Girl with ADHD

Girl with ADHD

Introduction to the Case

The case is of an 8-year-old Caucasian female presenting at the office accompanied by the father and the mother, who report that they have been referred to seek advice after the patient’s teacher suggested she might have ADHD. Per their primary care provider, the patient should be examined by a mental health practitioner to ascertain the condition. The parents shared the teacher-filled Conner’s Teacher Rating Scale-Revised, which indicated that the patient is inattentive, easily distracted, forgetful, and poor in reading, spelling, and arithmetic. She has a short attention span unless it is something she is interested in. The patient has no interest in school work and is easily distracted, never finishing what she started or following instructions. The patient does not complete her schoolwork. The parents do not believe the patient has ADHD because she is not “running around like a wild person, defiant, or have temper outbursts.”

(Girl with ADHD)

The assessment data indicates the patient does not see the issue as a big deal as she is “OK” in school and prefers art and recess. The patient perceives other subjects as boring or hard and feels lost sometimes. She admits to her mind wandering during class to things she enjoys and would sometimes think about nothing, and when the teacher calls her name, she would not remember what they were talking about. She perceives her life as just fine, loves her parents because they are good and kind to her, denies any abuse or bullying at school, and has no other current concern. The mental status exam indicates that the patient is well-developed for her age, and speech is clear, coherent, logical, and appropriately oriented to person, place, time, and event. Her dressing is appropriate for the weather and time of year, and her mannerism, gestures, and tics are noteworthy. She indicates a euthymic mood, bright affect, and no visual or auditory hallucinations, delusions, or paranoia. Her attention and concentration are grossly intact, insight and judgement appropriate, and has no suicidal or homicidal ideation.

Decision #1

Ritalin is the initial treatment for the patient’s ADHD for this patient. Ritalin led to the patient’s improved academic performance, although her attention declined as the day progressed. Per the guidance, the discontinuation of the drug would have the same side effects, and the side effects would wear off with time. Research shows that Ritalin has favorable effects on ADHD symptoms, especially in reducing hyperactivity and impulsivity (Verghese & Abdijadid, 2022). The drug is FDA-approved, and the prescription is appropriate for children 6 years and older.

The other two drug options were Adderall and Intuniv. Adderall was rejected because it has similar side effects as Ritalin, and shifting to it would not change the current state. Ritalin also reaches peak levels quicker than Adderall. Additionally, Adderall leads to loss of appetite, stomach upset, headache, fever, diarrhea, and nervousness (Brown et al., 2018). Intuniv has significant side effects like sedation, which is not favorable for a school-going child because it would be challenging to maintain concentration and attention throughout the day (Harricharan & Adcock, 2018). Intuniv also causes low blood pressure, dry mouth, irritability, constipation, and decreased appetite.

(Girl with ADHD)

Administering Ritalin aimed at addressing the negative symptoms of ADHD, particularly hyperactivity and impulsivity. Ritalin has been indicated effectiveness in treating ADHD and has favorable effects on the symptoms (Verghese & Abdijadid, 2022). Improving the symptoms would help the patient perform better at school. On ethical considerations, working with a minor raises ethical concerns regarding autonomy, beneficence, and informed consent. Any treatment option should follow the parents’ preferences and consent. Minors cannot make autonomous decisions, hence the need to involve the parent throughout the treatment process. Additionally, the PMHNP should evaluate the drug selected and its potential effects on the patient, ensuring beneficence.

Decision #2

Wellbutrin is the second-choice treatment in this case. Results indicate a slight improvement in symptoms, although the patient reports decreased appetite, which is worsening. Research also shows that Wellbutrin can improve ADHD and decrease symptoms associated with the illness (Verbeeck et al., 2019). It is an appropriate non-stimulant drug for patients that cannot or will not take stimulant drugs because not all people are responsive to stimulants, and some cannot tolerate them.

The other two options not selected initially are Intuniv and Strattera. Sedation is one of the serious side effects of Intuniv, which is not favorable for a student since it would be difficult for them to focus and pay attention all day (Harricharan & Adcock, 2018). Low blood pressure, dry mouth, irritability, constipation, and decreased appetite are additional side effects of Intuniv (Harricharan & Adcock, 2018). Strattera is a good alternative to Wellbutrin, associated with significant side effects in children, particularly suicidal ideation (Fedder et al., 2022). However, Strattera can also lead to decreased appetite, headache, constipation, nausea, feeling sleepy and weak, and heart attack in severe cases.

(Girl with ADHD)

Administering Wellbutrin aimed at decreasing ADHD side effects. Wellbutrin has indicated effectiveness in treating ADHD, working as an antidepressant and non-competitive antagonist of nicotinic acetylcholine receptors (Verbeeck et al., 2019). It is anticipated that the patient’s ADHD would improve after taking Wellbutrin. Ethically, the provider must consider the side effects of administering Wellbutrin, particularly suicidal ideation, which presents potential harm to the patient. The provider must involve parents in critical decision-making and develop a drug therapy of preference per the patient’s response to the current drug therapy. The PMHNP must also disclose to the parents any additional risks associated with taking Wellbutrin.

Decision #3

The last treatment option is Intuniv, a non-stimulant treatment of ADHD, targeting oppositional behaviors. Intuniv can help improve focus and attention, controlling behavior, and manage hyperactivity and overactivity. Research shows significant improvement in subjective ADHD rating scales and scales in executive function for children and adolescents using Intuniv (Harricharan & Adcock, 2018). It is also appropriate for children with ADHD who are not adequately controlled with methylphenidate.

The other two options rejected were clonidine and Wellbutrin. Clonidine is more sedating than Intuniv, hence would not improve the current state. It can also lead to the patient developing depression, sleeping difficulties, constipation, and feeling weak, tired, and sleepy (Yasaei & Saadabadi, 2022). Wellbutrin is a good alternative but has considerable side effects and is associated with a high treatment discontinuation due to increased risk to the patient as it leads to suicidal ideation (Huecker et al., 2022). It can also cause rhinitis, tachycardia, weight loss, dizziness, and tremors.

(Girl with ADHD)

Prescribing Intuniv is aimed at improving ADHD symptoms, especially focus, attention, controlling behavior, and managing hyperactivity and overactivity. The prescription also aimed to avoid side effects associated with stimulant drugs when treating ADHD in children. Intuniv indicates effectiveness in relieving ADHD symptoms; hence recommended as the third option (Harricharan & Adcock, 2018). It is ethical practice to consider drug-drug interaction when prescribing Intuniv to ensure no harm due to complications. The PMHNP should also disclose the drug’s risks and benefits to the parent and elaborate on effective monitoring areas to report during follow-up. Any treatment decision should follow the parents’ consent and preferences, given the patient is a minor.

Conclusion

The initial purpose of recommending each drug is to improve SDHD symptoms, help the patient be more focused and attentive in school and bolster memory and behaviors such as completing school work and any activity she started. The patient’s ADHD is initially being treated with Ritalin. The patient’s academic performance increased as a result of taking Ritalin, but her attention started to wane as the day went on. According to the instructions, stopping the medicine would have the same negative effects, but they would eventually go away. Ritalin has been shown to improve ADHD symptoms, particularly by lowering impulsivity and hyperactivity (Verghese & Abdijadid, 2022). The prescription is authorized for children aged 6 and older, and the medication is FDA-approved.

The second-choice treatment in this instance is Wellbutrin. Results show a little improvement in symptoms; however, the patient is reporting a worsening loss in appetite. According to research, Wellbutrin can treat ADHD symptoms and improve the condition overall (Verbeeck et al., 2019). Because not everyone responds to stimulants and some individuals cannot tolerate them, it is a suitable non-stimulant medication for patients who cannot or will not take stimulant medications. Intuniv, a non-stimulant medication for ADHD that focuses on oppositional behaviors, is the final option for treatment. The use of Intuniv can help regulate hyperactivity and overactivity as well as increase focus and attention. According to research (Harricharan & Adcock, 2018), Intuniv significantly improves executive function and subjective ADHD rating scales for kids and teenagers. It is also suitable for kids with ADHD whose symptoms are not sufficiently managed by methylphenidate.

References

Brown, K. A., Samuel, S., & Patel, D. R. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Translational pediatrics, 7(1), 36–47. https://doi.org/10.21037/tp.2017.08.02

Fedder, D., Patel, H., & Saadabadi, A. (2022). Atomoxetine. In StatPearls [Internet]. StatPearls Publishing.

Harricharan, S., & Adcock, L. (2018). Guanfacine hydrochloride extended-release for attention deficit hyperactivity disorder: a review of clinical effectiveness, cost-effectiveness, and guidelines.

Huecker, M.R., Smiley, A., Saadabadi, A. (2022). Bupropion. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470212/

Verbeeck, W., Bekkering, G. E., Van den Noortgate, W., & Kramers, C. (2019). Bupropion for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane database of systematic reviews, 10(10), CD009504. https://doi.org/10.1002/14651858.CD009504.pub2

Verghese, C., & Abdijadid, S. (2022). Methylphenidate. In StatPearls [Internet]. StatPearls Publishing.

Yasaei, R., & Saadabadi, A. (2022). Clonidine. In StatPearls [Internet]. StatPearls Publishing.

 

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