, S., Landau, S., & Thomson, L. (2019). Randomised controlled trial of the short-term effects of OROS-methylphenidate on ADHD symptoms and behavioural outcomes in young male prisoners with attention-deficit/hyperactivity disorder (CIAO-II). Trials, 20(1). https://doi.org/10.1186/s13063-019-3705-9
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
Díaz-Pérez, A., Navarro Quiroz, E., & Aparicio Marenco, D. E. (2020). Moral structuring of children during the process of obtaining informed consent in clinical and research settings. BMC Medical Ethics, 21(1). https://doi.org/10.1186/s12910-020-00540-z
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. The Journal of Clinical Psychiatry, 81(3). https://doi.org/10.4088/jcp.19m12979
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
Kamimura-Nishimura, K. I., Epstein, J. N., Froehlich, T. E., Peugh, J., Brinkman, W. B., Baum, R., Gardner, W., Langberg, J. M., Lichtenstein, P., Chen, D., & Kelleher, K. J. (2019). Factors Associated with Attention Deficit Hyperactivity Disorder Medication Use in Community Care Settings. The Journal of Pediatrics, 213, 155-162.e1. https://doi.org/10.1016/j.jpeds.2019.06.025
Karahmadi, M., Saadatmand, S., & Tarahi, M. J. (2020). Investigation of Efficacy of Short-Acting Methylphenidate (Ritalin) and Long-Acting (Matoride) on Symptoms of Attention Deficit Hyperactivity Disorder in Children Aged 6–18 Years: A Single-Blind, Randomized Clinical Trial. Advanced Biomedical Research, 9. https://doi.org/10.4103/abr.abr_9_20
Liang, E. F., Lim, S. Z., Tam, W. W., Ho, C. S., Zhang, M. W., McIntyre, R. S., & Ho, R. C. (2018). The Effect of Methylphenidate and Atomoxetine on Heart Rate and Systolic Blood Pressure in Young People and Adults with Attention-Deficit Hyperactivity Disorder (ADHD): Systematic Review, Meta-Analysis, and Meta-Regression. International Journal of Environmental Research and Public Health, 15(8), 1789. https://doi.org/10.3390/ijerph15081789
Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2020). Attention Deficit Hyperactivity Disorder (ADHD). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441838/
Nauman, M., Hahn, C., Nketiah, E., Ahmad, S., & Karmali, R. (2021). Adderall induced dilated cardiomyopathy in an adult male with ADHD. Journal of the American College of Cardiology, 77(18), 2325. https://doi.org/10.1016/s0735-1097(21)03680-9
Pozzi, M., Bertella, S., Gatti, E., Peeters, G. G. A. M., Carnovale, C., Zambrano, S., & Nobile, M. (2020). Emerging drugs for the treatment of attention-deficit hyperactivity disorder (ADHD). Expert Opinion on Emerging Drugs, 25(4), 1–13. https://doi.org/10.1080/14728214.2020.1820481
Attention deficit hyperactive disorder (ADHD) is a mental health condition characterized by inattention and hyperactivity commonly diagnosed in childhood. The impact of ADHD affects children’s schoolwork and daily social living. The purpose of this paper is to describe the assessment and treatment plan and reflect on a case of ADHD.
Assessment
The common differential diagnosis for ADHD include:
- Anxiety disorders
- Depression
- Learning disorders
Patients experiencing the above conditions have symptoms that may mimic ADHD (Drechsler et al., 2020). Poor concentration, easy distractibility, and memory loss are commonly seen in anxiety and depressed patients. In addition, he has significant weight loss due to loss of appetite commonly seen in depressed patients.Lastly, just like in ADHD, patients with learning disorders and some anxiety disorders, such as panic disorders, may experience learning difficulties.
My primary diagnosis for the patient is ADHD. According to DSM-V, hyperactive symptoms of ADHD include fidgeting, restlessness, inability to play quietly, excessive talking, motor agitation, inappropriate intrusion, and impatience (Cabral et al., 2020). On the other hand, inattention symptoms include inattention to details, making careless mistakes, not listening when spoken to, not following instructions, and being unable to complete or organize a task. In addition, they avoid tasks that require concentration, easily get distracted, and forgetful. The patient, in this case, has most of the symptoms of ADHD, including symptoms of impulsivity, hyperactivity, and inattention.
Plan
Management of ADHD patients includes the use of pharmacotherapy and psychotherapy. Pharmacologic agents commonly used in ADHD patients include psychostimulants such as methylphenidate (Drechsler et al., 2020). Psychostimulants aim at targeting impulsivity, distractibility, poor task adherence, hyperactivity, and lack of attention. Atomoxetine, a serotonin-noradrenaline receptor inhibitor (SNRI), is a non-psychostimulant that has also been used in patients who fail to tolerate methylphenidate (Nunez-Jaramillo et al., 2021). Other medications that have been utilized include antidepressants such as selective serotonin receptor inhibitors, SNRIs, and tricyclic antidepressants. The drugs can be used as adjunctive therapy for the management of anxiety and depression symptoms that may be present in ADHD patients.
Behavioral psychotherapy is crucial in the management of ADHD symptoms. Psychotherapy aims to improve attention and organizational skills and decrease distractibility (Drechsler et al., 2020). Another form of psychotherapy used is cognitive behavioral therapy, which helps alleviate depression and anxiety symptoms. Additionally, psychosocial treatments such as behavioral parent training and classroom management can allow the patients to adapt to school and home environments(Nunez-Jaramillo et al., 2021). Neuropsychological treatment, a cognitive training intervention, utilizes cognitive exercises to work on memory and impulsivity.
Follow-up for these patients includes looking into symptom alleviation, side effects of drugs used, and the response to the form of therapy used. Additional doses and more intensified psychotherapy are commonly used when the response is sub-optimal. Referrals to psychiatrists are vital while managing patients when the response is sub-optimal or non-tolerant to the medications, allowing for further evaluation (Price et al., 2020). One major social determinant of health I would advocate for ADHD patients is education access and equity. I would advocate for special schools and trained personnel to ensure the facilities can provide a good quality education while meeting their needs in an understanding environment. I would advocate for a health promotion program that engages in physical activity, stress adjustment, and mindfulness relaxation that may help the patient learn how to improve attention, impulsivity, and hyperactivity (Hahn, 2021). For such kind of patient with a previous medication non-adherence, it is crucial to educate the patient about the condition he is experiencing and why he needs to take the prescribed medication.
Reflection Notes
First, I would ensure I address what is causing the medication non-compliance, such as inadequate funds and lack of a therapist or psychiatrist. I would also encourage open communication that would help get more unmentioned concerns the patient may be facing in his employment and at school. I would also recommend the patient to a support group for patients with ADHD to help him adjust. I would need to reintroduce the patient to pharmacotherapy and psychotherapy as part of his treatment plan and schedule for follow-up (Price et al., 2020). The interventions would be successful if the patient is compliant, is reintroduced to medical insurance to cover the costs, can go to his psychiatrists’ or therapists’ consultation visits, and has a supportive social support group. The interventions may fail due to non-compliance, or the case may be a treatment-resistant form of ADHD. Referral is vital, especially when one cannot follow up on the patient (Streeter et al., 2023). examples of referrals include other therapists who may be close to where he works, social workers, or leaders of various ADHD support groups. One may contact the various persons for follow-up on the patient’s progress.
Conclusion
Inattention and hyperactivity are characteristic of ADHD patients. Proper diagnosis is needed to ensure prompt management of the patient. Treatment of ADHD involves psychotherapy, pharmacotherapy, and a good follow-up plan. Close follow-up and patient education for ADHD patients have been associated with positive health outcomes and an improved quality of life.
References
Cabral, M. D. I., Liu, S., & Soares, N. (2020). Attention-deficit/hyperactivity disorder: diagnostic criteria, epidemiology, risk factors and evaluation in youth. Translational pediatrics, 9(Suppl 1), S104–S113. https://doi.org/10.21037/tp.2019.09.08
Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current Concepts and Treatments in Children and Adolescents. Neuropediatrics, 51(5), 315–335. https://doi.org/10.1055/s-0040-1701658
Hahn R. A. (2021). What is a social determinant of health? Back to basics. Journal of public health research, 10(4), 2324. https://doi.org/10.4081/jphr.2021.2324
Núñez-Jaramillo, L., Herrera-Solís, A., & Herrera-Morales, W. V. (2021). ADHD: Reviewing the Causes and Evaluating Solutions. Journal of personalized medicine, 11(3), 166. https://doi.org/10.3390/jpm11030166
Price, M. E., Done, N., & Pizer, S. D. (2020). The Relationship Between Follow-up Appointments and Access to Primary Care. Journal of general internal medicine, 35(6), 1678–1683. https://doi.org/10.1007/s11606-020-05785-3
Streeter, C., Dankyi, S., & Akin-Ojo, I. (2023). Quality Improvement Project: Referral Process for Adults With Suspected ADHD. BJPsych Open, 9(Suppl 1), S76. https://doi.org/10.1192/bjo.2023.247