Case #1
A young girl with difficulties in school

A Young Girl With ADHD

 

Decision Point One


 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation

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 Wellbutrin 75 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie’s parent report that the teacher has indicated that Katie seems to be paying more attention during class. They have also noticed that Katie is able to attend more closely to her homework. However, her parents are somewhat concerned that Katie has been asking them “odd” questions such as “where do you go when you die?” and “when you die, do you get to see your pets that have died?” Her parents indicated that she had never had such questions before.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Assure the parents that the questions Katie are asking are age-appropriate and increase dose of Wellbutrin to 150 mg daily
Guidance to Student

While the mechanism of action of Wellbutrin can certainly improve ADHD symptoms (as in the case of Katie), antidepressants can also result in suicidal ideation in a child. Katie developed what appeared to be morbid thoughts, possibly suggesting a fascination with death. While there is insufficient information to suggest that she was entertaining suicidal ideation, her parents clearly indicated that she was not having these thoughts before the antidepressant therapy was initiated, which should be a source of concern for the PMHNP.

While some forms of psychotherapy are effective in improving ADHD symptoms, psychodynamic therapy has not been the subject of clinical trials, and as such, would not be a therapy of choice in children with ADHD.

In consideration of the other two choices, changing to Concerta may be the best choice.


Implement psychodynamic therapy
Guidance to Student

While the mechanism of action of Wellbutrin can certainly improve ADHD symptoms (as in the case of Katie), antidepressants can also result in suicidal ideation in a child. Katie developed what appeared to be morbid thoughts, possibly suggesting a fascination with death. While there is insufficient information to suggest that she was entertaining suicidal ideation, her parents clearly indicated that she was not having these thoughts before the antidepressant therapy was initiated, which should be a source of concern for the PMHNP.

While some forms of psychotherapy are effective in improving ADHD symptoms, psychodynamic therapy has not been the subject of clinical trials, and as such, would not be a therapy of choice in children with ADHD.

In consideration of the other two choices, changing to Concerta may be the best choice.


Change drug to Concerta 18 mg orally daily in the morning
Guidance to Student

While the mechanism of action of Wellbutrin can certainly improve ADHD symptoms (as in the case of Katie), antidepressants can also result in suicidal ideation in a child. Katie developed what appeared to be morbid thoughts, possibly suggesting a fascination with death. While there is insufficient information to suggest that she was entertaining suicidal ideation, her parents clearly indicated that she was not having these thoughts before the antidepressant therapy was initiated, which should be a source of concern for the PMHNP.

While some forms of psychotherapy are effective in improving ADHD symptoms, psychodynamic therapy has not been the subject of clinical trials, and as such, would not be a therapy of choice in children with ADHD.

In consideration of the other two choices, changing to Concerta may be the best choice.


Begin Strattera 25 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie’s parents seem absolutely delighted upon their return stating that Katie is paying more attention in school, but note that there is still room for improvement
  • They are somewhat concerned however about some sedation that she experiences following the medication. They report that Katie has been becoming more uncooperative with medications as she feels ‘sleepy’ after taking them
  • Her parents are also concerned about her decrease in appetite since starting the medication
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Assure parents that decreased appetite is a normal side effect of Strattera, and increase the dose to 25 mg orally in the morning
Guidance to Student

In response to the first choice, although decreased appetite is a side effect of Strattera, it does not address the parents’ concerns about Katie’s sedation, which can occur with Strattera use. It may help with residual inattention symptoms, however, if the medication is creating such negative side effects, compliance may become an issue.

CBT has some evidence of efficacy in treating ADHD symptoms, however, augmenting the medication is not going to effectively address the concerns that Katie’s parents have raised regarding side effects.

Discontinuing Strattera and beginning Adderall XR would be the most appropriate strategy in this case as changing agents may alleviate the unfavorable side effects, and may treat symptoms more effectively.


Augment treatment with CBT
Guidance to Student

In response to the first choice, although decreased appetite is a side effect of Strattera, it does not address the parents’ concerns about Katie’s sedation, which can occur with Strattera use. It may help with residual inattention symptoms, however, if the medication is creating such negative side effects, compliance may become an issue.

CBT has some evidence of efficacy in treating ADHD symptoms, however, augmenting the medication is not going to effectively address the concerns that Katie’s parents have raised regarding side effects.

Discontinuing Strattera and beginning Adderall XR would be the most appropriate strategy in this case as changing agents may alleviate the unfavorable side effects, and may treat symptoms more effectively.


Discontinue Strattera and begin Adderall XR 10 mg orally daily
Guidance to Student

In response to the first choice, although decreased appetite is a side effect of Strattera, it does not address the parents’ concerns about Katie’s sedation, which can occur with Strattera use. It may help with residual inattention symptoms, however, if the medication is creating such negative side effects, compliance may become an issue.

CBT has some evidence of efficacy in treating ADHD symptoms, however, augmenting the medication is not going to effectively address the concerns that Katie’s parents have raised regarding side effects.

Discontinuing Strattera and beginning Adderall XR would be the most appropriate strategy in this case as changing agents may alleviate the unfavorable side effects, and may treat symptoms more effectively.


Begin Adderall XR 10 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie’s parents seem absolutely delighted upon their return stating that Katie is paying more attention in school, but note that there is still room for improvement, particularly in the afternoon
  • They report that Katie’s teacher has reported that Katie is able to maintain her attention throughout the morning classes but come afternoon, she “daydreams.”
  • Katie’s parents are also concerned about her decrease in appetite since starting the medication
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Assure Katie’s parents that weight loss is common with stimulant medications used to treat ADHD
Guidance to Student

Whereas weight loss is common with stimulant medication, this option does not address Katie’s parents’ concerns about the return of symptoms in the afternoon.

Augmentation with family therapy is also a good idea as it can help Katie with her symptoms and further help her parents to understand the unique challenges that Katie experiences, as well as ways that they can help her with symptoms, however, this option does not address the return of inattentive symptoms in the afternoon.

Adding a small dose of immediate relate Adderall in the afternoon can help Katie to maintain attention throughout the afternoon and into the early evening when she must do homework. This would be the best option.


Augment medication with family thearpy
Guidance to Student

Whereas weight loss is common with stimulant medication, this option does not address Katie’s parents’ concerns about the return of symptoms in the afternoon.

Augmentation with family therapy is also a good idea as it can help Katie with her symptoms and further help her parents to understand the unique challenges that Katie experiences, as well as ways that they can help her with symptoms, however, this option does not address the return of inattentive symptoms in the afternoon.

Adding a small dose of immediate relate Adderall in the afternoon can help Katie to maintain attention throughout the afternoon and into the early evening when she must do homework. This would be the best option.


Add a small dose of immediate release Adderall in the early afternoon
Guidance to Student

Whereas weight loss is common with stimulant medication, this option does not address Katie’s parents’ concerns about the return of symptoms in the afternoon.

Augmentation with family therapy is also a good idea as it can help Katie with her symptoms and further help her parents to understand the unique challenges that Katie experiences, as well as ways that they can help her with symptoms, however, this option does not address the return of inattentive symptoms in the afternoon.

Adding a small dose of immediate relate Adderall in the afternoon can help Katie to maintain attention throughout the afternoon and into the early evening when she must do homework. This would be the best option.