Assignment: Assessing and Treating Clients With ADHD

Assignment: Assessing and Treating Clients With ADHD

 

Not only do children and adults have different presentations for ADHD, but males and females

may also have vastly different clinical presentations. They may also respond to medication

therapies differently. For example, some ADHD medications may cause chil

dren to experience

stomach pain, while others can be highly addictive for adults. In your role, as a psychiatric

mental health nurse practitioner, you must perform careful assessments and weigh the risks and

benefits of medication therapies for clients acr

oss the lifespan. For this Assignment, you consider

how you might assess and treat clients presenting with ADHD.

 

Learning Objectives

 

Students will:

 

Assess client factors and history to develop personalized therapy plans for clients with ADHD

 

Analyze factor

s that influence pharmacokinetic and pharmacodynamic processes in clients

requiring therapy for ADHD

 

Evaluate efficacy of treatment plans

 

Evaluate ethical and legal implications related to prescribing therapy for clients with ADHD

 

Learning Resources

 

Note:

 

To access this week’s required library resources, please click on the link to the Course

Readings List, found in the

 

Course Materials

 

section of your Syllabus.

 

Required Readings

 

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.

 

Note:

 

Retrieved from Wal

den Library databases.

 

Required Media

 

 

Laureate Education (2

016d).

Case study: A young Caucasian girl with ADHD

 

[Interactive media

file]. Baltimore, MD: Author

 

Note:

 

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

 

 

To prepare for this Assignment:

 

This case study will serve as the foundation

 

for this week’s Assignment.

 

Assignment: Assessing and Treating Clients With ADHD

Not only do children and adults have different presentations for ADHD, but males and females

may also have vastly different clinical presentations. They 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

mental health nurse practitioner, you must perform careful assessments and weigh the risks and

benefits of medication therapies for clients across the lifespan. For this Assignment, you consider

how you might assess and treat clients presenting with ADHD.

Learning Objectives

Students will:

Assess client factors and history to develop personalized therapy plans for clients with ADHD

Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients

requiring therapy for ADHD

Evaluate efficacy of treatment plans

Evaluate ethical and legal implications related to prescribing therapy for clients with ADHD

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course

Readings List, found in the Course Materials section of your Syllabus.

Required Readings

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.

Note: Retrieved from Walden Library databases.

Required Media

 

Laureate Education (2016d). Case study: A young Caucasian girl with ADHD [Interactive media

file]. Baltimore, MD: Author

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

 

To prepare for this Assignment:

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

Running head: ATTENTION DEFICIT HYPERACTIVITY DISORDER 1

 

A Young Girl with ADHD

Attention Deficit/Hyperactivity Disorder (ADHD) is a common psychiatric disorders usually diagnosed in school age children. It is a neuropsychiatric disorder that affects preschoolers, children, adolescents and adults all over the world. It is described by a pattern of reduced persistent attention, and increased impulsivity or hyperactivity (Sadock, 2015). It is a kind of behavioral issue that has received substantial awareness in both classroom and research settings as a result of its likely adverse effects on academic products and classroom functioning (Purpura & Lonigan, 2009). The National Institute of Mental Health (NIMH) approximates that its incidence rate is between 3% and 10%, with ADHD influencing around 2 million children in the United States (Neuropsychiatric ailment and treatment, 2008). ADHD is usually co-morbid with other psychiatric disorders including depressive and anxiety disorders, substance abuse, conduct disorder, and antisocial behaviors (Neuropsychiatric ailment and treatment, 2008). Children with untreated ADHD have higher than typical rates of accidents and injury (NIMH). Pharmacotherapy treatment for ADHD includes Stimulant and Non stimulant medications. The stimulant medications includes Methylphenidate, dextroamphetamine and Focalin (Sadock, 2015). The non-stimulant medications includes atomoxetine, Clonidine, and Guanfacine (Sadock, 2015). This paper will examine and addresses treatment options for this 8-year old Caucasian girl with Attention Deficit/Hyperactivity Disorder (ADHD) while analyzing ethical and legal implications regarding her treatment.

Decision #1

My first decision is to start chewable Ritalin (methylphenidate) IR 10 mg PO every morning.

Reason for selecting this decision

Ritalin is a brand name of methylphenidates, the mainly common prescribed stimulant medication for attention deficit hyperactivity disorder (ADHD). Ritalin is a stimulant categorized to the class of dopamine, norepinephrine reuptake inhibitor and releaser (DN-RIRe) (Stahl, 2014b). Ritalin is FDA approved for ADHD in both children and adults (Stahl, 2014b). It works by boosting dopamine and norepinephrine actions in particular brain regions which includes the dorsolateral prefrontal cortex and basal ganglia which may enhance wakefulness, hyperactivity concentration, attention and executive function (Stahl, 2014b). Ritalin has an established long-term efficacy as a first-line treatment for attention deficit hyperactivity disorder (ADHD) (Stahl, 2014b). In the class of stimulant drugs, Ritalin is the best known for the treatment of ADHD for more than 60 years (The Western journal of medicine, 2000). Stimulant medications such as Ritalin have been prescribed for decades for the treatment of ADHD and their recognition as cognition enhancers has recently risen among the healthy as well to boost mental performance (Fisher, 2008). Stimulant medications used to treat ADHD, like Ritalin, has been widely and lengthily studied and found to be safe. With over 6,000 patients treated in more than 200 clinical trials, methylphenidate is one of the best studied drugs in children and adolescents (Vitiello 2001).

According to research, Ritalin are more tolerated, acts quickly and have fewer side effects in most people than other medications (Haggerty, 2018). Psychostimulants, most commonly methylphenidates are mostly safe and well tolerated (Clancy et. al, 2011). Stimulants are the major treatment for ADHD and have been proven to be the most effective treatment with 80 percent response rate (Kolar et al., 2008). About 90 percent of cases, stimulant medication facilitates children to think before they act, improve their approach to schoolwork to get more focused and organized, get along better with others and break fewer rules; they often seem happier too (American Psychological Association, 2018). At the initial stage, the patient should not be placed on high amount of prescriptions of an oral dosage. The client is initiated at a less dosage, which reduces the chance of side effects. This will also give the provider the chance to keep assessing her response to it, and decide if the dosage should be increased, decreased or switched to another drug completely either because of side effects or for not having any therapeutic effect on the patient. Wellbutrin on the other hand was not selected due to numerous reasons. Wellbutrin has not been approved by the FDA for the treatment of ADHD. Wellbutrin including other antidepressants have been linked to suicidal ideation in children and adolescents and their Safety and efficacy have not been established (Stahl, 2014b). There is not enough scientific studies to back up Wellbutrin’s effectiveness and safety in treating ADHD (Low, 2018).

Intuniv belong to the nonstimulant medication types for ADHD. It’s an antihypertensive and centrally acting alpha 2A agonist (Stahl, 2014b). It has also not been approved by the FDA for the treatment of ADHD. The basic standard for treating ADHD is the use of a psychostimulant as the first line agent. Intuniv is a nonstimulant, and an option for ADHD patients who cannot take stimulants (Neuropsychiatric disease and treatment, 2008). Nonstimulants do not work as quickly as stimulants, but may be used when psychostimulant medications have been ineffective, unacceptable side effects have resulted, or the individual or child’s parents prefer a nonstimulant for other reasons. They do not appear to be as effective in improving symptoms of inattention (Low, 2018). Non-stimulants can be very effective for some kids with ADHD, but for most don’t have the same rate of success as stimulants, which work well in about 70 to 80 percent of cases (Rosen & Braaten, n.d.). Intuniv can cause an individual to be excessively sedated and sluggish throughout the day. There has also been reports of mania and aggressive behavior in ADHD patients taking Intuniv. Intuniv can cause changes in the blood pressure. It may lower the blood pressure about 30 to 60 minutes after first dose is taken and the highest reduction is seen after 2 to 4 hours of use (Stahl, 2014b).

Expected outcome

For the treatment of ADHD, the overall goal is to see reduction of symptoms of inattentiveness, motor hyperactivity, and/or impulsiveness that disrupt social, school, and/or occupational functioning (Stahl, 2014b). Starting her on Ritalin will help determine patient’s response to the medication and taking it in the morning is to help improve her attention and concentration while in class. With this decision, it is expected to see improvement in my client’s symptoms even with the first dosing but maximum therapeutics mat take several weeks (Stahl, 2014b). She was prescribed an Immediate Release (IR) of Ritalin which makes the drug a quick acting. Before her next appointment in four weeks, there will be noticeable improvement in her behavior. It is also expected that while in class, her attentiveness will improved. She will not be easily distracted, and not forget things she already learned. It is also expected to see an improvement in her performance in arithmetic, ability to spell and read (Pelham, et al., 1999). Not only any attention to what she is interested in, but the patient is also expected to have an extended time span of concentration to everything. IR chewable tablets offer a child-friendly alternative for patients or parents who are not satisfied with the available formulation options, especially those individuals who cannot or will not swallow tablets or capsules, and could improve treatment compliance. (Wigal, et. al, 2017). It is expected that she will have no side effects and tolerate this chewable form better than the others.

 

 

Difference between the expected outcome and the initial short-term outcome

As expected, during the 4 weeks follow up appointment, the client’s teacher reported her symptoms got considerably better in the morning, which has led to an improvement in her overall academic performance (Laureate Education, 2016d). But by noon, she is gazing off into space and daydreaming (Laureate Education, 2016d). The client also gave reports about her heart feeling funny (Laureate Education, 2016d). On assessment, her pulse was 130bpm (Laureate Education, 2016d). One of the side effects of Ritalin is an increases in norepinephrine peripherally which can cause autonomic side effects such as, tachycardia, hypertension, tremor and cardiac arrhythmias (Stahl, 2014b). There was a close relationship between the client’s actual results and the expected results. The client had an improvement in her symptoms, however the improvements does not last long. Side effects was also reported. The result of using Ritalin shows distinctively how it is effective in the morning, which signifies that the provider will have to decide on how to address the afternoon behavioral issues with the medication and the tachycardia.

Decision #2

From other list of drugs available in the decision tree, I choose to change to Ritalin LA 20 mg orally every morning.

Reason for selecting this decision

Since it was reported that though the IR formula of Ritalin was effective, but it dissipates before the school day finishes resulting her to stare into space, daydream. Also causing the side effects, tachycardia. It is important at this point for a provider to do something about the results and side effects of the medication. As a result of the tachycardia and the client having a decrease in attention during the afternoon it would be recommended to switch the formula of the same medication to a long acting one (Drugs.com, 2018). The encounter with stimulant drugs is how they deliver an effective dose over a required period of time. When Ritalin was first used to treat ADHD in 1961, it lasted three or four hours. But technology has been created to make the medication release gradually, peaking at the desired time (Ehmke, 2018). Ritalin IR is quickly absorbed, with its action initiating within 30 minutes of use, lasting only for about two to four hours before it gets is (Durand-Rivera, et. al, 2015). Sustained release Ritalin LA has an early peak and an 8 hours duration of action (Stahl, 2014b). Ritalin LA also has beads, but they’re 50-50, which means half the beads are going to be released immediately, to peak in the morning, the other half in the afternoon, for a total of six to eight hours. So as to have much more of a two-equal-phases effect on focus and attention (Ehmke, 2018). An observational study had an objective to evaluate effectiveness of Ritalin LA in children with ADHD and It demonstrated improvements in ADHD symptoms, confirmed overall good tolerability and safety, and revealed a longer perceived effect particularly after switching from immediate release formulations (Haertling et. al, 2014).

When there’s a side effects encountered such as the tachycardia, it is recommended to switch to another formulation of d,l-methylphenidate (Stahl, 2014b). Continuing the same formula and waiting to re-evaluate in 4 weeks will not be appropriate for the client. It means she will still be having a high heart rate and her symptoms will still not be controlled throughout her school day. It is also not recommended to switch to another agent at this time since there’s an improvement in symptoms. Since positive results were observed, improving the dosage rather than changing the drug could help. The provider just needs to select a better formula and dosage for further enhancement in symptoms. Also the dosage suggested in the case study is not recommended to be prescribed as an initial dose. For an extended-release form of Adderall, it is recommended to start with 10 mg/day in the morning, and can be increased on weekly basis by 5 to 10 mg, with a maximum dose generally of 30 mg/day (Stahl, 2014b). As a result of tachycardia and the client having a decrease in attentiveness in the afternoon, it would be advised to change the medication to a long acting formula (Drugs.com, 2018). prescribing Ritalin LA 20mg a day is an appropriate dose for clients who were previously taking using Ritalin 10mg daily and can be titrated up by 10mg weekly to the maximum dose of 60mg daily depending on response (Drugs.com, 2016). Ritalin LA 20mg would be the appropriate drug for symptoms like inattentiveness and concentration deficits (Denise et al. 2016).

Expected outcome

In four weeks, client is expected to return to the clinic with reduction in tachycardia and an improvement in her attention span throughout the day. It is also expected that her symptoms of staring into space, and daydreaming will improve. Overall improvement in her academic performance is also anticipated. Her increase heart rate is likewise expected to reduce to a normal range of 70-110 beats per minute for her age range (Medlineplus.gov, 2017).

Difference between the expected outcome and the initial short-term outcome

Patient returned in four weeks with reports that the switch to the LA preparation is lasting her throughout the school day (Laureate Education, 2016d). This brought along an improved academic performance. No reports of her staring into space and daydreaming unlike when she was on the Ritalin IR. Additionally her previous reports of her heart feeling funny has stopped. On assessment during this visit, her previously pulse of 130 had diminished to 92 beats per minute, which is a normal range for her age. It is evident that her response in four weeks after her medication was changed was significantly positive; it keeps her functioning normally throughout a school day, unlike formerly where it could only be noticed in the morning. There was a connection between the expected results and actual result for this client.

Decision #3

As my final decision, I chose to continue on the current dose of Ritalin LA 20mg and re-evaluate her in four weeks.

Reason for selecting this decision

Given that the client has shown continuous improvement with treatment, no alteration in her dose was necessary. There is no purpose to alter her medication or increase the dosage at this time. She is currently responding to the new Ritalin LA formula and dosage with no side effects. A change is always done when the prescribed dosage does not have a positive impact on the patient. In the situation when a prescribed dose does not produce a therapeutic effect in a client, the medication itself or dosage can be modified or altered. It can either be increased, reduced, stopped or switched to another drug. However, in this case, the client has reached an optimal clinical effect so there was no reason to change the medication. Stahl (2014b) recommended to continue treatment until all symptoms are under control or improvement is stable and then continue treatment until further notice as long as there’s a constant improvement. It is also suggested to reevaluate the client for the need for treatment periodically (Stahl, 2014b).

Expected outcome

It is expected that during her next four weeks appointment, the client, including her parent and teacher will report much further improvement. It is also expected that she will also continue to tolerate it with no side effects.

 

The difference in expected results and the real results.

There is also no need to obtain an EKG for this client since her heart rate is appropriate for her age. Ritalin LA 20 mg has demonstrated positive effect in resolving the client’s symptoms. She has continued to show over-all improvement in her symptoms and hence there is no reason to alter the dosage or switch to another medication (Coffey 2016). Maintaining the same formula and dosage under required prescription from the health professional is a better choice. She should also constantly be evaluated for side effects. Since Ritalin could temporarily slow normal growth in children, her weight and height should be constantly monitored (Stahl 2014b). Her heart rate and blood pressure should likewise be monitored regularly (Stahl 2014b). The client’s parent should also be advised to avoid dosing late in the day because of the risk of insomnia (Stahl, 2014b).

Ethical considerations.

It is ethical for a provider to prescribe the most suitable dose of drug and monitor the efficacy or potential side effects of the drug on clients. There’s a contend that by not allowing parents or guardians of the children to use these medications when diagnosed with attention deficit hyperactivity disorder(ADHD), the psychiatric and medical communities would be in violation of the principle of autonomy(Meppelink et. al., 2016). Justice too would be abused since the greater part of the burden of managing every one of the symptoms caused by this issue would descend on those with ADHD and relatively on their families (Meppelink et. al., 2016). There has been some debate over the utilization of stimulant medications and unethical practices involving children. A few people have utilized stimulants as a type of social control, attempting to wipe out socially inadmissible behaviors by controlling the child’s guardian into having stimulants recommended (Johns, 1994).It is vital that the child’s guardian completely comprehends the symptoms and appropriate utilization of stimulant prescriptions (Huss et. al., 2017).

Conclusion

Medications for ADHD can be very helpful in reducing impulsiveness and hyperactivity and increasing focus and attention (Low, 2018). The goal of every prescriber is to always obtain an optimal effect while reducing the risk to the client (Huss et al., 2017). There is no specific treatment that is right for every client in every situation, hence, in order to boost treatment it is vital to for providers to listen to the client and utilize a tailored approach to treatment (Coghill et al., 2013).

 

 

 

 

 

 

 

 

 

 

References

Abassi, L. (2015). Chewable Ritalin for the Kiddies. Retrieved from https://www.acsh.org/news/2015/12/14/chewable-ritalin-for-the-kiddies

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Washington, DC: Author.

Clancy, C.M., Change, S., Slutsky, J., & Fox, S. (2011). Attention deficit hyperactivity disorder: Effectiveness of treatment in at-risk preschoolers; long-term effectiveness in all ages; and variability in prevalence, diagnosis, and treatment. Table B. KQ2: Long-term(>1 year) effectiveness of interventions for ADHD in people 6 years and older.

Coffey, C. (2016). Pediatric neuropsychiatry. Philadelphia, Pa: Lippincott Williams & Wilkinsg

Coghill, D., Banaschewski, T., Zuddas, A., Pelaz, A., Gagliano, A., & Doepfner, M. (2013). Long-acting methylphenidate formulations in the treatment of attention-deficit/hyperactivity disorder: a systematic review of head-to-head studies. BMC Psychiatry, 13(1). doi:10.1186/1471-244x-13-237

Denise, F. & Cheryl, T. (2016). Resource manual for nursing research: generating and assessing evidence for nursing practice. Philadelphia

Durand-Rivera, A., Alatorre-Miguel, E., Zambrano-Sánchez, E., & Reyes-Legorreta, C. (2015). Methylphenidate Efficacy: Immediate versus Extended Release at Short Term in Mexican Children with ADHD Assessed by Conners Scale and EEG. Neurology Research International, 2015, 1-9. doi:10.1155/2015/207801

Ehmke, R. (2018). The Facts on ADHD Medications. Retrieved from https://childmind.org/article/the-facts-on-adhd-medications/

Fisher, M. (2008). Study uncovers how Ritalin works in brain to boost cognition, focus attention. Retrieved from https://news.wisc.edu/study-uncovers-how-ritalin-works-in-brain-to-boost-cognition-focus-attention/

Haertling, F., Mueller, B., & Bilke-Hentsch, O. (2014). Effectiveness and safety of a long-acting, once-daily, two-phase release formulation of methylphenidate (Ritalin ® LA) in school children under daily practice conditions. Attention deficit and hyperactivity disorders, 7(2), 157-64.

Huss, M., Duhan, P., Gandhi, P., Chen, C., Spannhuth, C., & Kumar, V. (2017). Methylphenidate dose optimization for ADHD treatment: review of safety, efficacy, and clinical necessity. Neuropsychiatric Disease and Treatment, Volume 13, 1741-1751. doi:10.2147/ndt.s130444

Johns, G. (1994). Treatment with Stimulant Medication as an Ethical Choice for Children Diagnosed With Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder. National Student Speech Language Hearing Association, 21, 45-49.

Laureate Education (2016d). Case study: A young Caucasian girl with ADHD [Interactive media file]. Baltimore, MD: Author

Low, K. (2018). Medications to Treat ADHD in Children and Adults. Retrieved from https://www.verywellmind.com/adhd-medication-20882

Meppelink, R., de Bruin, E. I., & Bögels, S. M. (2016). Meditation or Medication? Mindfulness training versus medication in the treatment of childhood ADHD: a randomized controlled trial. BMC psychiatry, 16, 267. doi:10.1186/s12888-016-0978-3

Methylphenidate Chewable Tablets – FDA prescribing information, side effects and uses. (2018). Retrieved from https://www.drugs.com/pro/methylphenidate-chewable-tablets.html

Once-daily treatment of ADHD with guanfacine: patient implications. (2008). Neuropsychiatric disease and treatment, 4(3), 499-506.

Pulse: MedlinePlus Medical Encyclopedia. (2017). Retrieved from https://medlineplus.gov/ency/article/003399.htm

Rosen, P., & Braaten, E., Ph.D. (n.d.). Changing Between Stimulant and Non-Stimulant ADHD Medication: What You Need to Know. Retrieved from https://www.understood.org/en/learning-attention-issues/treatments-approaches/medications/changing-between-stimulant-and-non-stimulant-medications-what-you-need-to-know

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

The Ritalin wars continue. (2000). The Western journal of medicine, 173(6), 366-7.

Understanding the Ritalin debate. (2018). Retrieved from https://www.apa.org/topics/adhd/ritalin-debate.aspx

Wietecha, L. A., Clemow, D. B., Buchanan, A. S., Young, J. L., Sarkis, E. H., & Kindling, R. L. (2016). Atomoxetine Increased Effect over Time in Adults with Attention-Deficit/Hyperactivity Disorder Treated for up to 6 Months: Pooled Analysis of Two Double-Blind, Placebo-Controlled, Randomized Trials. CNS Neuroscience & Therapeutics, 22(7), 546-557. doi:10.1111/cns.12533

Wigal, S. B., Childress, A., Berry, S. A., Belden, H., Walters, F., Chappell, P., Sherman, N., Orazem, J., Palumbo, D. (2017). Efficacy and Safety of a Chewable Methylphenidate Extended-Release Tablet in Children with Attention-Deficit/Hyperactivity Disorder. Journal of child and adolescent psychopharmacology, 27(8), 690-699.