NURS 6630 Week 9 A Young Girl With ADHD

Attention Deficit Hyperactivity Disorder (ADHD) Sample Paper

Neurodevelopmental disorders have undertaken several diagnostic evolutions in several past years. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is one of the standard diagnostics tools used. A popular belief is that attention deficit hyperactivity disorder (ADHD) is prevalent among children. It is stereotyped that it only affects the attention of children. New information has however shown that ADHD not only affect attention in children, but also involves hyperactivity and impulsivity. According to the National Institute of Mental Health (NIH, 2019), it is possible that this disorder can be present in adults contrary to common beliefs. 

ADHD is usually recognized in early childhood, especially during the preschool years and early school years and can continue into adulthood. It can cause issues such as inattention, hyperactivity, and impulsivity and patients usually present with these as the core symptoms. Some ADHD patients only present with one of the behaviors while other present with a combination. Specific issues seen with ADHD include poor performance in school, inability to think properly and behavioral problems. According to Krull (2019), patients can also have a difficulty in expressing their feelings and building relationships.

Using the DSM-5 criteria, ADHD symptoms must be present before the age of 12 years and also in more than one setting (APA, 2013). To diagnose ADHD, an authorized medical practitioner such as a psychiatrist or a pediatrician should be present. An expert in ADHD who is licensed to determine the presence of this disorder can also make the diagnosis. The signs to look out for in order to make a diagnosis are inattention, hyperactivity and impulsivity that has been present over a long period.

ADHD management and treatment consists of counseling, behavioral therapy, medication, or a combination of these options. The goal in managing and treating ADHD is to ensure the patient regains full function and can perform better in school, or work and have better relationships. Another goal is to ensure the patient can function in a society by being able to follow the rules. Successful treatment will increase the patient’s attention span, regulate their level of activity to normal and decrease their impulsiveness.

In this paper, the focus will be on an 8-year-old Caucasian female presenting to the clinic with symptoms that indicate ADHD. The best treatment option for this patient will rely on three decisions informed by ethical and treatment guidelines for the disorder. The overall pharmacodynamics and pharmacokinetics for the drugs will be discussed

Decision 1

After reviewing the patient, a diagnosis of ADHD is made. Decisions have to be made in order to properly manage and treat this patient. My first treatment decision for this 8-year-old school-going female is to start her on Ritalin chewable tablet 10 mg orally in the morning. This choice is mainly influenced by the patient’s clinical manifestations, and the benefit-risk assessment of the available options.

The objective of treatment is to improve the patient’s symptoms. According to Verbeeck et al. (2017), most pharmacological treatments for ADHD facilitate the transmission of catecholamines. ADHD patients are usually treated with stimulant drugs. Ritalin is a stimulant agent which is FDA approved for use as the first-line treatment for ADHD. Approximately 90% of patients on Ritalin show improvement of symptoms (Verbeevk et al., 2017).

Ritalin achieves this by increasing the action dopamine and noradrenaline in the prefrontal cortex thus stimulating the CNS. CNS stimulation helps foster cognition and attention and restores the patient’s ability to focus. The reason for prescribing the drug in the morning is because of the need to achieve concentration during the day. The drug also has a potential of causing insomnia.

The use of Bupropion is not selected because it is an antidepressant which is only used as an alternative when the patients cannot tolerate stimulants because of the side effects or if patients do not respond well to stimulants (Ng, 2017). Bupropion is registered as an antidepressant and is used off-label to treat ADHD. Despite its extensive use, it is not FDA approved for the treatment of ADHD in children. It is also associated with suicidal ideations as a side effect and evidence has shown that it is only effective in the treatment of ADHD that is comorbid with depression.

Intuniv is also not selected as it is a non-stimulant that is not recommended as the first-line treatment of ADHD. It usually takes long to start producing effects as opposed to Ritalin that takes a few minutes to start exhibiting its effects. Intuniv is however suggested as an augmenting agent if stimulants do not offer adequate improvement in symptoms (Stahl, 2017).

With the treatment option selected, I hope to see an improvement in the symptoms as soon as possible, with the patient reporting an improvement in school performance when she returns for a follow-up after 4 weeks. The patient returns four weeks later with improved symptoms but complains of some adverse effects including daydreaming and cardiac symptoms such as tachycardia. With this new information, a re-evaluation is necessary and another decision needs to made to manage this patient.

Decision 2

With new findings in the patient, my decision is to change to Ritalin LA 20 mg orally in the morning. The reason for this is that the symptoms shown could be as a result of Ritalin 10 mg chewable tablets being a short acting agent. The symptoms could also be prevented by reducing the dose to 5 mg. This would reduce the potential side effects but also the efficacy. A longer acting agent is therefore the best option to use on this patient. This way she gets a pulse dose in the morning and another dose four hours later.

I would not want to switch to another drug option because Ritalin seems to be effective in improving the symptoms. Keeping her on the same dose would not change anything in terms of relieving or minimizing the side effects. She would still have symptoms of tachycardia on the same dose. Changing her medication to Adderall is not an option I would consider because she seems to be responding well to Ritalin, an aspect Cortese et al. (2018) identify as a basis for sticking to the current treatment medication. It is recommended that when patients experience side effects, waiting and making adjustments on the current medications are made before switching to a different drug. If the patient does not show any improvement, then a change in medication can be made (Stahl, 2017).

The goals of treatment remain the same as before but with a new target of reducing the patients heart rate without affecting her concentration throughout the day. The patient returns to the clinic after four weeks and reports a relief of the side effects. Her heart rate is at 92 beats a minute. This shows that the new treatment with Ritalin LA 20 mg is working with significant improvement recorded over the past four weeks.

Decision 3

Because the patient seems to be doing well on the current treatment regimen, my plan would be to maintain her on the current dose of Ritalin LA and do a re-evaluation after four weeks. Ritalin seems to be working as Katie’s heart rate is back to normal and her attention is sustained throughout the day. She also reports no additional side effects. It is recommended that the lowest dose of a stimulant needed should be used to correct a disorder and for this reason, I would not increase the dose to 30 mg. Her heart rate of 92 is within the normal range for her age and an EKG is unnecessary at this point.

Ethical Considerations

When treating patients with ADHD, many ethical considerations have to be taken into account. These include choosing the right medication for the treatment of the condition. This is important as some drug classes such as nonstimulants have harmful side effect which the patient may not be able to tolerate. This is also important because the patients are still developing and some of these drugs may impede their development. Another consideration is the patient autonomy. Because the patient is a minor, she is not able to make any decisions as regards their health and treatment.

Parents therefore have to be incorporated in making decisions that pertain to the treatment of this patient and they have a right to agree to or deny treatment they don’t agree with. It is also important to try and involve the child in the treatment and breakdown everything to a language they can understand (NIH, 2019). Another ethical consideration is the cardiac effects that are associated with psychostimulants. A family history of cardiac disease should be taken into account before commencing treatment with stimulants. The last consideration is the side effects and the lowest effective dose should be prescribed and the patients monitored regularly for side effects (NIH, 2019). The patient should also be educated on these side effects.

Conclusion

In conclusion, ADHD is a disorder that starts in early childhood and can progress into adulthood if not managed well with psychotherapy and pharmacotherapy. ADHD usually present with three core symptoms i.e., inattention, hyperactivity and impulsiveness but not all patients present with all the symptoms at once. The NP has the ethical obligation to treat ADHD with the most effective options available.

The first-line treatment for ADHD are stimulants such as Ritalin. Other options of treatment include non-stimulants amphetamines and antidepressants such as bupropion. When treating patients with stimulants it is important to consider the potential side effects such as cardiac effects such as tachycardia as seen in the patient. It is also important to use the lowest effective dose to treat the patients. The patient should also be involved in their treatment and patient preference is key to ensure compliance to medication.

NURS 6630 Week 9 A Young Girl With ADHD References

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://psycnet.apa.org/doi/10.1176/appi.books.9780890425596

Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., & Carucci, S. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network metanalysis. Lancet Psychiatry, 5(9), 727-738. https://doi.org/10.1016/S22150366(18)30269-4

Krull, K. (2019). Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis. Retrieved from https://www.uptodate.com/contents/attentiondeficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis

National Institute of Mental Health. (2019). Attention-Deficit/Hyperactivity Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorderadhd/index.shtml

Ng, X. Q. (2017). A systematic review of the use of bupropion for attention-deficit hyperactivity disorder in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 27(2), 112-116. https://doi.org/10.1089/cap.2016.0124

Stahl, S. M. (2017). Prescriber’s guide (6th ed.). New Delhi, India: Cambridge University Press. https://assets.cambridge.org/97811076/75025/frontmatter/9781107675025_frontmatter.pdf

Verbeeck, W., Bekkering, G. E., Van den Noortgate, W., & Kramers, C. (2017). Bupropion for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane Database Of Systematic Reviews, 10(10), CD009504. https://doi.org/10.1002/14651858.CD009504.pub2

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NURS 6630 Week 3 Quiz Which Neurotransmitter is Considered the Major Excitatory Neurotransmitter?

NURS 6630 Week 9 A Young Girl With ADHD Week 9: Therapy for Patients With ADHD/ODD Instructions

ASSESSING AND TREATING PATIENTS WITH ADHD

Not only do children and adults have different presentations for ADHD, but males and females may also have vastly different clinical presentations. Different people may also respond to medication therapies differently. For example, some ADHD medications may cause children to experience stomach pain, while others can be highly addictive for adults. In your role, as a psychiatric nurse practitioner, you must perform careful assessments and weigh the risks and benefits of medication therapies for patients across the life span. For this Assignment, you consider how you might assess and treat patients presenting with ADHD.

TO PREPARE FOR THIS ASSIGNMENT:

• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with ADHD.

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.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formattingLinks to an external site..

LEARNING RESOURCES

Required Readings

• Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th Ed.) Cambridge University Press.
  • Chapter 11, “Attention Deficit Hyperactivity Disorder and Its Treatment” (pp. 449-485)
• American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disordersLinks to an external site. (5th ed., text rev.). https://go.openathens.net/redirector/waldenu.edu?url=https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
• Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS DrugsLinks to an external site., 26(3), 245–268. https://doi.org/10.2165/11599630-000000000-00000
• Martin, L. (2020). A 5-question quiz on ADHD. Psychiatric TimesLinks to an external site.. https://www.psychiatrictimes.com/view/5-question-quiz-adhd

Medication Resources

• U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugsLinks to an external site.. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
  Links to an external site.

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

armodafinilamphetamine (d)amphetamine (d,l)atomoxetinebupropionchlorpromazineclonidine	guanfacinehaloperidollisdexamfetaminemethylphenidate (d)methylphenidate (d,l)modafinilreboxetine

Required Media

• Case Study: A Young Caucasian Girl with ADHDLinks to an external site.

Note: This case study will serve as the foundation for this week’s Assignment.

Rubric – NURS_6630_Week9_Assignment_Rubric

NURS_6630_Week9_Assignment_Rubric
Criteria	Ratings	Pts
This criterion is linked to a Learning Outcome 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.	10 to >8.0 pts Excellent Point range: 90–100 The response accurately, clearly, and fully summarizes in detail the case for the Assignment…. The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient. 8 to >7.0 pts Good Point range: 80–89 The response accurately summarizes the case for the Assignment…. The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient. 7 to >6.0 pts Fair Point range: 70–79 The response inaccurately or vaguely summarizes the case for the Assignment…. The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient. 6 to >0 pts Poor Point range: 0–69 The response inaccurately and vaguely summarizes the case for the Assignment, or is missing…. The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.	10 pts
This criterion is linked to a Learning Outcome Decision #1 (1–2 pages)• 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.	20 to >17.0 pts Excellent Point range: 90–100 The response accurately and clearly explains in detail the decision selected…. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected…. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response…. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response…. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients…. Examples provided fully support the decisions and responses provided. 17 to >15.0 pts Good Point range: 80–89 The response accurately explains the decision selected…. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected…. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response…. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response…. The response accurately explains how ethical considerations impact the treatment plan and communication with patients…. Examples provided support the decisions and responses provided. 15 to >13.0 pts Fair Point range: 70–79 The response inaccurately or vaguely explains the decision selected…. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected…. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response…. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response…. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients…. Examples provided may support the decisions and responses provided. 13 to >0 pts Poor Point range: 0–69 The response inaccurately and vaguely explains the decision selected…. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing…. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing…. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing…. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing…. Examples provided do not support the decisions and responses provided, or is missing.	20 pts
This criterion is linked to a Learning Outcome Decision #2 (1–2 pages)• 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.	20 to >17.0 pts Excellent Point range: 90–100 The response accurately and clearly explains in detail the decision selected…. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected…. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response…. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response…. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients…. Examples provided fully support the decisions and responses provided. 17 to >15.0 pts Good Point range: 80–89 The response accurately explains the decision selected…. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected…. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response…. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response…. The response accurately explains how ethical considerations impact the treatment plan and communication with patients…. Examples provided support the decisions and responses provided. 15 to >13.0 pts Fair Point range: 70–79 The response inaccurately or vaguely explains the decision selected…. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected…. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response…. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response…. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients…. Examples provided may support the decisions and responses provided. 13 to >0 pts Poor Point range: 0–69 The response inaccurately and vaguely explains in detail the decision selected…. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing…. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing…. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing…. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing…. Examples provided do not support the decisions and responses provided, or is missing.	20 pts
This criterion is linked to a Learning Outcome Decision #3 (1–2 pages)• 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.	20 to >17.0 pts Excellent Point range: 90–100 The response accurately and clearly explains in detail the decision selected…. The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected…. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response…. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response…. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients…. Examples provided fully support the decisions and responses provided. 17 to >15.0 pts Good Point range: 80–89 The response accurately explains the decision selected…. The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected…. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response…. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response…. The response accurately explains how ethical considerations impact the treatment plan and communication with patients…. Examples provided support the decisions and responses provided. 15 to >13.0 pts Fair Point range: 70–79 The response inaccurately or vaguely explains the decision selected…. The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected…. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response…. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response…. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients…. Examples provided may support the decisions and responses provided. 13 to >0 pts Poor Point range: 0–69 The response inaccurately and vaguely explains in detail the decision selected…. The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing…. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing…. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing…. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing…. Examples provided do not support the decisions and responses provided, or is missing.	20 pts
This criterion is linked to a Learning Outcome 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.	15 to >13.0 pts Excellent Point range: 90–100 The response accurately and clearly summarizes in detail the recommendations on the treatment options selected for this patient…. The response accurately and clearly explains a justification for the recommendations provided, including clinically relevant resources that fully support the recommendations provided. 13 to >11.0 pts Good Point range: 80–89 The response accurately summarizes the recommendations on the treatment options selected for this patient…. The response accurately explains a justification for the recommendation provided, including clinically relevant resources that support the recommendations provided. 11 to >10.0 pts Fair Point range: 70–79 The response inaccurately or vaguely summarizes the recommendations on the treatment options selected for this patient…. The response inaccurately or vaguely explains a justification for the recommendations provided, including clinically relevant resources that inaccurately or vaguely support the recommendations provided. 10 to >0 pts Poor Point range: 0–69 The response inaccurately and vaguely summarizes the recommendations on the treatment options selected for this patient, or is missing…. The response inaccurately and vaguely explains a justification for the recommendations provided, including clinically relevant resources that do not support the recommendations provided, or is missing.	15 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.	5 to >4.0 pts Excellent Point range: 90–100 Paragraphs and sentences follow writing standards for flow, continuity, and clarity…. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 to >3.5 pts Good Point range: 80–89 Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time….Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. 3.5 to >3.0 pts Fair Point range: 70–79 Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time…. Purpose, introduction, and conclusion of the assignment is vague or off topic. 3 to >0 pts Poor Point range: 0–69 Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time…. No purpose statement, introduction, or conclusion were provided.	5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation	5 to >4.0 pts Excellent Point range: 90–100 Uses correct grammar, spelling, and punctuation with no errors. 4 to >3.5 pts Good Point range: 80–89 Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3.5 to >3.0 pts Fair Point range: 70–79 Contains several (3 or 4) grammar, spelling, and punctuation errors. 3 to >0 pts Poor Point range: 0–69 Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.	5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.	5 to >4.0 pts Excellent Point range: 90–100 Uses correct APA format with no errors. 4 to >3.5 pts Good Point range: 80–89 Contains a few (1 or 2) APA format errors. 3.5 to >3.0 pts Fair Point range: 70–79 Contains several (3 or 4) APA format errors. 3 to >0 pts Poor Point range: 0–69 Contains many (≥ 5) APA format errors.	5 pts
Total Points: 100

Case Study: A Young Caucasian Girl with ADHD

Attention Deficit Hyperactivity Disorder
A Young 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.

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.

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.

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

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 Point One

Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING

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 funny.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute

Decision Point Two

Continue same dose of Ritalin and re-evaluate in 4 weeks

Select what the PMHNP should do next:

Change to Ritalin LA 20 mg orally daily in the MORNING

Discontinue Ritalin and begin Adderall XR 15 mg orally daily

Decision Point Two

Change to Ritalin LA 20 mg orally daily in the MORNING

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

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 Point Three

Maintain current dose of Ritalin LA and reevaluate in 4 weeks

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.

NURS 6630 Week 9 A Young Girl With ADHD – Assessing and treating patients with ADHD Example 2

Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent neurodevelopmental disorder characterized by hyperactivity, impulsivity, and inattention. Such symptoms can significantly impede a child’s ability to undertake daily tasks. The clinical presentation of ADHD varies among individuals based on factors such as age group, gender, and unique circumstances (Magnus et al., 2023). Recognizing the diverse manifestations of the disorder is crucial for accurate diagnosis and effective management strategies.

The case is about Katie, an 8-year-old Caucasian girl, who is being assessed for possible ADHD based on observations made by her school teacher. The teacher’s report, documented through the “Conner’s Teacher Rating Scale-Revised,” describes a child who struggles academically and exhibits forgetfulness, easy distractibility, and limited attention span. These academic and attention-related difficulties contrast Katie’s account of a positive home environment and a good relationship with her parents. However, she does acknowledge occasional moments in school where she becomes engrossed in thoughts that compete with her immediate academic tasks.

Katie’s parents’ reluctance to acknowledge the ADHD possibility underscores a prevailing misunderstanding of the disorder, often associating it solely with overt hyperactivity. Their stance accentuates the importance of enlightening families about ADHD’s diverse presentations, especially the inattentive type. A deeper dive into Katie’s mental status does not reveal any significant neurological or psychiatric red flags. Her cognitive and emotional responses align with her age.

Nonetheless, the preliminary diagnosis of “Attention deficit hyperactivity disorder with predominantly inattentive presentation” calls for a meticulous evaluation to map out the best therapeutic interventions. Making medication decisions for young patients like Katie demands a holistic view, incorporating her age, symptoms, potential medication side effects, academic challenges, and the imperative of continuous monitoring. The overarching therapeutic goal is alleviating her symptoms, bolstering her educational journey, and ensuring holistic well-being. Weighing the benefits against potential medication risks is crucial.

Decision #1

Administer the patient with 10 mg chewable methylphenidate (Ritalin) tablets to take first thing in the morning. Based on the results of clinical trials, which consistently show methylphenidate to be a good starting treatment for ADHD in kids (Moran, 2023), this decision was made. Research has shown that Ritalin, a short-acting methylphenidate formulation, is quite effective. It not only has comparatively minor side effects but also significantly reduces symptoms like impulsivity, hyperactivity, and inattention in children with ADHD (Mechler et al., 2021). By treating Katie’s primary symptom of inattention, the goal of prescribing stimulant medication such as Ritalin is to help her focus better and perform better academically.

The options Wellbutrin XL (bupropion) and Intuniv extended-release were not selected as the treatment options for Katie since these medications are typically not the first choice for pediatric ADHD patients. Methylphenidate is more effective in managing symptoms of pediatric ADHD, making it a more appropriate initial option (Kazda et al., 2021). My goal with prescribing Ritalin is to reduce Katie’s lack of focus and improve her academic performance. Additionally, I will closely monitor for potential side effects such as decreased appetite, sleep disturbances, or abdominal discomfort and adjust dosage accordingly to minimize these effects.

In pediatric ADHD management, ethical considerations hold great importance. As a PMHNP, I must ensure that Katie and her parents understand the advantages, drawbacks, and potential side effects of Ritalin. Emphasizing collaborative decision-making while respecting their values and preferences is of utmost priority. Regular evaluation will be conducted to assess the efficacy of medication and adjust the treatment plan as necessary. Maintaining confidentiality remains essential; however, involving Katie’s parents in her treatment journey is equally vital. Ultimately, our goal is to provide both Katie and her family with the necessary knowledge and resources for effective management of ADHD symptoms.

Decision #2

Based on Katie’s current response and symptom presentation after the initial treatment, she should switch to Ritalin LA 20 mg, which should be taken orally in the morning. Katie’s teacher observed a significant improvement in her symptoms during the mornings following the administration of Ritalin. However, her inattention symptoms became noticeable again by the afternoon. This pattern suggests that while Ritalin effectively addresses her symptoms, its effect does not last throughout the school day. Prescribing Ritalin LA, an extended-release form of methylphenidate designed explicitly for sustained therapeutic effects, can provide symptom control for Katie throughout her school hours (Coghill et al., 2023).

The cardiovascular concerns raised should not be overlooked. Katie’s mention of her heart experiencing strange sensations and the subsequent discovery of her tachycardia (130 beats per minute) are significant indicators. There is a possibility that stimulant medications can lead to an increase in heart rate. However, switching to Ritalin LA might provide a smoother and more consistent release of medication, potentially reducing the cardiovascular side effects she encountered.

On the other hand, Adderall XR, which contains a combination of amphetamine salts, has been linked to a more pronounced profile of cardiovascular side effects when compared with treatments containing methylphenidate (Wolraich et al., 2019). Feedback from Katie and her parents plays a crucial role in the decision-making process. They acknowledge the advantages of Ritalin but also express legitimate worries about its potential side effects. Transitioning to Ritalin LA addresses both the requirement for efficacy and concerns regarding safety, striving for a more well-rounded therapeutic strategy.

From an ethical perspective, it is crucial to prioritize the principle of informed consent. Open communication with Katie and her parents is necessary to ensure they fully comprehend the reasoning behind switching medications, the anticipated advantages, and any possible adverse effects. One must consider their preferences, values, and concerns when making treatment decisions. Additionally, regular monitoring should be prioritized due to potential side effects associated with stimulants. This will promote Katie’s well-being and help reassure her parents while fostering trust in the therapeutic approach.

Decision #3

I would go with maintaining the current treatment plan, which is to continue taking Ritalin LA at the current dosage of 20 mg and reevaluate in four weeks, depending on the patient’s clinical condition and medication response. ADHD medication management should be tailored to the patient’s response and side effect profile (Drechsler et al., 2020). Ritalin LA may not need to be increased now because Katie’s academic performance has improved, and her reports of feeling “funny” in her heart have decreased. Moreover, increasing the dosage might make adverse effects like drowsiness and decreased appetite more likely (Carucci et al., 2021). There is no need to adjust the medication or dosage in light of the significant improvement and sufficient symptom control. Therefore, physicians should try to prescribe stimulants that have the lowest possible level of efficacy.

It is not necessary to get an EKG based on her current heart rate because her pulse has returned to normal, and her complaints of having a “funny” heart have stopped. It is recommended that patients with established medical conditions that may result in cardiac side effects from stimulants have their ECG monitored (Torres-Acosta et al., 2020). In this case, the child does not exhibit any such risk factors. To reduce the likelihood of side effects and improve academic performance, I intend to maintain Katie’s Ritalin LA dosage at the current level. Regular reevaluations also allow for ongoing monitoring of her response and possible adverse effects.

In this case, ethical concerns include ensuring Katie and her family are fully informed about the benefits and risks of the medication as well as their values and choices. Getting informed consent for interventions and protecting privacy and confidentiality are also essential. Effective communication is critical to establishing a therapeutic alliance and facilitating shared decision-making with Katie’s family.

Conclusion

Based on Katie’s symptoms, I recommend transitioning her to Ritalin LA 20 mg orally each morning. This choice is based on the observation that Ritalin has been effective in improving her symptoms in the mornings but loses its effect by the afternoon, indicating a short duration of action. By using Ritalin LA, an extended-release formulation, she will experience consistent therapeutic coverage throughout the day, which aligns better with her school hours. Furthermore, considering Katie’s reported cardiovascular concerns, it would be beneficial to opt for a medication like Ritalin LA that offers smoother drug release. On the other hand, Adderall XR may not be as suitable in this context due to its side effect profile and potential impact on cardiovascular health.

This approach considers input from Katie and her parents while prioritizing efficacy and safety. The goal is to manage symptoms while minimizing potential side effects effectively. Maintaining Katie’s well-being, academic performance, and overall quality of life are critical priorities in this treatment plan. Open communication with Katie and her family is crucial throughout the therapeutic process, along with regular monitoring, to ensure informed decision-making involving collaboration between all parties. This recommendation reflects current best practices by addressing patient-specific needs supported by evidence from primary literature sources.

NURS 6630 Week 9 A Young Girl With ADHD References

Carucci, S., Balia, C., Gagliano, A., Lampis, A., Buitelaar, J. K., Danckaerts, M., Dittmann, R. W., Garas, P., Hollis, C., Inglis, S., Konrad, K., Kovshoff, H., Liddle, E. B., McCarthy, S., Nagy, P., Panei, P., Romaniello, R., Usala, T., Wong, I. C. K., … Zuddas, A. (2021). Long term methylphenidate exposure and growth in children and adolescents with ADHD. A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 120, 509–525. https://doi.org/10.1016/j.neubiorev.2020.09.031

Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., Daley, D., Danckaerts, M., Dittmann, R. W., Doepfner, M., Ferrin, M., Hollis, C., Holtmann, M., Paramala, S., Sonuga-Barke, E., Soutullo, C., Steinhausen, H.-C., Van der Oord, S., Wong, I. C. K., … Simonoff, E. (2023). The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). European Child & Adolescent Psychiatry, 32(8), 1337–1361. https://doi.org/10.1007/s00787-021-01871-x

Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current concepts and treatments in children and adolescents. Neuropediatrics, 51(05), 315–335. https://doi.org/10.1055/s-0040-1701658

Kazda, L., Bell, K., Thomas, R., McGeechan, K., Sims, R., & Barratt, A. (2021). Overdiagnosis of attention-deficit/hyperactivity disorder in children and adolescents: A systematic scoping review. JAMA Network Open, 4(4), e215335. https://doi.org/10.1001/jamanetworkopen.2021.5335

Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2023). Attention Deficit Hyperactivity Disorder. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441838/

Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2022). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 230(107940), 107940. https://doi.org/10.1016/j.pharmthera.2021.107940

Moran, L. V. (2023). Long-term safety of methylphenidate in children with ADHD. The Lancet. Psychiatry, 10(5), 306–307. https://doi.org/10.1016/s2215-0366(23)00092-5

Torres-Acosta, N., O’Keefe, J. H., O’Keefe, C. L., & Lavie, C. J. (2020). Cardiovascular effects of ADHD therapies. Journal of the American College of Cardiology, 76(7), 858–866. https://doi.org/10.1016/j.jacc.2020.05.081

Wolraich, M. L., Hagan, J. F., Jr, Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W., & Subcommittee On Children And Adolescents With Attention-Deficit/Hyperactive Disorder. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4). https://doi.org/10.1542/peds.2019-2528