Assignment: Assessing and Treating Patients With ADHDNot 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 pagesExamine 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.Week 9: Therapy for Patients With ADHD/ODDDiego, a 9-year-old third grader, had always been an energetic child with a short attention span. For years, his mother attributed his behaviors to him being “all boy” and assumed it would improve as he grew older. Instead, daily tasks like chores and homework became increasingly overwhelming for Diego, resulting in disruptive behaviors at home and school. After being evaluated by his healthcare provider, Diego was diagnosed with and treated for attention deficit hyperactivity disorder (ADHD).ADHD is a prevalent disorder for patients across the lifespan, as more than 6 million children (CDC, n.d.) have been diagnosed with the disorder. Further, consider that about 60% of children with ADHD in the United States become adults with ADHD (ADAA, n.d.). Like Diego, individuals of all ages find that symptoms of ADHD can make life challenging. However, when properly diagnosed and treated, patients often respond well to therapies and have positive health outcomes.This week, as you study ADHD therapies, you examine the assessment and treatment of patients with ADHD. You also explore ethical and legal implications of these therapies.References:Centers for Disease Control and Prevention. (n.d.). Data and statistics about ADHD. https://www.cdc.gov/ncbddd/adhd/data.htmlAnxiety and Depression Association of America. (n.d.). Adult ADHD (Attention Deficit Hyperactive Disorder). https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/adult-adhdLearning ObjectivesStudents will:Assess patient factors and history to develop personalized therapy plans for patients with ADHDAnalyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for ADHDSynthesize knowledge of providing care to patients presenting for ADHDAnalyze ethical and legal implications related to prescribing therapy for patients with ADHDIdentify concepts related to psychopharmacologic treatments and therapy for patients across the lifespanLearning ResourcesRequired Readings (click to expand/reduce)Prince, J. B., Wilens, T. E., Spencer, T. J., & Biederman, J. (2016). Stimulants and other medications for ADHD. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 99–112). Elsevier.American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. https://doi.org/10.2165/11599630-000000000-00000Martin, L. (2020). A 5-question quiz on ADHD. Psychiatric Times.https://www.psychiatrictimes.com/view/5-question-quiz-adhdMedication Resources (click to expand/reduce)IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.armodafinilamphetamine (d)amphetamine (d,l)atomoxetinebupropionchlorpromazineclonidineguanfacinehaloperidollisdexamfetaminemethylphenidate (d)methylphenidate (d,l)modafinilreboxetineRequired Media (click to expand/reduce)Case Study: A Young Caucasian Girl with ADHDNote: This case study will serve as the foundation for this week’s Assignment.Attention Deficit Hyperactivity DisorderA Young Girl With ADHDBACKGROUNDKatie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.The parents give you a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.SUBJECTIVEKatie 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 EXAMThe client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She 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 presentationRESOURCES§ 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 OneSelect what you should do:Decision Point OneBegin Wellbutrin (bupropion) XL 150 mg orally dailyRESULTS OF DECISION POINT ONEClient returns to clinic in four weeksKatie’s parents inform you that they stopped giving Katie the medication because about 2 weeks into the prescription, Katie told her parents that she was thinking about hurting herself. This scared the parents, but they didn’t want to “bother you” by calling the office, so they felt that it would be best to just stop the medication as they would be seeing you in two weeksDecision Point TwoEducate the parents that Bupropion sometimes causes suicidal ideation in children and that this is normal, and re-start the drug at the previous doseRESULTS OF DECISION POINT TWOClient returns to clinic in four weeksKatie’s parents again report that after about a week of treatment with the Bupropion, Katie began telling her parents that she wanted to hurt herself and began having dreams about being dead. This scared her parents and they stopped giving her the medicationAt this point, they are quite upset with the results of their daughter’s treatment and are convinced that medication is not the answerDecision Point ThreeDiscuss the use of a medication such as Adderall and its evidence for treating ADHDGuidance to StudentBupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.You should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow you to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.
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