Treatment for ADHD

Summary of Case

Katie, a Caucasian 8-year-old girl, was brought to the office today by her parents. They were recommended by their primary healthcare provider (PCP). The PCP believed it was best if Katie had a psychiatric evaluation. The parents were given a copy of “Conner’s Teacher Rating Scale-Revised” to take to the PMHNP. Katie’s teacher completed the scale, and it was taken to their PCP. Katie’s teacher noted that she was easily distracted, inattentive, forgetful, seldomly followed instructions, and never finished school work. The parents are in denial. From a subjective perspective, Katie feels she is okay. She is interested in art. She gets lost momentarily. She loves her parents as they are good and kind to her. Mental examination shows she is well-grown for her age and well-dressed for the weather with clear, coherent, and logical speech. She has no tics, gestures, or noteworthy mannerisms, and her effect is bright. She denies any hallucinations or paranoid thoughts. Her attention and concentration were grossly intact during the interview, and she could count backward from 100 by serial 2’s and 5’s. She has no suicidal or homicidal ideation. Katie was diagnosed with attention deficit hyperactivity disorder (ADHD) and predominantly inattentive presentation.

Decision #1

My first choice of medication for Katie is Wellbutrin (Bupropion) XL, whereby she will take a total of 150mg orally daily. The decision to use Wellbutrin (Bupropion) XL 150mg as the first line for ADHD is because the selected medication is an atypical antidepressant that has been found to have higher efficacy in the management of ADHD in children and adolescents (Mucci et al., 2021). The bupropion mechanism of action, although not clear, includes weakly blocking the reuptake of norepinephrine and dopamine (Huecker et al., 2022). These neurotransmitters are responsible for attention and motivation, which leads to a reduction of ADHD symptoms within two weeks of use.

The other available options were not selected over Wellbutrin (Bupropion) XL due to concerns over the efficacy and risks of side effects. Wellbutrin (Bupropion) XL has a reduced risk of serious side effects as well as developing a dependency (Huecker et al., 2022). The provided options have lower efficacy in managing ADHD symptoms or have an increased risk of developing major side effects in long-term use as well as developing addictions.

The selection of Wellbutrin (Bupropion) XL as the first line for treating Katie’s symptoms was to reduce the ADHD symptoms as well as improve her ability to perform her daily activities such as learning. Wellbutrin (Bupropion) XL is linked to improved outcomes and can also help manage other comorbid psychiatric disorders not yet diagnosed in ADHD patients (Mucci et al., 2021).

The major ethical considerations include the patient’s autonomy, confidentiality, and maintaining her dignity. In this case, as Katie is too young to make her own decisions on treatment, her parents will be the main decision-makers. They will be informed of all available treatment options, efficacy, and risks to help them decide on the treatment plan that is best for Katie.

Decision #2

The second medication decision for Katie is Intuniv 1mg, to be taken orally at bedtime. I selected Intuniv based on the symptoms Katie presented. Intuniv (Guanfacine) is an FDA-approved alpha-2 adrenergic agonist for the management of ADHD symptoms in children between the ages of 6 and 17 years (FDA, n.d.). Intuniv is effective as it works by stimulating the alpha-2A receptors in the prefrontal cortex (Arnsten, 2020). The stimulated alpha-2A receptors in the prefrontal cortex result in an improved ability to recall things, better attention, and impulse control.

I did not select the other available options for the management of similar symptoms for various reasons. Firstly, although the other options are approved for the management of ADHD, they have a reduced efficacy. This means the benefits of the medications are felt several weeks after administration. Additionally, the other options also have a higher risk of serious side effects, such as seizures and fatigue, compared to Intuniv. The issue of the efficacy of the drug in reducing ADHD symptoms after administration is of concern in selecting medications, as some take longer to be effective (Mucci et al., 2021).

I decided to use Intuniv 1mg orally at bedtime as it improves prefrontal cortex functioning and, hence, higher cognitive function (Arnsten, 2020). This will help improve attention and motivation to learn as well as work on other major ADHD symptoms. Low doses at night will reduce the impact of side effects such as sleepiness.

Ethical considerations that may impact the treatment plan and communication with patients include the decisions to use the new drug and obtaining informed consent from Katie’s parents to include the new drug in the treatment plan. The parents must be provided with fully understandable information on the drug’s efficiency and associated risks.

 Decision #3

The third decision is to use Ritalin Methylphenidate 10mg orally in the morning. It is the last option to give to Katie. The medication belongs to a group of psychostimulants that works by inhibiting the reuptake of dopamine and norepinephrine, increasing their concentration levels in the brain (Briars & Todd, 2016). The medication is a first-line medication in the management of ADHD in children. However, in the case of Katie, it is the last option due to its stimulant nature (Faraone, 2018).

I would select Ritalin (methylphenidate) over the other two options as the last option if they failed to achieve the desired outcomes regarding the ADHD symptoms presented by Katie. A stimulant medication is more potent in managing ADHD in children aged 6 years and older due to its selective inhibition of the reuptake of neurotransmitters, especially dopamine and norepinephrine, leading to better ADHD symptom management (Faraone, 2018).

By deciding to use Ritalin (methylphenidate), I intend to improve the efficacy of the treatment and effectively manage to reduce the major symptoms of ADHD manifested by Katie. As earlier noted, methylphenidate increases the concentration of dopamine and norepinephrine in the brain, improving attention duration and moods (Faraone, 2018).

In this case, the ethical considerations that would impact the communication with the patient and the treatment plan would be considerations to use a psychostimulant on a child. The parents, as decision-makers, must be well informed about the drug’s potency and efficiency in managing ADHD as well as other comorbidities and the associated side effects, including the risk of addiction. This would help introduce the medication to the treatment plan with informed patient consent.

Conclusion

Katie has been diagnosed with ADHD and predominantly inattentive presentation. ADHD in children can is a neurodevelopmental disorder that affects children and adolescents, leading to increased inattention, hyperactivity, disruptive behavior, and impulsivity (Mucci et al., 2021). The management of ADHD in children requires starting treatment with medications with a low risk of side effects and addiction. Although some medications, such as Ritalin (methylphenidate), have the highest efficacy levels and are recommended as first-line medications for managing ADHD in children, they have a higher potential for side effects and the development of dependency (Faraone, 2018). Regardless of the efficacy of a drug if added to a treatment plan, it is important to have an ethically collaborative partnership with the patient or other legal decision-makers before deciding on adding medications to the treatment plan. Collaborative and ethical relationships improve patient outcomes as well as their experiences during the entire care period.

 References

Arnsten, A. F. T. (2020). Guanfacine’s mechanism of action in treating prefrontal cortical disorders: Successful translation across species. Neurobiology of Learning and Memory, 176, 107327. https://doi.org/10.1016/J.NLM.2020.107327

Briars, L., & Todd, T. (2016). A Review of Pharmacological Management of Attention-Deficit/Hyperactivity Disorder. The Journal of Pediatric Pharmacology and Therapeutics?: JPPT, 21(3), 192. https://doi.org/10.5863/1551-6776-21.3.192

Faraone, S. V. (2018). The pharmacology of amphetamine and methylphenidate: Relevance to the neurobiology of attention-deficit/hyperactivity disorder and other psychiatric comorbidities. Neuroscience and Biobehavioral Reviews, 87, 255–270. https://doi.org/10.1016/J.NEUBIOREV.2018.02.001

FDA. (n.d.). Clinical Pharmacological Review. Retrieved April 25, 2023, from https://www.fda.gov/media/80233/download

Huecker, M. R., Smiley, A., & Saadabadi, A. (2022). Bupropion. XPharm: The Comprehensive Pharmacology Reference, 1–4. https://doi.org/10.1016/B978-008055232-3.64054-1

Mucci, F., Carpita, B., Pagni, G., Vecchia, A. Della, Bjedov, S., Pozza, A., & Marazziti, D. (2021). Lifetime evolution of ADHD treatment. Journal of Neural Transmission 2021 128:7, 128(7), 1085–1098. https://doi.org/10.1007/S00702-021-02336-W

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BACKGROUND
Katie is an 8-year-old Caucasian female who was 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.

Treatment for ADHD

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’s primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she has already learned and 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 schoolwork and is easily distracted. Katie is also noted to start things but never finish them, 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 reported that she didn’t know what the “big deal” was. 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 reported that her home life was just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse or 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. The effect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes are readily appreciated. Attention and concentration are grossly intact based on Katie’s attendance to 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
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) Wellbutrin (Bupropion) XL 150mg orally daily
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) Intuniv 1mg orally at bedtime
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) Ritalin Methylphenidate 10mg PO in the morning
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.