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
The Assignment
Examine Case Study: A Young Caucasian Girl with ADHD You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
• Decision #1
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
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 schoolwork 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 schoolwork.
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 Click to see options it will take you to decision point two and three
Begin Intuniv extended release 1 mg orally at BEDTIME Click to see options it will take you to decision point two and three
Begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the MORNING Click to see options it will take you to decision point two and three
All references require creditable sources, nothing less than 5 years. References require doi or http. Please add conclusion.
Tips:
– Always use the choices given
– Continuation of psych meds may be needed before switching as they take time.
Staying the course (more time) or increasing for the second decision is a good choice as we do not switch if patient is doing well. This follows a similar path in past cases.
– Sticking with a med that works would be the best choice for the 3rd decision too.
– Remember to not be quick to switch any psych meds as many take a long time to start working.
EXAMPLE NOT TO BE USED WORD FOR WORD.
Assessing and Treating Clients with ADHD
Attention Deficit/Hyperactivity Disorder is currently the most common behavioral disorder in children and the numbers are continuing to rise (Schulz et al., 2010). The psychiatric mental health nurse practitioner needs to have the knowledge and understanding to diagnose and treat the disorder properly. The purpose of this paper is to explain three decisions that I made for an 8-year-old girl newly diagnosed with ADHD using credible resources for each choice made.
Decision #1
The first decision that I made for the client is to begin Ritalin (methylphenidate/MPH) chewable 10mg tablet once in the morning. I chose Ritalin because according to Stahl (2008), the medication has established long-term efficacy as a first-line treatment for ADHD. Wellbutrin is not a first line treatment in children with ADHD. The real effectiveness of Wellbutrin in the treatment of ADHD symptoms is unknown. Wellbutrin has the potential to be effective and well tolerated in children with ADHD and an alternative to stimulants, but currently, there is an insufficient database. Guanfacine is an excellent non-stimulant option for the client but is not approved by the FDA for the treatment of ADHD in children. Also, the standard of care for treating ADHD is to use a psychostimulant as the first line agent (Strange, 2008). Approximately 70-90% of clients with ADHD will respond to stimulant medication. Four weeks later the client returns for a follow-up. The teacher reports that her symptoms are better in the morning and her overall academic performance has improved. Unfortunately, the client’s heart rate is 130 which is considered tachycardic for a child of her age. The Ritalin should have been dosed at 5mg in the morning to start. Tachycardia in a client could be a sign of overdose (Stahl, 2008).
Decision #2
Moving on for the second decision I chose to start the client on Ritalin LA 20mg once per day. In recent years, new MPH medications are available which provide the possibility of once-daily dosing (Schulz, 2010). I wanted to stick with the Ritalin because it has been effective in treating the client’s symptoms, but it was too large of a dose in the morning and should have been dosed several times per day at 5mg. I believe that placing the client on a long-acting MPH will help the control the client’s symptoms throughout the write my essay school day. According to Stahl (2008), 20mg of Ritalin LA is the initial dose for a client starting the medication. I did not keep the client on the Ritalin 10mg in the morning because of her heart rate. Tachycardia is a dangerous side effect and can be life-threatening so the medication should be stopped right away (2009). I did not want to start the client on Adderall (amphetamine) because the client showed a response to the MPH according to her teacher. Adderall can be considered when clients do not respond to the methylphenidate class of stimulants (Stahl, 2008).
Four weeks later when the client returns for a follow up the outcome of placing her on the Ritalin LA is excellent. The client’s symptoms have improved at school, and the effects are lasting throughout the day, and she is no longer tachycardic with a heart rate of 92.
Decision #3
Lastly, for decision number three I kept the client on the Ritalin LA 20mg once per day and to reevaluate in four weeks. I chose this option because the client’s symptoms are being controlled and she is tolerating the medication well. Thus, being said, increasing the client’s medication to 30mg per day is not necessary at this time. The average resting heart rate of children ages 6-12 years old is between 75-118 beats per minute, so I did not find it necessary to obtain an EKG currently (Fenton, 2015). As time progresses, the client may need an increased dose of the Ritalin LA because she will gain weight and her body will become used to the medication, but for now, the 20mg is doing its job.
Ethical considerations in treatment plan and communication with clients
Many people have negative perceptions of the use of psychostimulants in children and adolescents. The parents are the decision makers for this population, and many parents could be in denial that their child needs to be on medication. Clear communication about exactly how ADHD affects the brain, and a person’s behavior is necessary to explain. Also, the explanation of how psychostimulants are useful in the treatment of ADHD (Foreman, 2006). The nurse practitioner must always respect the client’s autonomy and decision on treatment.
Conclusion
In conclusion, ADHD is a condition that requires special attention to handle. ADHD may be mistaken for disciplinary issues hence causing mishandling of the people with the disease. Parents should learn to observe their children as they grow to notice any sign or symptom of the disorder. Realizing the condition at an early age enables seeking of medical assistance early. Therefore, the situation is corrected at an old age. Children diet should be carefully checked to ensure a balanced diet. The steady diet promotes the growth of children’s’ brains hence reducing the chances of Attention Deficit Hyperactivity Disorder
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-free essay sample
Assessing and Treating Clients with ADHD
Student’s Name
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Professor’s Name
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Assessing and Treating Clients with ADHD
Introduction
Children with ADHD experience difficulties concentrating on their academic activities. Ritalin is one of the best medications that can help overcome the negative impact of ADHD. The medication has fewer symptoms compared to other drugs. Prescribing the medication requires the consent of parents. Therefore, during the initial prescription, parents should be aware of the medication their child will take. All the decisions should also focus on reducing the negative impact on a patient (Mayes et al., 2020). The ADHD case study involves a series of decisions and ethical considerations that culminate in the successful treatment of ADHD.
Decision #1
The first decision is to prescribe Ritalin (methylphenidate/MPH) chewable 10mg tablet once every morning.
Rationale
One of the reasons for selecting Ritalin is its long history of efficacy in the treatment of ADHD. The drug is also approved and friendly to children such as the 8-year old patient in the case study. Research also shows that medication is a first-line medication for the treatment of ADHD (Pakdaman et al., 2018). Case studies also indicate Ritalin is used by millions of doctors globally to treat children who have learning disabilities in school. For example, the medication is effective in helping students to focus on their learning tasks (Ten et al., 2020). Statistics also indicate that the drug is efficient due to its 80 percent success for all patients who use it. Ritalin also generates 70-90 percent positive results for all the patients who take the stimulant.
Ritalin 10mg is also friendly to children since it does not cause severe side effects compared to other available drugs in the market. Evidence-practice also shows that it is safe to start medication with a low dosage, especially while treating ADHD among children (Liebenberg, 2017). The low dose will help in further assessment to determine the effectiveness and side effects. Clinicians who prescribe high doses during initial treatment can be held liable if the medication causes severe effects (Liebenberg, 2017). One of the common side effects of drugs is a high heart rate. Other common side effects include drowsiness and change in vision and dizziness.
The treatment plan did not include selecting the other two drugs including Wellbutrin 150mg orally daily and Ituiniv extended release 1mg orally at bedtime. One of the reasons for not selecting Wellbutrin is because it is not a first-line medication in the treatment of ADHD (Jensen & Breindahl, 2019). Also, it is an antidepressant whereas the treatment of ADHD requires stimulants. Stimulants are effective since they increase dopamine levels in the brain. High dopamine levels are effective in increasing the focus, pleasure, and attention while reducing hyperactivity and other impulsive behaviors (Jensen & Breindahl, 2019). Although initial research shows that Wellbutrin could be effective in treating patients, there is insufficient data available to justify its use (Demontis et al., 2019). Intuiniv is also a medication that is not preferable in the current case study. One of the reasons is that medicine is not approved by FDA for use among children (Demontis et al., 2019). It is also a non-stimulant that makes the drug less effective as a first-line medication in the treatment of ADHD. The patient should report back to the clinic for further assessment after four weeks.
Expected Outcomes
The patient will report back to the clinic after four weeks for further assessment of the symptoms and determination of the drug. One of the expected outcomes is that the student will concentrate on schoolwork and report improved academic performance (Mayes et al., 2020). The expected report should be from the teacher who noticed the signs of ADHD. It is also expected that the patient will suffer from an increased heart rate. Research shows that Ritalin is effective, but it can cause conditions such as tachycardia in children (Mayes et al., 2020). It is also important to ask the patient whether they have other negative outcomes such as dizziness or drowsiness (Pakdaman et al., 2018). If any of the side effects are evident, it will be critical to make a decision that will reduce the severity and threat of the effects on the recovery process or the academic performance of the student (Pakdaman et al., 2018). The parents are also critical in making such observations to ensure the patient remains safe.
Projected Outcomes vs. Results
The 9-year old girls report back to the clinic for further assessment after four weeks. It is the role of the clinicians to make observations and ask questions to determine the progress the patient has made over the four weeks.
According to the assessment, the patient shows significant progress. A report from the teacher indicates that she has made tremendous improvement in her academic work. The teacher also indicates that her concentration and focus in class is also improving gradually. According to the report, the symptoms are better in the morning and worsen as the day progresses. The changes in the improvement between morning and evening were not part of the expectations. Therefore, such a challenge should be considered in the decision #2 treatment plan.
Unfortunately, the patient’s heart rate is 130 whereas the normal rate if 70-110 for children aged 7-9 years. The high heart rate or tachycardia is an indication of an overdose drug according to Stahl (2013). Clinicians are required to express caution while prescribing the medication. For example, it is safe to start with a 5mg dose in the morning to avoid the high heart rate (Liebenberg, 2017). Research shows that a high heart is responsible for the deaths of children across the world.
Decision #2
The second decision is to prescribe Ritalin 5mg tablet QID to the patient.
Rationale
The second decision is to continue with the current medication since it is generating the expected results. It is also unsafe to constantly change medication to treat mental disorders such as ADHD (Liebenberg, 2017). Changing the medication can trigger adverse effects on patients, especially children thus undermine the rate of recovery. However, it is prudent to change the dosing to prevent negative outcomes such as a high heart rate (Liebenberg, 2017). The focus is to reduce the heart rate to a range of between 70 and 110 which is normal for children her age. According to evidence-based practice, Ritalin 5mg tablets can be dosed several times a day, at most four times.
Taking the long-acting MPH is also effective for the patient. For example, it will suppress the symptoms of ADHD while at school. It will help improve concentration while studying and avoid absentmindedness (Jensen & Breindahl, 2019). Katie admits that her mind wanders away while she is in class listening to the teacher. The medication is thus safe due to the small dosage. It will also help counter another problem that the teacher identified. According to the first clinic assessment report, the teacher indicated that the symptoms deteriorate as the day progresses (Jensen & Breindahl, 2019). Therefore, taking small doses regularly is essential in overcoming such a challenge in the treatment of ADHD patients.
It was not prudent to prescribe Adderall since it is one of the best medications that clinicians should consider when MPH does not work. However, currently, the medication is working positively and thus there is no need to change (Demontis et al., 2019). It is expected that in the next four weeks, the patient will record better progress. The patient also experienced a high heart rate. It is not safe to introduce another medication to counter the high heart rate (Demontis et al., 2019). One of the prudent measures is to reduce the dosage or scatter it over some time. For example, taking 5mg four times a day is safe and it will control the negative outcomes effectively and promote positive results.
Expected Outcomes
The patient returns to the clinic after four weeks for further assessment. It is expected that the patient will record a lower heart rate within the normal range. For example, the patient should have a heart rate below 100. The purpose of reducing the heart rate below 100 is to ensure the child is out of the danger zone (Demontis et al., 2019). Research shows that children can die if their heart rate is above the normal range (Mayes et al., 2020). It is also expected that the patient will continue demonstrating significant improvement in concentrating on school work and during class time. A report from the teacher should indicate that the student is no longer caught unawares or absentminded. The student should also admit that wandering away from the class has ceased significantly.
Another expectation is that the patient should record a stable reduction in the symptoms. For example, the symptoms should not deteriorate in the evening. Previously, the teacher had indicated that the student was demonstrating a deteriorating condition as the day went by. Another critical indicator is that the student should demonstrate significant improvement in academic performance. The performance will be measured using metrics such as completing homework and class assignments on time and scoring higher grades.
Projected Outcomes vs. Results
The patient reports back to the clinic after four weeks. The results indicate a significant improvement as projected. A report from the teacher indicated that the student was performing excellently in class. According to the report, the student was no longer experiencing wandering thoughts in class. She also recorded an improvement in her classwork. However, the report indicated that still, the student needed to enhance concentration on some tasks such as homework completion. The outcome was not expected but it is almost to the projected outcomes that the patient may require another four weeks of taking the medication. The teacher indicates that if the medication is administered for another four weeks, there is hope for a full recovery.
The assessment of the heart rate showed that it had dropped significantly. For example, the heart rate was at 92 which is within the normal expected range. Therefore, it is safe to continue administering the medication without fear of heart failure (Mayes et al., 2020). Another outcome is that the symptoms did not deteriorate as the day went by. According to the teacher’s report, the patient was stable throughout the day thus showing positive progress.
Another outcome that was not projected is that the patient was reported to be taking the medication in compliance with the prescription instructions. One of the risks of prescribing medication to students, especially when they need to take it four times a day is that some forget (Mayes et al., 2020). The non-compliance can thus undermine the quality of treatment or present adverse effects. The parents and teachers indicate that she always took her medication on time. It was also reported that the patient did not experience any change in weight, which is remarkable while treating mental disorders (Mayes et al., 2020). Research shows that several medications are responsible for increasing the risk of weight gain (Mayes et al., 2020). However, Ritalin is the safest among them all.
Decision #3
The third decision is to continue with the current medication Ritalin 5mg orally QID.
Rationale
The purpose of continuing with the drug is since it has demonstrated positive results in the past which is remarkable. The reports from the teachers indicate that the student is now concentrating in class. Her academic performance is also back to normal (Pakdaman et al., 2018). Therefore, no need to change the medication since it is always generating the desired results. In addition, it is not prudent to change the dosage since it can cause tachycardia (Pakdaman et al., 2018). Previously, the high dosage had led to a risky heart rate of 130. It is thus important to maintain both the drug and dosage.
The decision did not involve changing the drug or adding another drug. Stahl (2013) shows that polypharmacy is not recommended especially for children. The reason is that it can cause adverse effects on their bodies. It can also affect other organs in the body such as the heart or liver (Pakdaman et al., 2018). Another reason for continuing with the medication is that it has no side effects on the patient. Most of the medications used to treat mental disorders such as Zoloft are effective but they lead to weight gain (Liebenberg, 2017). Clinicians are forced to change the medications or prescribe lower drugs which have minimal side effects. Therefore, it is safe to continue with the current medication. Additionally, the heart rate of the patient has reduced significantly thus showing there are no risks of heart attack (Liebenberg, 2017). The patient has also not complained of any symptoms related to heart problems. It is thus not a requirement to get EKG or other tests related to the side effects of Ritalin.
Expected Outcomes
The expected outcomes are that the patient will improve in various areas such as academic performance and concentration in class. It is also expected that despite the positive progress that she will continue taking the medication four times a day. Non-compliance with drugs while treating mental disorders is one of the reasons for relapse (Liebenberg, 2017). A relapse can cause negative results since it impacts a patient’s health and prolongs the treatment. It is also necessary to caution the parents and the student that they should not administer another drug since drug interaction can undermine the recovery process (Jensen & Breindahl, 2019). Another outcome is that she will not add any weight which will help the patient to continue taking the medication according to the prescriptions.
Ethical Issues in Treatment
Healthcare workers encounter different situations that require critical decision-making. Ethical issues affect how healthcare workers made the decisions, communicate to patients and provide treatment. One of the ethical issues is providing clear information about treatment and medication (Demontis et al., 2019). The patient is an 8-year-old girl, and thus she cannot make decisions regarding her treatment. According to the law, it is the parent who should make the decision (Pakdaman et al., 2018). It is thus prudent to explain to the parents about the proposed medications, their side effects, and efficacy (Pakdaman et al., 2018). Clear information will help them to make an informed choice and consent to treatment. Clinicians should always respect a patient’s autonomy and decision. Healthcare workers should maintain confidentiality to safeguard the patient’s information. It is also necessary to utilize nursing knowledge and experience to write my paper help the parents make the best decision that will not harm the patient (Pakdaman et al., 2018). Clinicians should always abide by the ‘do no harm’ principle. All the ethical issues are relevant to the case study and they will impact treatment and communication.
Conclusion
ADHD is a common condition that therapists and healthcare providers experience in their daily routine. Understanding the best treatment procedures and medications is essential to provide quality care. One of the best medications for ADHD is Ritalin. The medication has few side effects compared to other drugs in the market. Ritalin, however, should be prescribed in a small dose to prevent side effects such as increased heart rate. The case study involved an 8-year-old patient who is not concentrating on schoolwork. Ritalin is effective in helping children to focus and overcome wandering thoughts. One of the side effects that were evident during the treatment was a high heart rate. Tachycardia is a condition that can be fatal is not well controlled. Due to such effects of medications, clinicians should always inform the parents about the medication, efficacy and side effects. Ethical considerations are essential in the delivery of safe and quality care.
References
Demontis, D., Walters, R. K., Martin, J., Mattheisen, M., Als, T. D., Agerbo, E., … & Cerrato, F. (2019). Discovery of the first genome-wide significant risk loci for attention-deficit/hyperactivity disorder. Nature Genetics, 51(1), 63-75. DOI: https://doi.org/10.1038/s41588-018-0269-7
Jensen, C. M., & Breindahl, T. (2019). Patients in medical treatment for attention-deficit/hyperactivity disorder (ADHD): Are they at risk in drug screening?. ADHD Attention Deficit and Hyperactivity Disorders, 11(3), 333-340. DOI: https://doi.org/10.1007/s12402-018-0282-9
Liebenberg, R. (2017). Side effects of ADHD medication in adults and children. Mental Health Matters, 4(5), 34-36. https://hdl.handle.net/10520/EJC-a0c8875da
Mayes, S. D., Waxmonsky, J. G., Baweja, R., Mattison, R. E., Memon, H., Klein, M., … & Waschbusch, D. (2020). Symptom Scores and Medication Treatment Patterns in Children with ADHD versus Autism. Psychiatry Research, 112937. https://doi.org/10.1016/j.psychres.2020.112937
Pakdaman, F., Irani, F., Tajikzadeh, F., & Jabalkandi, S. A. (2018). The efficacy of Ritalin in ADHD children under neurofeedback training. Neurological Sciences, 39(12), 2071-2078. DOI: https://doi.org/10.1007/s10072-018-3539-3
Stahl, S. M., & Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge university press.
Ten, W., Tseng, C. C., Chiang, Y. S., Wu, C. L., & Chen, H. C. (2020). Creativity in children with ADHD: Effects of medication and comparisons with normal peers. Psychiatry Research, 284, 112680. https://doi.org/10.1016/j.psychres.2019.112680
