ASSIGNMENT: ASSESSING AND TREATING PATIENTS WITH ADHD

Assessing and Treating Patients with ADHD
Attention Deficit Hyperactive Disorder (ADHD) is a common disorder that affects a significant proportion of the population globally. ADHD is largely diagnosed during childhood since the affected demonstrate abnormal behaviors such as inattention, impulsivity, and learning difficulties. Psychiatric mental health nurse practitioners diagnose and treat those affected by ADHD. They make their decisions with the aim of ensuring safety and quality in the treatment process. Therefore, this essay examines a case study involving a child diagnosed with ADHD, develops appropriate treatments and explores ethical considerations that would affect the treatment.

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The child in the case study is Katie. Katie is an eight-year-old child that has been referred for psychiatric review by her primary care provider. The PCP feels that Katie should be evaluated by psychiatry since her teacher suggested that she might be suffering from ADHD. The Conner’s Teacher Rating Scale-Revised completed by Katie’s teacher shows that Katie is inattentive, forgets things she has learned, easily distracted, poor in spelling, arithmetic, and reading. She also has short attention span, pays attention to things she is only interested in, and lack interest in schoolwork. Katie also rarely finishes her schoolwork or follows through on instructions. Katie confirms these findings when subjective data is obtained. Mental status examination reveals that her attention and concentration are grossly intact. Katie is diagnosed with attention deficit hyperactive disorder, predominantly inattentive presentation. The factors that will influence Katie’s treatment decisions include her age, symptoms, and her response to treatment.
Decision 1
Selected Decision
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning
Why the Decision was Selected
Methylphenidate is an FDA approved drug for treating ADHD in children. Methylphenidate is a stimulant of the central nervous system that increases the levels of catecholamines in brain areas involved in reward and motivation (Matthijssen et al., 2019). Ritalin has been shown to reduce up to 70% of the core symptoms of ADHD as compared to placebo. The effects can be sustained for at least 24 months, translating into improved functioning among the affected children. Ritalin also has favorable side effect profile on children, which makes it a drug of choice for ADHD (de Faria et al., 2022). A study by Sugaya et al., (2022) found that methylphenidate was highly effective in improving functionality and reducing the symptoms of ADHD for preschool children with ADHD. The effects were sustained even after 8 weeks of treatment. Therefore, these observations inform the selection of methylphenidate for Katie.
Why the Other Two Options were not Selected
I did not select the decision to begin Wellbutrin (bupropion) XL 150 mg orally daily. This is because Wellbutrin is an antidepressant that is used for smoking cessation. It is also not the first-line drug of choice for ADHD in children. I also did not select the decision to start Katie on Intuniv extended release 1 mg orally bedtime. This is because of its associated side effects such as sedation and hypotension, which may affect treatment adherence (Hendrix, 2020).
What I was Hoping to Achieve
Methylphenidate increases the concentration of catecholamines that influence learning and behavior in the brain. As a result, I was hoping that Katie’s attention, academic performance, and social functioning would improve with the decision. Methylphenidate also has high tolerability level when used for ADHD (Sugaya et al., 2022). Therefore, I expected Katie not to develop any side or adverse effects to the treatment.
Ethical Considerations
Ethical considerations may affect my treatment plan and communication with patients. For example, psychiatric mental health nurse practitioners must promote autonomy in the treatment of mental health problems. They must seek informed consent before initiating Katie on any treatment (Sakala, 2022). As a result, Katie parents’ decision to decline the available treatments will affect the treatment plan.
Decision 2
Selected Decision
Change to Ritalin LA 20 mg orally daily in the morning
Why the Decision was Selected
Katie returned the clinic in four weeks with report that her teacher noted improved symptoms of ADHD in the morning. There is also improvement in her academic performance. However, Katie’s teacher noted that Katie stares off into space and daydreams again by the afternoon. These observations imply that the initial dosage of methylphenidate is inadequate to last her throughout the day. There has been mild improvement in ADHD symptoms. The optimum therapeutic dose of Ritalin has not been achieved. Parents reported that Katie’s pulse rate is 130, which is an expected side effect that improves with time (Matthijssen et al., 2019). Therefore, it is appropriate to change the current treatment to a long acting form of Ritalin to produce effects that would last throughout the day.
Why the Other Two Options were not Selected
I did not select the decision to continue the same dose of Ritalin and re-evaluate in 4 weeks. This is because the initial dosage of Ritalin resulted in minimal improvement in symptoms. Continuing with the same dosage will not contribute to improved academic performance and functioning. I did not select the decision to discontinue Ritalin and begin Adderall XR 15 mg orally daily. This is because discontinuing Ritalin is not recommended since Katie tolerates it and there have been mild improvement in symptoms (de Faria et al., 2022). There is no indication for discontinuing the treatment at this time.
What I was Hoping to Achieve
I was hoping that a change to long acting form of Ritalin would produce improvements lasting Katie throughout the day. This is due to the prolonged effect of Ritalin LA. I was also hoping that Katie’s academic performance and functioning would improve with the new dosage of Ritalin (Man et al., 2023).
Ethical Considerations
Ethical considerations may affect treatment plan and communication at this step. One of the ways is the need for the promotion of safety in the client’s treatment. PMHNP must ensure the selected treatments minimize harm while optimizing its associated benefits. Evidence-based data must inform the selection of treatments for psychiatric conditions (Man et al., 2023). Katie’s current treatment will be changed should she develop any adverse effects to the prescribed Ritalin LA.
Decision 3
Selected Decision
Maintain the current dose of Ritalin LA and revaluate in 4 weeks
Why the Decision was Selected
Katie returned to clinic in four weeks with reports of continued improvement in symptoms. Katie’s academic performance is still improved. The switch to the LA preparation is lasting Katie throughout the school day. The reports of Katie’s heart feeling have also gone away and her pulse is 92. The findings mean that the desired therapeutic effect of Ritalin LA has been achieved (Sugaya et al., 2022). Therefore, it would be appropriate to maintain the current dose of Ritalin for sustained improvement in symptoms.
Why the Other Two Options were not Selected
I did not select the decision to increase Ritalin LA to 30 mg orally daily. This is because of the increased risk of drug toxicity. There has been optimum improvement in her symptoms (Sugaya et al., 2022). I did not select the decision to obtain EKG based on current heart rate . This is because Katie’s pulse rate is within the normal range.
What I was Hoping to Achieve
I was hoping to sustain the improvement in Katie’s symptoms. The maintained dosage is expected to sustain the improvement in Katie’s academic performance and functioning (de Faria et al., 2022). I was also hoping for continued tolerance by Katie.
Ethical Considerations
PMHNP must make ethical decisions that protect the rights of their patients. The selected treatments must not subject the patient to any form of harm. The selection of methylphenidate aimed at minimizing the potential of harm since it is an FDA recommended first-line of drug for ADHD. This consideration safeguards Katie’s rights to beneficence and non-maleficence in the treatment process (Sakala, 2022).
Conclusion
In summary, the use of methylphenidate was effective in this case study. Methylphenidate is an FDA-approved drug for use in treating ADHD in children. Methylphenidate is also tolerable and produces minimal side effects when used in this population. The first decision resulted in minimal improvement in Katie’s symptoms. The teacher reports that she stared off in the afternoon. This informed the decision to prescribe her a long acting form of Ritalin. The long acting form of Ritalin was effective, hence, the decision to continue with it in the third step of her treatment (Man et al., 2023). Ethical considerations influenced Katie’s treatment plan. The PMHNP was mandated to ensure the protection of Katie’s right to autonomous care, beneficence, and non-maleficence (Sakala, 2022). Ethical considerations ensure the delivery of high-quality, safe, and efficient care when treating psychiatric conditions.

References
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
Hendrix, C. (2020). Attention Deficit Hyperactivity Disorder (ADHD).
Man, K. K. C., Häge, A., Banaschewski, T., Inglis, S. K., Buitelaar, J., Carucci, S., Danckaerts, M., Dittmann, R. W., Falissard, B., Garas, P., Hollis, C., Konrad, K., Kovshoff, H., Liddle, E., McCarthy, S., Neubert, A., Nagy, P., Rosenthal, E., Sonuga-Barke, E. J. S., … Sandersleben, H. U. (2023). Long-term safety of methylphenidate in children and adolescents with ADHD: 2-year outcomes of the Attention Deficit Hyperactivity Disorder Drugs Use Chronic Effects (ADDUCE) study. The Lancet Psychiatry, 10(5), 323–333. https://doi.org/10.1016/S2215-0366(23)00042-1
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
Sakala, E. P. (2022). Clinical Psychiatry, Epidemiology, Ethics, Patient Safety Review: 2023. Kaplan Medical.
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

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In 4-5 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

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

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

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

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

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.