A Young Caucasian Girl with ADHD Case Study Paper

A Young Caucasian Girl with ADHD Case Study Paper

To prepare for this Assignment:

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

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 A Young Caucasian Girl with ADHD Case Study Paper:

  • Decision #1
    • Which decision did you select?
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
  • Decision #2
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
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  •  Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
  • Decision #3
    • Why did you select this decision? Support your response with evidence and references to the Learning Resources.
    • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
    • 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.A Young Caucasian Girl with ADHD Case Study Paper. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Decision Point One

 

Begin Intuniv extended release 1 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Katie’s teacher reports no change in her classroom behaviors
  •  Katie's parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish”

Decision Point Two

 

Increase Intuniv to 2 mg orally at BEDTIME

 

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  •  katie's parents report that Katie is even more sedate and has been refusing to get out of bed in the morning. Her teacher reports that she has gone from being a “daydreamer” in class to being on the “verge of falling asleep.”
  •  Katie's parents state that there were two instances where Katie fell asleep on the school bus on her way to school in the morning prompting the school nurse to call Katie’s parents

Decision Point Three

 

Maintain current dose of Intuniv

 

Guidance to Student

Intuniv is a nonstimulant medication used in the treatment of ADHD. It is generally used to treat the oppositional behaviors associated with ADHD. Although less sedating that clonidine, Intuniv can be quite sedating. Whereas the PMHNP can definitely improve symptoms by decreasing the dose, it is clear that after 4 weeks of therapy Katie is experiencing sedation with no real improvement in attention. However, decreasing the drug to 1 mg at bedtime and evaluating the effect may be considered. Clearly, the current dose of Intuniv cannot be maintained as it is having a negative impact on Katie’s academic performance and quality of life.A Young Caucasian Girl with ADHD Case Study Paper.

Although Strattera a second-line agent, the most appropriate course of action would be to discontinue Intuniv at this point and begin Strattera 10 mg orally daily, as this drug primarily targets attention span and concentration and is not associated with the same levels of sedation as Intuniv.

Decision Point One

 

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

RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance. However, by the afternoon, Katie is “staring off into space” and “daydreaming” again
  •  Katie’s parents are very concerned, however, because Katie reported that her “heart felt funny.A Young Caucasian Girl with ADHD Case Study Paper” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute

Decision Point Two

 

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

 

RESULTS OF DECISION POINT TWO

  •  Client returns to clinic in four weeks
  •  Katie’s academic performance is still improved, but her attention continues to worsen throughout the school day
  •  Katie is still reporting that her heart feels “funny.” Today’s pulse rate is 122 beats per minute, regular rhythm

Decision Point Three

 

Change to Ritalin LA 20 mg orally daily in the morning

 

Guidance to Student

Ritalin LA would be a good choice in this case as the side effect of tachycardia could be related to the immediate release Ritalin. There is no indication for a STAT EKG unless Katie’s pulse were irregular or there were other signs of cardiac abnormality noted. Discontinuation of immediate release Ritalin in favor of immediate release Adderall would be of questionable benefit, and may be associated with the same side effect. Additionally, immediate release preparations will not last throughout the school day to maintain Katie’s attention.A Young Caucasian Girl with ADHD Case Study Paper.

 

RESULTS OF DECISION POINT ONE

Begin Wellbutrin (bupropion) XL 150 mg orally daily

 

  • Client returns to clinic in four weeks
  • Katie’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 weeks

Decision Point Two

 

Educate the parents that Bupropion sometimes causes suicidal ideation in children and that this is normal, and re-start the drug at the previous dose

 

 

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie'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 medication
  • At this point, they are quite upset with the results of their daughter’s treatment and are convinced that medication is not the answer

Decision Point Three

 

R

Refer the parents to a pediatric psychologist who can use behavioral therapy to treat Katie’s ADHD

efer the parents to a pediatric psychologist who can use behavioral therapy to treat Katie’s ADHD

 

Guidance to Student

Bupropion 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.A Young Caucasian Girl with ADHD Case Study Paper. 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.

The PMHNP 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 the PMHNP to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.

Decision Tree Assignment

Here is a general framework for what I am looking for on the decision tree assignments.A Young Caucasian Girl with ADHD Case Study Paper.

Provide an introduction to the disease state discussed in the case. I am looking for a high-level summary that briefly describes the key aspects of that disease state. I do not want several pages of information related to the diagnosis of the disease state.

Provide a high-level summary of the important pieces of information from the case-study that is presented. I do not want the entire case study presented. The goal is that you would be able to give your essay to someone that does not know anything about the assignment and for that individual to be able to understand the purpose of your essay. Again….focus on the important pieces of information that will help you make your decision.

You also want to mention the purpose of the assignment. This can be brief.

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Decision Point 1, 2, and 3.

At each decision point, list the options that are presented and describe your rationale for choosing the option you chose.

do not want general answers….”I chose sertraline because sertraline is an SSRI and SSRIs are approved for depression/anxiety”. I want VERY SPECIFIC reasons you chose the option you chose. These reasons must be backed by good evidence. Feel free to include studies comparing agents, side effects, dosing, patient considerations, therapeutic practice guidelines, comorbid conditions, etc....  You will also need to explain your rationale for not choosing the other two options.  This is very important in your learning. Please remember that you will have MANY more medications to chose from than three in clinical practice. When you make your choice, you also need to describe your goals of treatment. What do you want to achieve by initiating the therapy you picked. Again….be specific. Defend your choices like you are in a courtroom.

After each decision, you will be presented with the outcome of that decision. You need to discuss how that outcome was what you expected or if it was different than what you expected and why.

You will do the above for all three decision points.

You need to use evidence to support your rationale. [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. Credible reference material only will be accepted. Sites such as WebMD and drugs.com (among others) will not be counted.A Young Caucasian Girl with ADHD Case Study Paper]

Don’t forget to include information related to the ethical considerations and how they might impact your treatment plan and communication with your clients.

In summary: What needs to be in your essay.

Introduction regarding disease state
High-level summary of patient case
Purpose of the essay statement

Decision 1
What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected? Why?

Decision 2
What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected? Why?

Decision 3
What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected?A Young Caucasian Girl with ADHD Case Study Paper. Why?

Conclusion with Ethical considerations

***Do not use the start over button and complete several different times. That is not the point. If you do use the START OVER button, I do not want your paper to reflect this. I have had students do it multiple times and address incorrect outcomes in their paper. I have also had students submit a paper that defends using all three options presented at decision point number one. You will need to click the option to move to the next screen which will provide you with the outcome and the options for the next decision point.  You will receive a ZERO on the assignment if you do not follow the instructions correctly. I had a handful of students last semester complete the assignment incorrectly.A Young Caucasian Girl with ADHD Case Study Paper.  Please ask questions if you do not understand.

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.A Young Caucasian Girl with ADHD Case Study Paper. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.

Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.

 

SUBJECTIVE

Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.A Young Caucasian Girl with ADHD Case Study Paper”

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.A Young Caucasian Girl with ADHD Case Study Paper. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

 

RESOURCES

  • Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Revision and restandardization of the Conners' Teacher Rating Scale (CTRS-R): Factors, structure, reliability, and criterion validity. Journal of Abnormal Child Psychology, 26, 279-291.

 

Decision Point One

Select what the PMHNP should do:

Begin Wellbutrin (bupropion) XL 150 mg orally daily

Begin Intuniv extended release 1 mg orally at BEDTIME

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

A Young Caucasian Girl with ADHD Case Study Paper