ADHD : the 4 best treatments

BACKGROUNDKatie 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 you 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.

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 outbursts” 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.” ADHD. ADHD. ADHD. ADHD. ADHD. ADHD. ADHD. ADHD. ADHD. 

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 EXAMThe 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 has dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. The self-reported mood is euthymic.

The effect 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 attendance at the clinical interview and her ability to count backward 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 Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNINGRESULTS OF DECISION POINT ONE·    

Client returns to the 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 “heartfelt funny.”

You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minuteDecision Point Two Discontinue Ritalin and begin Adderall XR 15 mg orally daily RESULTS OF DECISION POINT TWO·    

Client returns to the 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 maybe worse because it was started at a higher dose. You 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 that may be caused by a high starting dose of medication.  

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.

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