Assessing and Treating Clients With ADHD

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. 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.”

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. 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

 

Decision Point One

Begin Wellbutrin (bupropion) XL 150 mg orally daily

RESULTS OF DECISION POINT ONE

·  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

· Select what the PMHNP should do next:

·

· 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

·

· Discontinue Wellbutrin and begin Strattera (atomoxetine) 10 mg orally daily

·

· Discontinue Wellbutrin and begin Adderall (amphetamine d, l) extended release 5 mg orally daily

Attention Deficit Hyperactivity Disorder A Young Girl With ADHD

 

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

· Select what the PMHNP should do next:

·

· Increase Intuniv to 2 mg orally at BEDTIME

·

· Discontinue Intuniv and begin Dexedrine (dextroamphetamine) 5 mg orally daily

·

· Discontinue Intuniv and begin Focalin (dexmethylphenidate) XR 10 mg orally daily

A Young Girl With ADHD

 

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.” You obtain a pulse rate and find that Katie’s heart is beating about 130 beats per minute