Feb 23, 2024 Case Study: A Young Caucasian Girl With ADHD
NURS 6630 Case Study: A Young Caucasian Girl With ADHD
Case Study: A Young Caucasian Girl With ADHD
This case study is about Katie, an 8-year-old Caucasian female that has been brought to the office for assessment by her parents. Their primary care provider referred Katie for psychiatric evaluation, as she felt that she might have ADHD. The parents submit the Conner’s Teacher Rating Scale-Revised that shows that Katie’s teacher reported Katie to be inattentive, easily distracted, forgets things easily, and poor in spelling, arithmetic and reading. She also has short attention span, lacked interest in schoolwork, and rarely follows instructions or starts things but never finishes them. Katie’s parents denied that their daughter has ADHD, as she has not demonstrated abnormal behaviors. Katie acknowledged that she finds other subjects besides arts and recess boring. She also reported feeling lost, her mind wandering, and distracted in class activities. Mental status examination revealed Katie having grossly intact attention and concentration with euthymic mood and absence of delusions, hallucinations or suicidal thoughts.
The patient factors that would influence decisions made when prescribing medications for Katie are varied. One of them is age. Age influences the pharmacokinetics and pharmacotherapy of medications, hence, selective prescription when dealing with children and the elderly. The other factor is the Conner’s Teachers Rating Scale-Revised score. The aim will be to improve to score, as way of enhancing Katie’s behaviors and functioning in social and academic activities. Therefore, the aim of the treatment in this case study would be to improve the Conner’s Teacher Rating Scale-Revised, as it will indicate an improvement in Katie’s cognitive and behavioral functioning. The treatment seeks to improve aspects such as attention span and Katie’s ability to engage in complex tasks as well as complete assigned tasks and follow instructions.
Decision Point One
Selected Decision
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.
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Reason for Selection
Ritalin is a central nervous system stimulant recommended for use in treating ADHD in children. It exerts its effects on the dopaminergic system in the prefrontal complex to cause inhibitory control of the limbic system (Tarrant et al., 2018). The findings in the study by Pertermann et al., (2019) informed the decision to administer Ritalin. Besides it being the recommended drug for children with ADHD aged above 6 years according to the study by Tarrant et al. (2018), Ritalin also modulates the neural noise that contribute to the cognitive and behavioral symptoms associated with ADHD in children (Pertermann et al., 2019).
Why the Other Options Were Not Selected
I did not select the option to begin Wellbutrin (bupropion) XL 150 mg orally daily because it is recommended for use in treating ADHD in adults (Deang et al., 2019). The findings by Xiang (2017) also do not recommend the use of Wellbutrin in children, as they found that Wellbutrin has smaller effect sizes when compared to Ritalin. I also did not select the decision to begin Intuniv extended release 1 mg orally at bedtime because it is only indicated for use in cases where patients cannot tolerate stimulants such as Ritalin. It is also indicated in cases where stimulants have been found ineffective (Webb, 2019). The effectiveness of other stimulants has not been established, hence, the decision not to administer Intuniv.
What I Was Hoping to Achieve
I was hoping to achieve improvement in the attention span of Katie with the administration of Ritalin. I was also hoping to witness improvement in her cognitive skills, as evidenced by improved engagement in complex tasks and following instructions due to modulation of neural noise contributing to ADHD symptoms (Pertermann et al., 2019).
Ethical Consideration
While Ritalin has comparable effectiveness to that of Wellbutrin in treating ADHD in children, its large effect size influenced the adopted decision. The decision is also despite the fact that the prevalence of side effects such as headache is high in the use of Ritalin when compared to Wellbutrin (Xiang, 2017). However, the fact that Ritalin produces sustained, long-term effectiveness in managing the symptoms of ADHD informed the decision (Matthijssen et al., 2019). Therefore, it shows the ethical dilemma of balancing between safety of treatment and promotion of patient autonomy.
The Assignment
Assessing and Treating Clients with ADHD
Attention Deficit Hypersensitivity Disorder (ADHD) is one of the most common psychiatric problems encountered by children. According to Harpin (2017), this disorder is mostly diagnosed among children below the age of 12 years. Studies also show that the symptoms of ADHD improve with age, but when the disorder is diagnosed later in life, the patient might exhibit worsened symptoms. However, several treatment options have been proposed to help in the management of ADHD among the pediatric population.
Case Summary
The case involves an 8-year old Caucasian child called Katie, who came to the clinic to undergo a psychiatric evaluation in the company of her mother. Her primary care provider suspects that the patient might be having ADHD. When her teacher used the Conner’s Teacher Rating Scale-Revised, it was realized that symptomatology such as forgetfulness, reading issues, spelling limitations, arithmetic limitations, vulnerability to distractions and lack of attentiveness manifested in the patient. The patient’s attention span is low. She displays a lack of interest in schoolwork, and she is also easily distracted. The patient’s parents are reluctant with ADHD diagnosis, claiming that the patient does not display defiant behaviors or temper outbursts. According to Katie, there are no issues with her home life while no incidences of bullying have occurred at her school. However, the child was diagnosed with attention deficit hyperactivity disorder, the predominantly inattentive one when she underwent a mental health assessment.
Patient Factors
The paper demonstrates decisions made in formulating the most effective care plan in the management of the patient’s condition. Patient factors such as age and race, which affect the pharmacokinetics and pharmacodynamics of drugs will be considered when prescribing medications for this patient. Other important factors include the scores displayed by the Conner’s Teacher Rating Scale-Revised which reveals an ADHD diagnosis and the patient’s symptoms. Therefore, the purpose of this paper entails focusing on the decisions made when prescribing drugs for the patient to achieve the treatment goals such as improving the Conners’ Rating Scales – Revised (CRS-R) scores, and managing the patient’s symptoms to promote her school performance and social functioning within the next 4 to 12 weeks.
Decision #1
Selected Decision
The best initial treatment option for the patient is Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.
Reason Behind Decision 1:
I made this decision as a result of the safety profile of the drug exhibited among children above the age of 6 years, with great effectiveness in the management of ADHD symptoms, as demonstrated by the research conducted by Huss et al., (2017). Ritalin (Methylphenidate) has an FDA approval regarding the management of ADHD in children such as Katie. Harpin (2017) postulates that the drug acts via noncompetitively inhibiting the reuptake of dopamine and noradrenaline at the noradrenaline transporter (NAT) as well as dopamine transporter (DAT) sites. This actions ensures that the levels of dopamine as well as noradrenaline become elevated at the synaptic cleft. Another study conducted by Patwardhan (2021) shows that Ritalin displays great tolerance, adherence, and effectiveness in the management of ADHD among children between the ages of 6 to 17 years. Additionally, by considering the patient’s race, methylphenidate undergoes hepatic metabolism through the CYP3A4 pathway, which is predominant among Caucasian females, displaying the highest level of activity (Mucci et al., 2021).
Intuniv is a long-acting non-stimulant medication for the management of ADHD. I preferred Ritalin to Intuniv since studies show that the latter displays great effectiveness as an adjunct to stimulant medication, rather than mono-therapy (Huss et al., 2017). Additionally, a study carried out by Patwardhan (2021) revealed that the drug is associated with increased side effects of somnolence in approximately 38% of patients taking this medication, which is very rare with Ritalin.
According to Mucci et al. (2021), Wellbutrin is a norepinephrine-dopamine reuptake inhibitor (NDRI) whose functions entails ADHD management. The drug is also appropriate as an adjunct to stimulants and not considered as the first choice for the management of ADHD in children as displayed by most study guidelines (Patwardhan, 2021).
Expected Outcome
The patient is expected to display at least a 50% reduction in ADHD symptoms within the next four weeks, as displayed by a study carried out by Patwardhan (2021). She should be able to regain interest in doing daily activities, homework and even going to school (Mucci et al., 2021). Her attentiveness and class performance are expected to improve within this time. Her scores on the Conners’ Rating Scales – Revised (CRS-R) are also expected to improve within this time.
Ethical Considerations Impact on Treatment Plan
According to the legal and ethical guidelines, the PMHNP must take into account the patient’s race and ethnicity in formulating the most effective treatment plan (Harpin, 2017). Consequently, given that the patient is a minor, the parents must be involved in making healthcare decisions concerning their daughter. As such the PMHNP must create a balance between beneficence and autonomy when taking care of this patient.
Case Study: A Young Caucasian Girl With ADHD: Decision #1
Case Study: A Young Caucasian Girl With ADHD
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.
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. 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.
Case Study: A Young Caucasian Girl With ADHD 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.”
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.
Case Study: A Young Caucasian Girl With ADHD-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.
Case Study: A Young Caucasian Girl With ADHD Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation
Decisions Made and Outcomes (Needed to formulate the paper) (Must use and formulate paper based off of the chosen decision. Then tell why the other two decision were not a good choice with in-text citations noted for each.)
Choices for Decision 1: Select what the PMHNP should do:
Begin Wellbutrin (bupropion) XL 150 mg orally daily
Begin Intuniv extended release 1 mg orally at BEDTIME
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
Decision Choice Chosen: Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING
***Explain why other two choice were rejected (not adequate choices)***
Case Study: A Young Caucasian Girl With ADHD Outcome: RESULTS OF DECISION POINT ONE:
Client returns to 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 “heart felt” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute
Choices for Decision 2: Select what the PMHNP should do:
Continue same dose of Ritalin and re-evaluate in 4 weeks
Change to Ritalin LA 20 mg orally daily in the MORNING
Discontinue Ritalin and begin Adderall XR 15 mg orally daily
Decision Choice Chosen: Change to Ritalin LA 20 mg orally daily in the MORNING
***Explain why other two choice were rejected (not adequate choices)***
Case Study: A Young Caucasian Girl With ADHD Outcome: RESULTS OF DECISION POINT TWO:
Client returns to clinic in four weeks
Katie’s academic performance is still improved, and the switch to the LA preparation is lasting Katie throughout the school day
Katie’s reports of her heart feeling “funny” have gone away. Pulse was 92 during today’s office visit
Choices for Decision 3: Decision Point Three Select what the PMHNP should do next:
Maintain current dose of Ritalin LA and reevaluate in 4 weeks
Increase Ritalin LA to 30 mg orally daily
Obtain EKG based on current heart rate
Decision Choice Chosen: Maintain current dose of Ritalin LA and reevaluate in 4 weeks
***Explain why other two choice were rejected (not adequate choices)***
Case Study: A Young Caucasian Girl With ADHD Outcome: Guidance to Student
RESULT FROM CHOOSING TO MAINTAIN CURRENT DOES OF RITALIN LA AND REEVALUATE IN 4 WEEKS
Case Study: A Young Caucasian Girl With ADHD: Guidance to Student
At this point, Katie’s symptoms are well controlled (her attention is sustained throughout the school day) and her side effects have gone away following change to a long-acting preparation. There is no indication at this point that the dose should be increased as it is always advisable to use the lowest effective dose of stimulant medication. Katie’s heart rate is appropriate for an 8 year old girl and an EKG would not be indicated based on her heart rate.
Make sure that this paper has at least 6 References from 2014. Please use in-text citations for each section of each decision.Don’t forget the ethical considerations for this assignment. Make it a section by itself.***
***Also please make sure when looking at the ethical consideration for this assignment that you look at how the Caucasian (male) ethnicity and pain medications interact.***
SOME RESOURCE for Case Study: A Young Caucasian Girl With ADHD Assignment
Note: Review all materials from the Discussion.
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.
Course Texts These course texts are available through Stahl Online Resources http://stahlonline.cambridge.org/ Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press. Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
The management of attention deficit hyperactivity disorder (ADHD) among the pediatric population is quite challenging due to the limited amount of evidence supporting the safety of several recommended drugs for this disorder. To illustrate further the management of ADHD, the case of an 8-year-old Caucasian female has been provided. The patient presents with symptoms of ADHD as suggested by her teacher who completed the Conner’s Teacher Rating Scale-Revised. Her teacher claims that the patient is forgetful most of the time, and easily distracted with a very short concentration time.
The patient also displays poor language, spelling, and arithmetic skills, hurting her overall school performance. The teacher also reported that lately, the patient has been failing to follow instructions, leaving her homework incomplete. Despite the patient’s parents refusing their daughter has ADHD, the patient reports that she gets bored most of the time at school with a lack of interest in school work. She however denies bullying of any kind at school with a good home life experience. With the findings of the conducted mental status examination and the Conner’s Teacher Rating Scale-Revised, the patient has been diagnosed with Attention deficit hyperactivity disorder, predominantly inattentive presentation.
Several factors were considered when deciding on the specific pharmacological agent and the right dosage to prescribe in the management of the patient’s condition. Such factors include the young age of the patient, her Caucasian race, her ADHD diagnosis, and the reported symptoms. The completed Conner’s Teacher Rating Scale-Revised can also help determine the severity of the patient’s condition which is crucial in determining the dosage of the selected drug. As such, this discussion aims at developing the most effective treatment plan for the 8-year-old patient in the management of ADHD, with a rationale for each decision made.
Decision#1
Selected Decision and Rationale
Administering Methylphenidate 10mg chewable tablets once a day in the morning was selected as the initial intervention. Methylphenidate is a stimulant to the central nervous system that acts via noncompetitive blockage of noradrenalin and dopamine reuptake into the terminals, by inhibiting the action of the dopamine and noradrenaline transporters thus raising dopamine and noradrenaline levels in the synaptic cleft (American Psychiatric Association, 2013; Cipriani et al., 2018). Previous evidence supports the substantial effectiveness of Methylphenidate in the management of children diagnosed with ADHD, with a great safety profile and high tolerability levels (Hodgkins et al., 2012).
The drug is only recommended for children of age 6 and above (Grimmsmann & Himmel, 2021). Finally, with consideration of the patient’s Caucasian race, the drug is metabolized in the liver via the CYP3A4 pathway, which is predominant among this ethnic population, hence limiting the risks of toxicity (Bonati et al., 2018). The chewable tablet formulation is normally recommended for children to promote compliance (Kikuchi et al., 2021).
Intuniv was an inappropriate choice for this patient given that previous studies report that the drug being a non-stimulant is more effective in the management of ADHD when used together with a stimulant (Pelham III et al., 2022). Wellbutrin on the other hand is a norepinephrine-dopamine reuptake inhibitor (NDRI) discouraged among children below the age of 9 years old due to its elevated risks of seizures (Kikuchi et al., 2021).
Expected Outcome.
Up to 50% of the patient’s symptoms will be resolved within the following 4 weeks (Kikuchi et al., 2021). She will be able to concentrate for longer hours with increased attention and memory (Hodgkins et al., 2012). Her overall academic performance will also improve significantly.
Ethical Consideration
Based on the provisions of legal and ethical guidelines for nurses, the PMHNP is obliged to consider the patient ethnicity and race to promote culturally sensitive care (Bonati et al., 2018). The patient’s parents also have a legal right to information concerning the health of their child, for sound decision-making (American Psychiatric Association, 2013). Respecting the patient’s autonomy is key to promoting patient satisfaction.
Decision#2
Selected Decision and Rationale
Out of the options provided, the most effective second intervention was to change the treatment regimen to a long-acting Ritalin 20mg administered once daily in the morning. The patient has reported the potential effectiveness of the drug in managing ADHD symptoms (Hodgkins et al., 2012). However, since the dose is quite limited to resolving the patient’s symptoms all day, using a long-acting agent will help prolong the duration of action, improving the patient’s attention, concentration, and memory the entire day (Cipriani et al., 2018).
Studies show that long-acting Methylphenidate lasts in the body system for up to 10 to 12 hours (American Psychiatric Association, 2013). The side effect reported of elevated heart rate is common among pediatric patients on methylphenidate which resolves as the patient continues taking the drug (Pelham III et al., 2022). Consequently, previous evidence confirms that using a long-acting agent, hence reduces the concentration of the drug at one point, reducing the risks of toxic doses, when used for a long time (Kikuchi et al., 2021).
Maintaining the dose of methylphenidate was not necessary as the patient will continue experiencing limited effectiveness of the drug later in the day (Grimmsmann & Himmel, 2021). Administering Adderall in place of Methylphenidate was also inappropriate at the moment given that the former is associated with increased risks of cardiovascular complications which would compromise the health of the patient (Bonati et al., 2018).
Expected Outcome
The patient will be able to attain full concentration and attention level with the use of the drug for 4 weeks (Pelham III et al., 2022). This should help promote her overall academic performance and interest in school activities. The side effect of increased heart rate is expected to return to normal within this period (Grimmsmann & Himmel, 2021).
Ethical Considerations
“Not harm” is one of the main ethical obligations of nurses, especially when taking care of children (Bonati et al., 2018). As such, the PMHNP needed to explain to the parents of the patient why the side effect occurred and the main cause of action to resolve the side effect and promote the health of their child (Kikuchi et al., 2021).
Decision#3
Selected Decision and Rationale
Advising the patient to continue taking the long-acting Methylphenidate 20mg once daily and report for reevaluation after 4 weeks was considered the final decision. The patient reported completely resolved side effects with improved effectiveness of the drug in the management of ADHD symptoms all day (Hodgkins et al., 2012). Previous evidence demonstrates that patients on Ritalin may exhibit maximum benefit within 8 to 12 weeks of treatment therapy (American Psychiatric Association, 2013; Cipriani et al., 2018). Most pediatric patient on Methylphenidate has reported great tolerance to the medication with a desirable safety profile in long-term use (Grimmsmann & Himmel, 2021). However, in rare cases, the patient may exhibit ineffectiveness to the medication which might call for the dose titration, hence the need for reevaluating the patient after four weeks (Kikuchi et al., 2021).
At this point, it was not appropriate to increase the dose of methylphenidate to 30mg as studies show that low effective doses are safer for use by children, with reduced risks of adverse effects (Pelham III et al., 2022). Consequently, based on the current patient heart rate, it is not necessary to obtain EKG, as her pulse is within the normal limits of a child of her age (Bonati et al., 2018).
Expected Outcome
For the next four weeks, the patient will report further improvement in ADHD symptoms all day (Grimmsmann & Himmel, 2021). S
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