Therapy for patients with ADHD – Katie is an 8-year-old Caucasian female

Therapy for patients with ADHD – Attention Deficit Hyperactivity Disorder A Young Girl With ADHD. Katie is an 8-year-old Caucasian female who is brought to your office today by her mother & father.

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Therapy for patients with ADHD – Katie is an 8-year-old Caucasian female

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 is an 8-year-old Caucasian female

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.

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MENTAL STATUS EXAM – Katie is an 8-year-old Caucasian female

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 -Katie is an 8-year-old Caucasian female

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

Link to Case study:  https://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6630/DT/week_09/1.html

Therapy for patients with ADHD – Attention Deficit Hyperactivity Disorder A Young Girl With ADHD

Introduction

Children suffering from attention-deficit /hyperactivity disorder (ADHD) manifest with behavioral issues that range from inattentiveness, hyperactivity, impulsivity, and oppositional conduct accompanied by poor academic progress. Coghill et al. (2021) note that these psychiatric disorders are the most prevalent neurodevelopmental disorder occurring in children and adolescents who present to mental health, pediatric, and primary care services. These scholars report that ADHD’s global prevalence stands at about 5% in children and teenagers and almost 3% in adults (Cortese et al., 2018). The disease leads to a significant burden at the individual, family, and community/society level, as ADHD is known to adversely affect the patient’s quality of life and daily functioning.

            Individuals with ADHD may register poor performance in their educational outcomes and are more prone to injuries, accidents, and conflicts. Additionally, ADHD is closely linked to other psychiatric and neurodevelopmental disorders and a host of physical conditions. To decrease the impact and incidence of these symptoms, mental health collaborates with other healthcare providers to accurately identify ADHD and implement effective interventions through medications and non-medication treatment once a correct diagnosis is made. Most importantly, the physician should utilize effective evidence-based treatments coupled with a well-thought-out decision-making process. Subsequently, the paper outlines a 3-point decision-making process to establish an appropriate medication-based treatment for an eight-year female diagnosed with ADHD. The paper considers evidence-based research and ethical guidelines that inform the recommended pharmacological interventions.

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Decision Point #1

            At decision point 1 (DP#1), the options were to either start Wellbutrin (bupropion) XL 150 mg PO daily or begin Intuniv extended-release 1 mg PO at bedtime or begin Ritalin (methylphenidate) chewable tablets 10mg PO in the morning. Upon consideration, I opted for treatment option three of initiating Ritalin chewable tablets of 10 mg PO in the morning. In a study with 69 patients (age 6–14 y) diagnosed with ADHD receiving methylphenidate or atomoxetine, methylphenidate had a treatment response of 90.7% (Garg, Arun, & Chavan, 2014). Furthermore, Su et al. (2016) conducted a study on the short-term efficacy of osmotic release oral system methylphenidate (OROS MPH). They found that the medication was associated with significantly reducing ADHD symptoms among children and adolescents at the end of the four-week maintenance period. I opted to initiate Ritalin 10mg PO in the morning because of these findings and the fact that methylphenidate is recommended as the first-choice treatment in patients less than 18 years.

Why the Other Two Options Provided In the Exercise Were Not Selected

In a meta-analysis study conducted by Stuhec et al. (2015), 28 trials were included; the study’s main objective was to identify double-blinded, placebo-controlled, non-crossover studies for ADHD. The study determined that bupropion (OR1.64, 95% CI: 0.5, 5.43) compared to placebo treatment discontinuation was not statistically different, unlike methylphenidate, whose comparison to the same placebo was found to be statistically significantly lower (OR=0.35, 95%CI, 0.24, 052). Likewise, Intuniv 1mg extended-release administration was rejected because while this drug may ameliorate ADHD symptoms in the short term by 50-67.5%, a substantial number are nonresponses or experience intolerable side effects (McCracken et al., 2016).

Treatment goals, Ethical Considerations, and Communication with Patients

At DP#1, the primary goal is to lessen the effects of ADHD symptoms on the patient and optimize her ability to compensate or cope with the remaining challenges. For example, her schoolwork improved by completing her classwork and demonstrating enhanced independence in getting ready for school in the morning without supervision. I would communicate with the parents on the need for their involvement and learn about ADHD, understand how ADHD impacts their child, and focus on teaching one thing at a time. The guiding principle that necessitated the selection of Ritalin 10mg PO in the morning is always to do what is in the child’s best interests and do no harm (King et al., 2015). The selection of this medication would minimize the risk of harm.

Results of DP#1

The patient returned to the clinic after four weeks, and the parents reported that Katie’s teacher told them she had noted the pupil’s symptoms were much better in the morning, leading to improved academic performance. By afternoon though, Katie was daydreaming again while she reported to her parents that her heart felt funny at home. Her pulse rate is 130 beats per minute.

Decision Point #2

The treatment options at DP# are either to continue the same dose of Ritalin 10 mg and reevaluate in 4 weeks, change to Ritalin LA 20 mg PO daily in the morning, or discontinue Ritalin and begin Adderall XR 15 mg PO daily. The second option of changing to Ritalin LA 20mg PO daily in the morning was selected. Ritalin LA allows for once-a-day dosing in the morning. MPH-ER formulations allow for once-daily dosing in the morning and can last throughout the school hours (Wigal et al., 2017).

Why the other Two Options provided in the Exercise were not Selected

The first option of continuing with the same dose of Ritalin and waiting to reevaluate after four weeks was rejected because, despite reducing ADHD symptoms, the patient’s parents reported episodes of daydreaming in the afternoon and a significantly high heart rate of 130 beats. Besides, the MPH has a short half-life of 2-3 hours and a short effect lasting three to four hours (Durand-Rivera et al., 2015). As an immediate-release formulation, the patient would require 2-3 daily administrations to alleviate the patient’s symptoms throughout school hours. Switching from Ritalin to Adderall seemed attractive as the latter is a psychostimulant offering an efficacious, less frequently dosed alternative to the former. Sichilima & Rieder (2009) found that Adderall can raise one’s blood pressure and heart rate and make the patient breathe harder. There is also the increased risk of abuse leading to dependence and eventual addiction. The ethical principle of not causing harm to the patient dictated the selection of Ritalin LA 20 mg.

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Treatment Goals, Ethical Considerations, and Communication to Patient

The Treatment goals at DP# 2 were to manage the ADHD symptoms and ongoing monitoring for adverse effects. An additional goal was to educate the parents on the need for evidence-based non-pharmacological interventions to reinforce the medications. These interventions include exercises and metacognitive therapy. According to Lian et al. (2021), studies have established that children with ADHD who exercise performed better on tests of attention and were less impulsive. Lian et al. (2021) further determined that exercise intervention improved the general executive functions of children and adolescents with ADHD. Using non-pharmacological interventions like exercises also decreases the amount of medication taken.

Results of DP#2

After four weeks, the patient returned to the clinic, and her academic performance improved. The switch to Ritalin LA preparation lasts throughout the school day, and the patient reports her heart feeling funny is gone. Similarly, her pulse stands at 92 during today’s visit to the clinic.

Decision Point #3

The treatment options are to either maintain a current dose of Ritalin LA and reevaluate in 4 weeks, increase Ritalin LA to 30 mg orally daily, or obtain EKG based on current heart rate. I opted for the option to maintain the current dose of Ritalin LA 20g PO and reevaluate in 4 four weeks. The choice selected is to maintain the current dose of Ritalin LA (20 mg) in the morning.

When administered in the morning, Ritalin LA 20mg reached a higher plasma MPH concentration when compared to Concerta in the first four hours post-dose (Gonzalez et al., 2002). Additionally, in an observational study conducted in Germany with 262 patients with a mean age of 10.9 years and 212 who switched to Ritalin LA, they recorded a CGI improvement in 59% of the patients (Haertling et al., 2015). At this juncture, the client’s symptoms are well controlled and maintained during school hours, and she reports no side effects.

Why the Other Two Options Provided In the Exercise Were Not Selected

Increasing the current dose of Ritalin LA to 30 mg is ruled out because the patient presents no symptoms to necessitate an increase in dosage. ADHD medication guidelines recommend that one determine and then use the lowest effective dose. As Wigal et al. (2015) note, a number of doses need to be administered to establish the lowest dose required to achieve optimal treatment. In 27.7% of pediatric patients in this study, they received a final open-label dose of 30 mg, but the decision outcomes at DP#2 indicate that an optimal treatment dose has already been achieved. Likewise, there is no need to get an EKG based on the current heart rate as 92 beats per minute is normal for an eight-year-old girl since the normal range for an eight-year-old girl is 59 to 123 bpm.

Treatment Goals, Ethical Considerations, and Communication to Patient

At DP#3, the long-term goals are to effectively control, maintain, and alleviate ADHD symptoms in the child and have follow-up activities after four weeks, then three months, and six months to monitor the patient. Having determined the lowest effective dose, medication compliance is advised, and patient and parent education on ADHD. Parent training in behavior management is also to be integrated into the proposed treatment plan for the patient’s ADHD. The ethical principle of beneficence guided the integration of patient education as non-pharmacological treatments do not have side effects commonly associated with medications.

Conclusion

The primary treatment goal was to decrease the effects and manifestation of ADHD symptoms on the child patient’s functions while simultaneously optimizing the patient’s ability to either cope or compensate for the challenges. Among the medications commonly used to treat ADHD in children, the efficacy of Ritalin is emphasized. From the outset, one must be aware that two formulations of Ritalin (methylphenidate/MPH) exist either as immediate-release (IR) MPH and long-acting/LA or extended-release(ER) formulation (McGough et al., 2005). Ritalin 10 mg chewable tablets administered in the morning were effective but only for a short period during school hours, as witnessed by her staring into space and daydreaming that mainly manifested in the morning. Like any other drug, the medication has side effects, but the child patient successfully managed to contain them. Suffice it to say that the decision to maintain the medication Ritalin but switch to an extended-release formulation was premised on the fact that there were significant improvements in the patient’s symptoms when she made her second visit to the clinic after four weeks. The clinical visits after every four weeks ensure treatment monitoring, with each follow-up visit giving room to review target symptoms and executive functions.

The decision to maintain the dosage of MPH-ER at 20mg proved effective since all the target symptoms were controlled, and target goals were realized. The patient’s performance at school had increased, she had no side effects of complaining about, and with non-pharmacological approaches like exercises, the treatment regime is set to continue. Most importantly, using Ritalin LA 20 mg in the morning daily is bound to help treat and manage the symptoms so they do not persist into adulthood. A multimodal approach is required where non-medication like exercises and psychotherapy are used besides the medications.

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References

Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., … & Simonoff, E. (2021). 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, 1-25.

Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., … & Cipriani, A. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 5(9), 727-738.

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.

Garg, J., Arun, P., & Chavan, B. S. (2014). Comparative short term efficacy and tolerability of methylphenidate and atomoxetine in attention deficit hyperactivity disorder. Indian pediatrics, 51(7), 550-554.

Gonzalez, M. A., Pentikis, H. S., Anderl, N., Benedict, M. F., DeCory, H. H., Dirksen, S. J., & Hatch, S. J. (2002). Methylphenidate bioavailability from two extended-release formulations. International journal of clinical pharmacology and therapeutics, 40(4), 175-184.

Grcevich, S., Rowane, W. A., Marcellino, B., & Sullivan-Hurst, S. (2001). Retrospective comparison of Adderall and methylphenidate in attention deficit hyperactivity disorder treatment. Journal of child and adolescent psychopharmacology, 11(1), 35-41.

Greenhill, L. L., Swanson, J. M., Vitiello, B., Davies, M., Clevenger, W., Wu, M., … & Wigal, T. (2001). Impairment and deportment responses to different methylphenidate doses in children with ADHD: the MTA titration trial. Journal of the American Academy of Child & Adolescent Psychiatry, 40(2), 180-187.

Haertling, F., Mueller, B., & Bilke-Hentsch, O. (2015). Effectiveness and safety of a long-acting, once-daily, two-phase release formulation of methylphenidate (Ritalin® LA) in school children under daily practice conditions. ADHD Attention Deficit and Hyperactivity Disorders, 7(2), 157-164.

Huss, M., Duhan, P., Gandhi, P., Chen, C. W., Spannhuth, C., & Kumar, V. (2017). Methylphenidate dose optimization for ADHD treatment: review of safety, efficacy, and clinical necessity. Neuropsychiatric disease and treatment.

King, N., Reid, D., & Dingle, A. D. (2013). Making Ethical Treatment Decisions in ADHD: Psychotropic Medication Use in Child and Adolescent Populations. Child and Adolescent Psychopharmacology News, 18(2), 1-4.

Liang, X., Li, R., Wong, S. H., Sum, R. K., & Sit, C. H. (2021). The impact of exercise interventions concerning executive functions of children and adolescents with attention-deficit/hyperactive disorder: a systematic review and meta-analysis. International Journal of Behavioral Nutrition and Physical Activity, 18(1), 1-17.

McCracken, J. T., McGough, J. J., Loo, S. K., Levitt, J., Del’Homme, M., Cowen, J., … & Bilder, R. M. (2016). Combined stimulant and guanfacine administration in attention-deficit/hyperactivity disorder: a controlled, comparative study. Journal of the American Academy of Child & Adolescent Psychiatry, 55(8), 657-666.

McGough, J. J., Pataki, C. S., & Suddath, R. (2005). Dexmethylphenidate extended-release capsules for attention deficit hyperactivity disorder. Expert Review of Neurotherapeutics, 5(4), 437-441.

Sichilima, T., & Rieder, M. J. (2009). Adderall and cardiovascular risk: A therapeutic dilemma. Paediatrics & Child Health, 14(3), 193.

Stuhec, M., Munda, B., Svab, V., & Locatelli, I. (2015). Comparative efficacy and acceptability of atomoxetine, lisdexamfetamine, bupropion and methylphenidate in the treatment of attention deficit hyperactivity disorder in children and adolescents: a meta-analysis with focus on bupropion. Journal of affective disorders, 178, 149-159.

Su, Y., Yang, L., Stein, M. A., Cao, Q., & Wang, Y. (2016). Osmotic release oral system methylphenidate versus atomoxetine for the treatment of attention-deficit/hyperactivity disorder in Chinese youth: 8-week comparative efficacy and 1-year follow-up. Journal of Child and Adolescent Psychopharmacology, 26(4), 362-371.

Wigal SB, Nordbrock E, Adjei AL, Childress A, Kupper RJ, Greenhill L. Efficacy of methylphenidate hydrochloride extended-release capsules (Aptensio XR™) in children and adolescents with attention-deficit/hyperactivity disorder: a phase III, randomized, double-blind study. CNS Drugs. 2015;29(4):331–340

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