Attention deficit hyperactivity disorder (ADHD) refers to a complex disorder that affects brain development among children and adults. The illness affects brain development to perform executive functions. Often, people with ADHD tend to have trouble focusing, controlling, and being organized. Among the ADHD signs in children include being hyperactive, being inattentive, and being impulsive in particular ways. ADHD disorder among kids can be categorized into three groups depending on the signs. There are hyperactive/impulsive, inattentive, and a combination of the inattentive and the hyperactive/impulsive children.
Case Summary
The ADHD patient is an 8-year old, Caucasian girl named Katie. Katie was taken to the psychiatric mental practitioner by the father and mother to help in determining if she has ADHD. According to the revaluation results provided by the teacher in the Conners Teacher Rating Scale-Revised, Katie is inattentive, easily distracted, she tends to easily forget things that she has learned, poor in arithmetics, spelling, as well as reading. The teacher also stated that Katie only pays attention to things that interest her. However, schoolwork does not hence being highly unattentive during classwork. Another sign shown by Katie is that she starts things and leaves them halfway without finishing, therefore failing to follow instructions and completing the school work. However, Katies states that she is okay and she does not have any of the ADHD signs.
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Typically, it is appropriately developed for her age, with clear, coherent, and logical speech. Besides, she has dressed appropriately and oriented well to people, place, and time. She denies experiencing any visual and auditory hallucinations, delusional, or paranoid. Based on the clinical interview, her attention and concentration are grossly intact. Katie said that she does not have any suicidal or homicidal thoughts. She is, therefore, diagnosed with Attentive deficient Hyperactivity Disorder (ADHD. This paper aims to examine the three treatment decisions that a practitioner may consider.
Decision 1
The Psychiatric Mental Health Nurse practitioner (PMHNP) should start Katie’s treatment by prescribing the Wellbutrin XL 150mg PO daily, the Intunivextended-release 1mg PO at bedtime, or the chewable tablets of Ritalin (Methylphenidate) 10 mg PO Q AM. Usually, stimulants are the first drugs options for administration for ADHD patients. In this case, a Psychiatric Mental Health Nurse practitioner (PMHNP) choose to start with Ritalin (Methylphenidate) chewable tablets 10mg PO Q AM. The medication assists in enhancing focus in patients with the issue of inattentiveness. The Ritalin prevents the reuptake of DA and NE that promote the neurotransmitters to reach the peak level in the presynaptic cleft (Busardo et al., 2016).
Usually, the Wellbutrin takes a few weeks until the therapeutic effects to occur in the patient. For that reason, it cannot be used as the first-line treatment. It is a third-line treatment. For the Intunniv, it is used as the adjunctive management of ADHD. It targets behavioral symptoms such as defiance and aggression, but not the center inattentiveness ADHD symptoms (Arcangelo et al., 2017).
After the return to the clinic four weeks after the start of the medication, the patient’s parents state that the teacher said that there were positive effects. Katie’s teacher established that Kattie has less of the inattentive symptoms, especially in the morning, and this has contributed to the overall improvement in her academic performance. However, she changed in the afternoon, where she starts staring and daydreaming while in class. This makes the parents so concerned about Katie. Katie had reported that she feels like her heart is racing; the heart rate is 130 beats per minute. These results are exactly as the practitioner anticipated them. The therapeutic effect of Ritalin is short as the duration of action, and thus medication increases the level of peripheral norepinephrine that causes side effects like tremor and tachycardia (Stahl, 2013).
Decision 2
considering that the results are positive, the PMHNP can continue prescribing the same medication of Ritalin dose and reevaluate it after four weeks. The practitioner may also decide to change the medication to Ritalin LA 20 mg orally daily QAM or even discontinue Ritalin and begin Adderall XR 15 mg orally daily. The practitioner decided to switch Ritalin LA 20 mg orally daily medication. Usually, long-acting stimulant formulations are always effective, like their short-acting alternatives. Additionally, they are better and more advantageous due to their improved compliance, lower potential for abuse, as well as higher consistency together with extensive coverage throughout the day (Lopex & Leroux, 2013).
Since the patient's symptoms can persist, the practitioner shouldn't continue treating the patient with the same medication. Nevertheless, it is also not a good idea to give the patient a new dosage of stimulants as she is responding well to the Ritalin irrespective of the negative effects experienced. For that reason, the medication was switched from Ritalin (Methylphenidate)10 mg PO Q AM to Ritalin LA 20 mg orally daily QAM.
After four weeks and returning to the practitioner, it is established that there is still a development in the academic performance of Katie after switching the medication. The teacher sate the effect of the new medicine lasts her throughout the school day. Also, the high rate of throbbing in her heart has gone, and her heartbeat has declined from 130 to 92 beats per minute. The outcome is as anticipated. According to López & Leroux (2013), Ritalin LA 20 mg orally daily QAM is known for raising the functional performance of the patient and, at the same time, maintain the therapeutic effects for 24 hours.
Decision 3
At this point in the patient's care, the practitioner should maintain the current dose of Ritalin LA and reevaluate the effect of the medication four weeks later. The PMHNP can decide to increase the dose of the medication to Ritalin LA 30 mg orally daily or even obtain an EKG based on the current heart rate. The PMHNP decided to maintain the current dose of Ritalin LA and reevaluation in 4 weeks as the therapeutic medication has already been met without any significant adverse effects. It is, therefore, advisable to continue the patient with the medication. According to Advanced Cardiac Life Support (2019), a heart rate of 92 beats is appropriate for children aged 2 to 10. Therefore, there will be no need for EKG.
The primary reason why the practitioner should continue using the same medication is that the patient has a positive response to the drug. Additionally, there are no adverse effects that are expected to be experienced as a result of medicine. For that reason, the practitioner should continue evaluating the drug and adjust it as needed.
Ethical considerations might impact your treatment plan and communication with clients.
Like any other health practitioner, various ethical considerations are essential for the PMHNP to consider when treating ADHD patients. In the case of Katie, she is a minor. Therefore, the practitioner should communicate through the patient. The practitioner needs the consent of parents to treat the child. Also, the PMHNP needs to train and educate these parents on ADHD illness. As seen in the case, the parents were in denial of their child suffering from the disease. There should be open and constant communication between the practitioner, teacher, and the parents of the patient. This is to ensure that the correct information is obtained and utilized to facilitate appropriate medical practices.
References
Advanced Cardiac Life Support. (2019). Normal Values in Children. Retrieved from https://www.aclsmedicaltraining.com/normal-values-in-children/
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th Ed.). Ambler, PA: Lippincott Williams & Wilkins.
Busardo, F. P., Kyriakou, C., Cipolloni, L., Zaami, S., & Frati, P. (2016). From Clinical Application to Cognitive Enhancement: The Example of Methylphenidate. Current Neuropharmacology , 14 (1), 17–27. https://doi-org.ezp.waldenulibrary.org/10.2174/1570159X13666150407225902
López, F. A., & Leroux, J. R. (2013). Long-acting stimulants for treatment of attention-deficit/hyperactivity disorder: a focus on extended-release formulations and the prodrug lisdexamfetamine dimesylate to address continuing clinical challenges. Attention deficit and hyperactivity disorders , 5 (3), 249–265. 10.1007/s12402-013-0106-x
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th Ed.). New York, NY: Cambridge University Press.
