Assessing and Treating Patients with ADHD Essay

Assessing and Treating Patients with ADHD Essay

Proper psychiatric conditions diagnosis and management depend on the quality of clinical assessment. Attention Deficit Hyperactivity Disorder (ADHD) is a healthcare condition affecting both genders and individuals of all ages. According to DSM-5, an ADHD diagnosis, like in this case, occurs when the patient presents with more than six inattention symptoms or five symptoms in adults, and the symptoms must have persisted for more than six months and are inappropriate for the development level (Stern et al., 2016). Nurse practitioners are tasked with diagnosing and managing patients with mental health issues. A careful clinical diagnosis using the presenting symptoms and DSM-5 criteria helps with definitive management. The care provider’s primary interest is in the disappearance of the signs and avoidance of side effects. Remission and side effects guide patient management. This essay focuses on the management decisions of an 8-year-old Caucasian female with ADHD over time, driven by the patient’s response to medications.

Decision Point #1

Katie, an 8-year-old Caucasian female, presents to the NP. The teacher and parents report that Katie is inattentive, easily distracted, forgets things, and has poor spelling, reading, and arithmetic skills. She does not pay attention to details at school and admits that her mind often wanders and is blank. When questioned, she does not know what to answer and attends activities only when interested. She usually starts duties/chores, leaves them incomplete, and has problems organizing tasks and activities. The teacher reports that Katie hardly follows through with activities or instructions for any job, is disinterested in schoolwork, and is easily distracted. The patient denies the allegations and says school life is okay. She also admits that she finds some subjects boring because she feels lost and denies other symptoms and associated factors, such as bullying and abuse from home. The objective and subjective data presented are vital in developing management objectives and evaluating outcomes for further management.

The first decision for this patient is to begin the patient on Ritalin (methylphenidate) chewable tablets 10 mg orally OD (morning). The objectives are to ensure a reduction in the symptoms of inattention the patient is exhibiting and improve school performance (Stern et al., 2016). Ritalin is an FDA-approved medication for patients above six years for use in ADHD. In addition, it is a CNS stimulant, and stimulants are the first-line medications for ADHD (Brown et al., 2018). In addition, it is clinically effective as it increases dopamine levels in the brain, increasing attention and focused behavior. The drug’s side effects include palpitations, nausea, vomiting, sleep disturbance, and decreased appetite, which the nurse practitioner can manage with dose adjustment. Ritalin does not develop tolerance despite the number of days of the dosage taken and does not produce withdrawal symptoms despite the number of years a client has used it (Brown et al., 2018). These properties make it a medication of choice for the long-term and short-term management of ADHD. Thus, Ritalin is the choice intervention for this patient with ADHD.

The second option is Wellbutrin (bupropion) XL 150 mg orally daily. Bupropion is a substituted cathinone and FDA-approved medication for MDD, smoking cessation, and seasonal schizoaffective disorder (Hile, 2020). The medication inhibits dopamine, serotonin, and norepinephrine and increases their level in the brain, hence its potency in ADHD. However, the medication is not FDA-approved for ADHD but is used as an off-label drug. The medication is not the first option because few studies exist to show its efficacy or safety in children. In addition, bupropion is prone to misuse due to dependence and addiction (Hile, 2020)

The third option is Intuniv extended release 1 mg orally at BEDTIME. Intuniv is a s selective central alpha-2A agonist medication that is FDA-approved for use in ADHD. The medication. The dose is within the recommended drug dose. However, the drug has a high rate of somnolence (in over 38% of patients), ruling it out as a drug of choice (Childress et al., 2020). Other side effects include sedation, fatigue, low blood pressure, and nausea which could negatively affect the child. The medication is also a non-stimulant and, thus, a second-line treatment for ADHD. Non-stimulants have less efficacy in managing the problem despite having fewer side effects and are thus used as second-line treatment options (Stern et al., 2016).

Ethical and legal consideration for Katie’s management is the parent’s approval of the treatment regimen. Parents of children below the legal consent age have the ultimate right over their children’s management. Their decisions can only be overruled by a court of law determining their decision to present more harm than good. Education to the client and family on the reason for the medication and education pertinent to the medication, such as dose, frequency, function, and side effects, is also vital for this patient. Information will ensure medication adherence and help the care provider evaluate the management outcomes correctly.

Decision Point #Two

The patient returns to the hospital and has marked improvement in their inattentive symptoms. The goal of the first decision was to reduce these symptoms. The patients have had improved symptoms reflected on the teacher’s reports and Katie’s improved school performance. However, the symptoms reappear in the afternoons (partial remission), and she has developed tachycardia and a “funny heart feeling.” This decision aims to reduce the heart rate, improve symptom relief in the afternoon, and improve school performance (achieve total remission).

The decision is to switch the medication to Ritalin LA 20mg. The medication is long-acting and produces effects over a long time, compared to Ritalin, and is suitable for long-term therapy (Stern et al., 2016). The FDA recommends drug titration to help achieve total remission. Increasing the dose to the therapeutic threshold will help increase symptom remission in the morning and the afternoon. Low-dose Ritalin causes severe side effects, especially experienced by patients who decide to reduce the medication dose. Palpitations are common in low doses, and increasing the dose of Ritalin will achieve the desired effects of symptoms remission (Verghese & Abdijadid, 2022). The second decision, to continue the same dose of Ritalin and re-evaluate in 4 weeks, is avoided because the patient has only achieved partial remission and is developing side effects due to the low dose. Maintaining the same dose of the medication means that the patient will continue to achieve partial remission, which will not help achieve the treatment goals, hence ruling out the decision.

The other option is to discontinue Ritalin and begin Adderall XR 15 mg orally daily. Adderall is a non-stimulant that is FDA-approved for the management of narcolepsy and ADHD (Kerna et al., 2020). The medication is safe for use in patients who are three years or older. The medication is a second-line treatment option and can be used when other medications fail to elicit the desired responses. However, Ritalin LA has shown clinical efficacy in managing inattentive symptoms; thus, it is necessary to change the medication (Verghese & Abdijadid, 2022). This decision’s ethical and legal considerations ensure the decision relays the most benefits to the patient and the least harm and that the dose is within the licensed limits to prevent toxicity and overdose. The drug side effects also increase with the increase in the dose of the drug above the minimum licensed dose. The intention is to ensure optimum patient outcomes with minimal side effects.

Decision Point #3

After the second decision, the patient comes to the hospital and shows total remission, and the symptoms of inattentiveness and school performance have significantly improved. In addition, the palpitations and tachycardia have also subsided. At this point, the objective is to ensure the patient achieves total remission without possible side effects. Continuing the same dose of Ritalin is the choice decision because the patient has achieved remission. The medication is safe, does not cause withdrawal or tolerance, and can thus be used as a long-term therapy (Verghese & Abdijadid, 2022). Increasing the drug dose will not produce any further clinical changes and will put the patient at risk for more severe side effects. In addition, the patient has achieved total remission, and there is no need to change the therapy. Obtaining an EKG is not a sole intervention but part of continuous management. It is crucial to monitor the heart status using the EKG and maintain the dose of Ritalin LA 20mg daily.

Summary

Katie presents with more than six symptoms of inattentiveness. The best decision is to put her on an FDA-approved medication, a CNS stimulant, because stimulants are the first-line medications in managing ADHD. Medications in the second-line treatment and those not FDA-approved are given a lower priority. The client’s response to the medication guides further treatment. The patient achieved partial remission, and some side effects, common in low-dose Ritalin and an increase in the dose of Ritalin, was vital to achieve total remission and reduce the side effect. After the patient’s response to the dose increment, the last decision was to maintain the therapy. There was no need to change the dose or the drug because the current drug achieved remission and is suitable for long-term use. Nurse practitioners should carefully evaluate their patients and offer management interventions that meet the objectives and achieve total remission.

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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. https://doi.org/10.21037/tp.2017.08.02

Childress, A., Hoo-Cardiel, A., & Lang, P. (2020). Evaluation of the current data on guanfacine extended release for treating ADHD in children and adolescents. Expert Opinion on Pharmacotherapy, 21(4), 417-426. https://doi.org/10.1080/14656566.2019.1706480

Hile, A. L. (2020). Bupropion for the Treatment of ADHD. Lynchburg Journal of Medical Science, 2(1), 15.

Kerna, N. A., Flores, J. V., Holets, H. M., Nwokorie, U., Pruitt, K. D., Solomon, E., & Kadivi, K. (2020). Adderall: On the Razor’s Edge of ADHD Treatment, Enhanced Academic and Physical Performance, Addiction, Psychosis, and Death. EC Psychology and Psychiatry, 9, 65-71. https://doi.org/10.31080/ecpp.2020.09.00801

Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier

Verghese, C., & Abdijadid, S. (2022). Methylphenidate. In StatPearls [Internet]. StatPearls Publishing.

Verghese, C., & Abdijadid, S. (2022). Methylphenidate. In StatPearls [Internet]. StatPearls Publishing.

Please be mindful of plagiarism and APA format, I have included the rubric. Please use my course resources as one of my references as instructed. Please include Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier

Learning Resources
Required Readings (click to expand/reduce)

Prince, J. B., Wilens, T. E., Spencer, T. J., & Biederman, J. (2016). Stimulants and other medications for ADHD. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 99–112). Elsevier.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

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. https://doi.org/10.2165/11599630-000000000-00000

Martin, L. (2020). A 5-question quiz on ADHD. Psychiatric Times.

https://www.psychiatrictimes.com/view/5-question-quiz-adhd

Medication Resources (click to expand/reduce)

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U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

armodafinil
amphetamine (d)
amphetamine (d,l)
atomoxetine
bupropion
chlorpromazine
clonidine
guanfacine
haloperidol
lisdexamfetamine
methylphenidate (d)
methylphenidate (d,l)
modafinil
reboxetine
Required Media (click to expand/reduce)

Case Study: A Young Caucasian Girl with ADHD

Note: This case study will serve as the foundation for this week’s Assignment.

Assignment: Assessing and Treating Patients With ADHD
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 for this Assignment:
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.
The Assignment: 5 pages
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.