Case #1
A young girl with difficulties in school

A Young Girl With ADHD

 

Decision Point One


 315.0 Specific Learning Disorder with Impairment in Reading and 315.1 Impairment in Mathematics

RESULTS OF DECISION POINT ONE

Decision Point Two
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Begin Donepezil 10 mg po daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie’s parents feel that Katie is no different. She has had no changes in school performance, but has been having trouble falling asleep at night
  • Additionally, Katie has reported having “scary dreams” to her parents and has been feeling “stomach sick”
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Explain that the side effects will abate with time and increase to 15 mg orally daily.
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it Katie did meet the diagnostic criteria for this condition, donepezil is not FDA approved for treatment of this disorder, instead, is FDA approved for treatment of Alzheimer’s disease. Although used off-label in memory disorders in other conditions, there is nothing to suggest that it would be effective in consideration of Katie’s presenting symptoms. It is also noted that Katie is demonstrating side effects to this medication, and increasing the dose would not be appropriate.

Augmentation with Trazodone to address the side effects of this medication is not appropriate.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.


Augment with Trazodone 50 mg po at HS.
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it Katie did meet the diagnostic criteria for this condition, donepezil is not FDA approved for treatment of this disorder, instead, is FDA approved for treatment of Alzheimer’s disease. Although used off-label in memory disorders in other conditions, there is nothing to suggest that it would be effective in consideration of Katie’s presenting symptoms. It is also noted that Katie is demonstrating side effects to this medication, and increasing the dose would not be appropriate.

Augmentation with Trazodone to address the side effects of this medication is not appropriate.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.


Reconsider Diagnosis
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it Katie did meet the diagnostic criteria for this condition, donepezil is not FDA approved for treatment of this disorder, instead, is FDA approved for treatment of Alzheimer’s disease. Although used off-label in memory disorders in other conditions, there is nothing to suggest that it would be effective in consideration of Katie’s presenting symptoms. It is also noted that Katie is demonstrating side effects to this medication, and increasing the dose would not be appropriate.

Augmentation with Trazodone to address the side effects of this medication is not appropriate.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.


Begin Abilify 5 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie’s parents feel that Katie is no different, and in fact, believe that she is getting more fidgety and at times, agitated. Katie tells you that she feels sick to her stomach and has had headaches since starting the new medication
  • Katie’s parents further report that Katie’s teacher called to report that Katie has been more impulsive in class. For instance, she is now blurting out answers and will abruptly get up from her seat and begin walking around the room
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Increase Abilify to 10 mg po daily
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it were, Abilify is not an appropriate medication choice as it is not FDA approved for this condition.

Katie is demonstrating what appears to be “activation” as well as nausea, and headaches, which are usual side effects of Aripiprazole. Additionally, she is developing what appear to be impulse control problems, a more concerning side effect of Aripiprazole. Although a lower dose of Abilify may be associated with fewer symptoms of activation, decreasing the dose is not appropriate as Katie lacks sufficient indications for treatment with an atypical antipsychotic.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.


Decrease Abilify to 2 mg po daily
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it were, Abilify is not an appropriate medication choice as it is not FDA approved for this condition.

Katie is demonstrating what appears to be “activation” as well as nausea, and headaches, which are usual side effects of Aripiprazole. Additionally, she is developing what appear to be impulse control problems, a more concerning side effect of Aripiprazole. Although a lower dose of Abilify may be associated with fewer symptoms of activation, decreasing the dose is not appropriate as Katie lacks sufficient indications for treatment with an atypical antipsychotic.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.


Reconsider Diagnosis
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it were, Abilify is not an appropriate medication choice as it is not FDA approved for this condition.

Katie is demonstrating what appears to be “activation” as well as nausea, and headaches, which are usual side effects of Aripiprazole. Additionally, she is developing what appear to be impulse control problems, a more concerning side effect of Aripiprazole. Although a lower dose of Abilify may be associated with fewer symptoms of activation, decreasing the dose is not appropriate as Katie lacks sufficient indications for treatment with an atypical antipsychotic.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.


Begin Clonidine 0.1 mg po daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie’s parents report that Katie’s teacher has called several times to report that Katie has been falling asleep in her morning classes. They report that although she is more alert after lunch, she still appears “removed” from other students. During recess, Katie has been reported to just “sit” on the bench and interacts with none of her peers. The teacher further reports that she has noticed no changes in Katie’s academic performance
  • Katie’s parents also report that Katie has been having some problems with vomiting which has been improving only in the past week
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Increase Clonidine to 0.2 mg po at HS
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it were, clonidine would not be an appropriate medication choice as it is not FDA approved for this condition.

Katie is demonstrating fatigue which is a side effect of clonidine, similarly, vomiting is a side effect of the medication as well. While it may be prudent to give the drug at night to minimize daytime side effects, clonidine appears to be providing minimal help for Katie in terms of her presenting symptoms.

Rational Emotive Behavioral Therapy would be very inappropriate as nothing in the scenario tells us that Katie has difficulty with irrational beliefs.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.


Augment with Rational Emotive Behavior Therapy
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it were, clonidine would not be an appropriate medication choice as it is not FDA approved for this condition.

Katie is demonstrating fatigue which is a side effect of clonidine, similarly, vomiting is a side effect of the medication as well. While it may be prudent to give the drug at night to minimize daytime side effects, clonidine appears to be providing minimal help for Katie in terms of her presenting symptoms.

Rational Emotive Behavioral Therapy would be very inappropriate as nothing in the scenario tells us that Katie has difficulty with irrational beliefs.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.


Reconsider diagnosis
Guidance to Student

The information provided in the scenario is not suggestive of the diagnostic criteria for Specific Learning Disorder with Impairment in Reading and Mathematics. Even if it were, clonidine would not be an appropriate medication choice as it is not FDA approved for this condition.

Katie is demonstrating fatigue which is a side effect of clonidine, similarly, vomiting is a side effect of the medication as well. While it may be prudent to give the drug at night to minimize daytime side effects, clonidine appears to be providing minimal help for Katie in terms of her presenting symptoms.

Rational Emotive Behavioral Therapy would be very inappropriate as nothing in the scenario tells us that Katie has difficulty with irrational beliefs.

At this point, the most appropriate course of action would be for the PMHNP to reconsider the diagnosis.