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Attention Deficit Hyperactivity Disorder
CASE STUDY:
Young
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 ScaleRevised”. 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.
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SUBJECTIVE
Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her
favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and
sometimes hard because she feels “lost”. She admits that her mind does wander during class to
things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about
nothing and the teacher will call my name and I don’t know what they were talking about.”
Katie reports that her home life is just fine. She reports that she loves her parents and that they
are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other
concerns at this time.
MENTAL STATUS EXAM
The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is
clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed
appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or
tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no
delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact
based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s
and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.
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
Select what the PMHNP should do:
Begin Wellbutrin (bupropion) XL 150 mg orally daily
Begin Intuniv extended release 1 mg orally at BEDTIME
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in
the MORNING
3
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.
•
Note: Support your rationale with a minimum of five CURRENT, FREE, 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.
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)
4
•
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.
LEARNING RESOURCES
Required Readings
•
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and
practical applications (5th Ed.) Cambridge University Press.
o
Chapter 11, “Attention Deficit Hyperactivity Disorder and Its Treatment” (pp.
449-485)
5
•
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental
disordersLinks to an external site. (5th ed., text
rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonl
ine.org/doi/book/10.1176/appi.books.9780890425787
•
Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and
clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS
DrugsLinks to an external site., 26(3), 245–268. https://doi.org/10.2165/11599630000000000-00000
•
Martin, L. (2020). A 5-question quiz on ADHD. Psychiatric TimesLinks to an external
site.. https://www.psychiatrictimes.com/view/5-question-quiz-adhd
Medication Resources
•
U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugsLinks to an
external site.. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
Links to an external site.
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
•
guanfacine
•
amphetamine (d)
•
haloperidol
•
amphetamine (d,l)
•
lisdexamfetamine
•
atomoxetine
•
methylphenidate (d)
•
bupropion
•
methylphenidate (d,l)
•
chlorpromazine
•
modafinil
•
clonidine
•
reboxetine
Third scenario (I think the best of all)
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
Discontinue Intuniv and begin Focalin (dexmethylphenidate) XR
10 mg orally daily
RESULTS OF DECISION POINT TWO
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, and that
her academic performance has improved considerably
• Katie’s parents are very concerned, however, about Katie’s
decreased appetite. They say that Katie was never a “big
eater” but have become concerned that her appetite has
worsened
•
Decision Point Three
Maintain current dose of Focalin XR and re-evaluate at next
clinic visit in 4 weeks
Guidance to Student
Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side
effects such as decreased appetite are not unusual with stimulant medications. The side effect may
not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg
daily, the most prudent course of action from the available choices would be to maintain the current
dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No
action will be required if it stabilizes or improves. However, worsening of appetite may herald the
need to decrease to 5 mg orally daily.
Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side
effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to
increase the dose (recall that with stimulants, you always want to use the smallest effective dose).
Common side effects are not an indication to discontinue the drug and begin a different medication,
therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.
Second Possible Scenario
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
Discontinue Ritalin and begin Adderall XR 15 mg
orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
• Katie’s academic performance is still improved, and the XR
preparation has helped sustain her attention throughout the
school day, however, you also learn that Katie is having
tachycardia with this medication, too
•
Decision Point Three
Decrease to Adderall XR 10 mg orally daily
Guidance to Student
Adderall XR should be initiated at 10 mg orally daily and increased by 5–10 mg/day at weekly
intervals; maximum dose generally 30 mg/day. Tachycardia is one of the side effects of Adderall,
and may be worse because it was started at a higher dose. The PMHNP should decrease the dose
to 10 mg orally daily and re-evaluate at the next office visit.
Continuing the same dose will most likely not significantly improve the side effect of tachycardia, so
maintaining the current dose of medication would not be prudent as Katie may refuse to take the
medication if it causes unpleasant side effects.
There is no indication to move to a second line agent at this point due to a side effect which may be
caused by a high starting dose of medication.
First Scenario:
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
Discontinue Ritalin and begin Adderall (amphetamine d, l) 10 mg
orally daily
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.
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