Case Study An 8-Year-Old Caucasian Girl with ADHD

Sample Paper On Assessing And Treating Clients With ADHD

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is one of the most common mental disorders affecting children and many adults with an estimated 8.4 percent of children and 2.5 percent of adults with ADHD (American Psychiatric Association, 2018). ADHD symptoms, such as high activity levels, difficulty remaining still for long periods of time and limited attention spans, are common to young children and are first identified in school-aged children when it leads to disruption in the classroom or problems with schoolwork (APA, 2018).

As a provider, to diagnose ADHD, start by asking about a child’s health, behavior, and activity; talk with parents and kids about the things they have noticed, ask parents to complete checklists about their child’s behavior, and also ask parents to give the child’s teacher a checklist too (Hasan, 2017). 

After all information has been gathered, the provider may diagnose ADHD if the child’s distractibility, hyperactivity, or impulsivity go beyond what’s usual for their age, the behaviors have been going on since the child was young, distractibility, hyperactivity, and impulsivity affect the child at school and at home, and a health check shows that another health or learning issue isn’t causing the problems (Hasan, 2017).

The aim of ADHD treatment is to improve symptoms, optimize functional performance, and remove behavioral obstacles; therefore, therapy should start with medications in children six years and older including behavioral treatments which are particularly helpful if medication response is poor or associated with adverse effects (Felt, Biermann, Christner, Kochhar, & Van Harrison, 2014).

The case study for this assignment is on a eight year old Caucasian female who is brought to the office by her mother and father referred by their primary care provider to be evaluated by psychiatry to determine whether or not the client has ADHD after the teacher filled the “Conners Teacher Rating Scale-Revised” which the score shows client is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic.

The parents seem to be in denial of the client having ADHD. The purpose of this paper is to show how to assess and develop personalized therapy plans for children with ADHD based on the decision concerning the medication to prescribe to the client, the influence of pharmacokinetic and pharmacodynamic, and including ethical and legal implications related to prescribing therapy for children with ADHD.

Decision One

The first decision choice is to start the client on Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning. Methylphenidate is the most effective and safest short term drug treatment and should be the preferred first choice medicine for children with ADHD (Iacobucci, 2018). 

According to a study by Storebo et al. (2018), findings suggest that methylphenidate might improve some of the core symptoms of ADHD by reducing hyperactivity and impulsivity, and helping children to concentrate; therefore, might also help to improve the general behavior and quality of life of children with ADHD.

Ritalin works by Increasing norepinephrine and especially dopamine actions by blocking their reuptake and also by enhancing dopamine and norepinephrine actions in certain brain regions (Stahl, 2014b). Short-term adverse effects of Ritalin include headache, nausea, agitation, anxiety, wakefulness, irregular heartbeat, increased blood pressure, and, in rare cases, seizures (Auday, 2014). 

Wellbutrin (bupropion) XL 150 mg orally daily is not the best choice for this client. Wellbutrin is an antidepressant and is approved by Food and Drug Administration (FDA) for treating depression and use to help people stop smoking; therefore, it isn’t approved by the FDA to treat attention deficit hyperactivity disorder (ADHD); however, some providers prescribe Wellbutrin off-label to treat ADHD, so it isn’t recommended for children since its safety and effectiveness hasn’t been established (Cafasso, 2019). 

The other option Intuniv extended release 1 mg orally at bedtime is also not the best choice at this time for the client. Although Intuniv, an extended-release, non–central nervous system stimulant is approved for the treatment of ADHD in children six to 17 years of age; however, it can cause hypotension along with other side effects such as sedation, somnolence and fatigue (Bernknopf, 2011). At this point Ritalin remains the best choice.

I hope to achieve a decrease in reduction of symptoms of inattentiveness, hyperactivity, that disrupt social, school functioning. After four weeks, the client returned back to the clinic. Parents report that the client’s teacher noticed her symptoms are much better in the morning, which has resulted in improvement in her overall academic performance; however, by the afternoon, the client is “staring off into space” and “daydreaming” again. 

Her parents are concerned especially because the client reported that her “heart felt funny.” Her heart rate is beating at about 130 beats per minute which means the client is tachycardic.

Decision Two

My next decision is to change to Ritalin LA (long-acting) 20 mg orally daily in the morning. According to Medscape (2019), Ritalin LA is also a once-daily agent designed to mimic the effect of the 2 doses of immediate-release methylphenidate by releasing methylphenidate from beads: 50% immediate release peak in the morning and 50% delayed release in the afternoon, for a total of six to eight hours (Medscape, 2019). 

Therefore, its effectiveness will be maintained throughout the day which will also help prevent the client from being tachycardic while controlling ADHD symptoms. Continuing the same dose of Ritalin is not appropriate for this client as the effect of the medication is only seen in the morning and the client is experiencing an increase in heart rate which could lead to life threatening issues. 

Changing to Adderall XR 15 mg orally daily is also not the best choice at this time due to switching medications especially when the client is still adjusting to current medication and there’s a notable difference in behavior. Side effects of Adderall include dizziness, insomnia, headache, overstimulation, tremors, weight loss, stomach ache, dry mouth, and irritability (Stahl, 2013).

I am hoping that with change from immediate release to long acting, the client’s daydreaming and staring off into space will be eliminated, heart rate will be within normal limits while symptoms continue to be under control. The expectation with decision two is that the client will continue with the current treatment plan with no side effects and improvement in symptoms are stable. 

The client returned to the clinic after four weeks reporting academic performance has still improved, and the switch to the LA preparation is lasting throughout the school day. Client also reports of her heart feeling “funny” have gone away. Heart rate is 92 during the office visit.

Decision Tree

At this point, my next decision is to maintain the current dose of Ritalin LA and reevaluate in 4 weeks as the client is showing improvement with current treatment. Client’s academic performance at school has improved, she is able to concentrate through the day, and not experiencing any side effects from the medication. The option to increase Ritalin to 30 mg orally daily is not necessary because the client seems to be tolerating the current dose with no side effects which should be taken into consideration before increasing the dose.

Obtaining an ECG based on the current heart rate of 92 is unnecessary too at this time because the client’s heart rate is within the normal limits for her age. I am hoping that the client continues treatment until all symptoms are under control, stable, and as long as improvement persists.

Pharmacodynamics And Pharmacokinetic

According to Hui C, James, and Darrell (1999), Methylphenidate has 2 chiral centers, but the drug used in therapy consist only of the three pair of enantiomers. d-threo-Methylphenidate is more potent than the l-enantiomer. Methylphenidate is administered as a racemic mixture which undergoes stereoselective clearance. It is a short-acting stimulant with a duration of action of 1 to 4 hours and a pharmacokinetic half-life of 2 to 3 hours.

Maximum drug concentration after oral administration occurs at about 2 hours and is absorbed well from the gastrointestinal tract and easily passes to the brain.

Methylphenidate is efficacious for short term treatment for children with ADHD although its mechanism of action is not understood, but may be associated with its influence on multiple neurotransmitters, especially the release and reuptake of dopamine in the striatum (Hui C et al., 1999).

Ethical Considerations With Conclusion Case Study An 8-Year-Old Caucasian Girl With ADHD

The first principle described in the code of ethics published by the American Academy of Child and Adolescent Psychiatry calls upon physicians to maintain a “developmental perspective” when caring for children (Kepple & Madaan, 2012).

As a practitioner, it is imperative that there be effective communication when planning treatment with the client and her parents. An ethical practitioner should be able to engage in a trusting, respectful, appropriate, and balanced informed consent with the patient. It is also imperative that a practitioner keep up-to-date with empirical findings on all psychiatric treatments, including their indications, adverse effects, and contraindications.

References