Assessing and Treating Clients With ADHD Decision tree case study
To prepare for this Assessing and Treating Clients With ADHD Decision tree case study Assignment:
This case study will serve as the foundation for this week’s Assignment.
Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD
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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. Assessing and Treating Clients With ADHD Decision tree case study.
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. Assessing and Treating Clients With ADHD Decision tree case study. 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.” Assessing and Treating Clients With ADHD Decision tree case study
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. Assessing and Treating Clients With ADHD Decision tree case study
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.
The Assignment:
Examine Case Study: A Young Caucasian Girl With ADHD You will be asked to make three decisions concerning the medication to prescribe to this client Assessing and Treating Clients With ADHD Decision tree case study. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients Assessing and Treating Clients With ADHD Decision tree case study
Introduction
Attention Deficit Hyperactive Disorder (ADHD) is a psychiatric disorder that affects children’s’ functioning ability and presents with developmentally inappropriate patterns of inattentiveness, impulsivity, and hyperactivity. Severe forms of ADHD can cause significant problems in a child’s life and daily routine. Since they often behave differently as expected and have a very short attention span, they usually cause trouble thus need a lot of attention. As one of the most common neurobehavioral disorders among children and adolescents, appropriate pharmacological treatment is vital to preventing the spanning of impairment and symptoms to adulthood.
Case Study Overview
This case involves an 8-year-old Caucasian female named Katie who was referred by her PCP for a psychiatric evaluation that would help to establish an ADHD diagnosis. The psychiatric assessment and evaluation prompted a diagnosis of ADHD with a predominantly inattentive presentation. Therefore, this paper discusses the psychopharmacological three-point decisions of managing Katie. It will also discuss the expected outcomes and actual outcomes of management at every decision point and the ethical considerations that may influence the treatment plan and communication with the client and family.
Decision #1
Decision Selected
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.
Reason for Selecting This Decision
Ritalin is a cognitive enhancer stimulant approved for the management of ADHD. It acts by influencing norepinephrine and dopamine in the CNS to speed up the brain’s activity (Maia et al., 2017). When compared to other stimulants, Ritalin is readily available, affordable, and reaches peak performance faster. Wellbutrin is also a good option as some PMHNPs use it off label to manage ADHD in adults since it increases the presence of dopamine and norepinephrine in the frontal cortex (Archives, Consult & Psychopharmacology, 2016). However, it is not the best choice for managing an 8-year-old due to its key side effect of suicidal ideation. Similarly, intuniv could be a good option since it is used to manage opposition behaviors in children diagnosed with ADHD (Bello, 2015). However, its effect on improving a child’s attention is minimal and it causes sedation, increasing a patient’s sluggishness.
Expected Outcome
It was expected that Katie’s ability to pay attention in school and her academic performance would slightly improve after starting her on Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning. Ritalin s approved by the FDA to manage ADHD in children aged 6 years or younger since it focuses on the neurotransmitters dopamine and norepinephrine in the frontal cortex to improve listening skills and reduce the symptoms of concertation and attention (Banaschewski et al., 2016).
Difference between Expected Outcome and Actual Outcome
After four weeks, Katie returned to the clinic accompanied by her parents. She reportedly had an improvement in symptoms in the morning and a general improvement in her academic performance. However, in the afternoon, she could hardly concentrate. Katie also reported a funny heart feeling although her pulse rate was 130b/min and regular. The funny heart feeling reported by Katie was likely Ritalin’s side effect. Ritalin IR (immediate-release) commonly causes tachycardia (Maia et al., 2017). Besides, it can hardly help Katie to be attentive throughout the day. Therefore, to achieve the therapeutic goals, it is advisable to switch to a long-acting preparation.
Decision # 2
Decision Selected
Change to Ritalin LA 20mg orally in the morning
Reason for Selecting This Decision
Although Katie had some improvement in her academic performance and could reportedly be attentive in class in the morning, she could hardly pay attention to the remainder of the day. This was a clear indication that she needed a long-acting formulation of Ritalin, which would also help to decrease the severity of tachycardia as a side effect (Haertling, Mueller & Bilke-Hentsch, 2015).
Expected Outcome
It was expected that Katie’s attention span in school would last the whole day as compared to before when she could only pay attention in the morning hours hence more improvement in her academic performance. Besides, it was also expected that Katie will no longer experience a ‘funny heart feeling’ and that she will have an appropriate pulse rate for her age(Haertling, Mueller & Bilke-Hentsch, 2015).
Difference between Expected Outcome and Actual Outcome
After four weeks, Katie returned to the clinic accompanied by her parents with reports of the significant improvement in her academic performance and ability to concentrate the entire day. She also reported that the funny heart feeling had diminished and her pulse was 92 illustrating good progress in treatment.
Decision #3
Decision Selected
Maintain the current dose of Ritalin and re-evaluate the patient in 4 weeks.
Reason for Selecting This Decision
Based on Katie’s progress, it was evident that her symptoms were gradually diminishing and she could pay attention for the whole day in school. It was also evident that the side effects experienced by the patient went away after changing to a long-term formulation. There are no indications for increasing the dosage of Ritalin when managing such a patient for ADHD. Besides, since current evidence suggests that the most effective strategy to manage ADHD is by maintaining low dosages of the stimulant medications, the best decision is to maintain the current dosage of Ritalin and to re-evaluate the patient after 4 weeks (Haertling, Mueller & Bilke-Hentsch, 2015).
Expected Outcome
It was expected that Katie would improve further in terms of her academic performance, attention span and ability to concentrate. Her interest in schoolwork and ability to remember will improve markedly. She will also not experience tachycardia or any other adverse effects associated with Ritalin LA 20mg.
Difference between Expected Outcome and Actual Outcome
There was no huge difference between the expected outcome and the actual outcome. Katie returned to the clinic after four weeks with reports of marked improvement in her academic performance, interest in schoolwork, and ability to pay attention in school the whole day. After changing to a long-acting formulation, she experienced no side effects.
How Ethical Considerations Might Impact Treatment Plan and Communication with Families and the Client
It is important to observe the ethical principle of non-maleficence and beneficence by ensuring that the benefits of a selected drug for treatment outweigh the potential harm when managing pediatric patients with ADHD. As suggested by Gardner, Ruest & Cummings (2016), the discussions about the treatment plan should include informing the client about every decision made, involve the parents and family, and maintain transparency. During these discussions, a PMHNP should also incorporate details about the risks, benefits, and alternative treatments.
Conclusion
ADHD is a psychiatric disorder that commonly manifests in children and adolescents with developmentally inappropriate patterns of inattentiveness, impulsivity, and hyperactivity. Appropriate management with either short or long-acting stimulant medications helps to prevent spanning of symptoms and impairment to adulthood. Long-acting formulations are very efficacious and effective with long-term outcomes.
References
Archives, C. P., Consult, C., & Psychopharmacology, S. (2016). Adult ADHD: pharmacologic treatment in the DSM-5 era. Current Psychiatry, 15(10), 18-25.
Banaschewski, T., Buitelaar, J., Chui, C. S., Coghill, D., Cortese, S., Simonoff, E., & Wong, I. C. (2016). Methylphenidate for ADHD in children and adolescents: throwing the baby out with the bathwater. Evidence-Based Mental Health, 19(4), 97-99.
Bello, N. T. (2015). Clinical utility of guanfacine extended-release in the treatment of ADHD in children and adolescents. Patient preference and adherence, 9, 877.
Gardner, K., Ruest, S., & Cummings, B. (2016). Diagnostic Uncertainty and Ethical Dilemmas in Medically Complex Pediatric Patients and Psychiatric Boarders. Hospital Pediatrics, 6(11), 689-692.
Haertling, F., Mueller, B., & Bilke-Hentsch, O. (2015). Effectiveness and safety of a long-acting, once-daily, two-phase release formulation of methylphenidate (Ritalin® LA) in school children under daily practice conditions. ADHD Attention Deficit and Hyperactivity Disorders, 7(2), 157-164.
Maia, C. R. M., Cortese, S., Caye, A., Deakin, T. K., Polanczyk, G. V., Polanczyk, C. A., & Rohde, L. A. P. (2017). Long-term efficacy of methylphenidate immediate-release for the treatment of childhood ADHD: a systematic review and meta-analysis. Journal of attention disorders, 21(1), 3-13.