Practicum: Decision Tree 1
Practicum: Week 3 Decision Tree
Students name:
Walden University
NURS-6660N-6
Instructor:
Date
Practicum: Decision Tree 2
According to the American Academy of Pediatrics [AAP] (2019),
attention-deficit/hyperactivity disorder (ADHD) is one of the most common neurodevelopmental
disorders. ADHD profoundly affects children’s academic achievement, well-being, and social
interactions. In a survey conducted by AAP in 2016, 9.4 percent of children in the United States
aged two years to seventeen years were noted to have had an ADHD diagnosis, including 2.4
percent of children aged two years to five years (AAP, 2019, p. 2). The American Psychiatric
Association’s [APA] (2013) Diagnostic and statistical manual of mental disorders [5th ed.]
(DSM-5) notes that for an individual to be diagnosed with ADHD, they must meet a certain
diagnostic criterion, and the symptoms must be present by age 12 years. For adolescents aged 17
years and older, and for adults to be diagnosed with ADHD, they must present with five or more
symptoms of either inattention or hyperactivity and impulsivity. For those younger than 17 years
to be diagnosed with ADHD, they must present with at least 6 of the symptoms listed for ADHD
in the DSM-5. The symptoms must be a persistent pattern of inattention and/or hyperactivity that
interferes with developmentally appropriate functioning for at least 6 months. The symptoms
must be noted to present in at least two settings such as at home, and at school. The purpose of
this paper is to examine the case 1 scenario as presented by Laureate Education (2017b) and
make three decisions on the diagnosis and treatment of the client in the scenario (Katie). This
paper will also address how ethical considerations might impact communication and treatment of
clients and their families (APA, 2013, AAP, 2019, Laureate Education, 2017b, Sadock, Sadock
& Ruiz, 2014).
Decision Point One
Based on the information provided by Laureate Education [Producer] (2017b) on Katie, I
decided that the appropriate diagnosis for her is 314.00 Attention-Deficit/Hyperactivity Disorder,
Practicum: Decision Tree 3
predominantly inattentive presentation. This decision is based on Conner’s Teacher Rating
Scale-Revised (CTRS) that the parents presented as filled by Katie’s teacher. The CTRS listed
that Katie is inattentive, easily distracted, makes careless mistakes in her homework, forgets
things she already learned, is poor in spelling, reading, and arithmetic, has a short attention span,
only pays attention to things that attract her, and has difficulty socializing with her peers. The
symptoms as noted in Katie’s CTRS report are more than the minimum of six symptoms
required to meet the criteria for 314.00 Attention-Deficit/Hyperactivity Disorder, predominantly
inattentive presentation (APA, 2013, AAP, 2019, Conners et al., 1998, Laureate Education,
2017b, Sadock, Sadock & Ruiz, 2014).
I decided against the diagnosis of 299.00 Autisms Spectrum Disorder (ASD), mild and
co-occurring; 300.23 Social Anxiety Disorder because Katie’s symptoms do not include some of
the key symptoms of ASD as noted in the DSM-5. According to the DSM-5, symptoms for ASD
include deficits in social-emotional reciprocity, deficits in nonverbal communicative behaviors
used for social interaction, and deficits in developing, maintaining, and understanding
relationships. Although Katie was noted to be poor in spelling, reading and arithmetic, I decided
against the diagnosis of 315.0 Specific Learning Disorder (SLD) with Impairment in Reading
and 315.1 Impairment in Mathematics because Katie did not present with key symptoms of SLD
as noted in the DSM-5 such as inaccurate or slow and effortful word reading, difficulty
understanding the meaning of words, or difficulties with mastering number sense, number facts
or calculations (APA, 2013, AAP, 2019, Conners et al., 1998, Laureate Education, 2017b,
Sadock, Sadock & Ruiz, 2014).
Decision Point Two
Practicum: Decision Tree 4
Based on the information provided in Katie’s scenario and my decision above of
diagnosing her with ADHD, predominantly inattentive presentation, my decision point two is to
start her on Adderall XR 10 mg orally daily. The decision to start her on Adderall XR 10 mg is
based on AAP’s guidelines on treatment of ADHD in children aged between 6 years and 12
years of age. The AAP guidelines for treatment note that there is sufficient evidence from
research that stimulants should be considered as first-line treatment of ADHD in children. Stahl
(2013) and Sadock, Sadock & Ruiz note that Adderall XR is approved for treatment of ADHD
by the Food and Drug Administration agency (FDA). There is also strong evidence that
stimulants should be used as first-line treatment options based on their great efficacy in treatment
of ADHD. Stahl and Sadock, Sadock & Ruiz also note that stimulants have generally mild and
tolerable side effects. However, stimulants are contraindicated in children, adolescents, and
adults with known cardiac risks and abnormalities (APA, 2013, AAP, 2019, Laureate Education,
2017b, Sadock, Sadock & Ruiz, 2014, Stahl, 2013, Stahl, 2014b).
Although Strattera is FDA approved for treating ADHD, I decided against starting Katie
on Strattera 25 mg orally daily because Strattera is not recommended by AAP guidelines or any
other evidence-based research that I saw as a first-line treatment option for ADHD in children.
Although Wellbutrin may be used as an option for treating ADHD, Stahl notes that it is not
approved by FDA for treatment of ADHD in children. Wellbutrin is also not listed among the
first-line treatment options for ADHD by any research article or text books that I read (APA,
2013, AAP, 2019, Laureate Education, 2017b, Sadock, Sadock & Ruiz, 2014, Stahl, 2013, Stahl,
2014b).
The expectations and goal of treatment with Adderall XR 10 mg orally daily for Katie
was complete reduction of ADHD symptoms after initiation of treatment, and no side effects.
Practicum: Decision Tree 5
When she returned to the clinic after 4 weeks, her parents were absolutely excited with her
progress. Although her focus was improved, and she was paying more attention in school, her
symptoms were reappearing in the afternoon, and her parents were also concerned about her
decrease in appetite since starting treatment. Return of symptoms in the afternoon can be
explained by Stahl’s note that Adderall XR has up to 8-hour duration of clinical action. Katie’s
parents’ concerns of her decreased appetite can be explained as a side effect of Adderall XR
(AAP, 2019, Laureate Education, 2017b, Sadock, Sadock & Ruiz, 2014, Stahl, 2013, Stahl,
2014b).
Decision Point Three
My decision point three is based on Katie’s presentation during this visit. It is also based
on Katie’s parents’ delightfulness with her improvement of her ADHD symptoms. Besides
deciding to continue Katie’s Adderall XR 10 mg orally daily, I decided to add a small dose of
immediate release Adderall in the early afternoon. The rationale for adding a small dose of
immediate release Adderall in the early afternoon is based on Stahl’s note that immediate release
Adderall has a 3-6-hour duration of clinical action. If administered to Katie in the early
afternoons, a small dose of immediate release Adderall could help Katie in maintaining attention
throughout the afternoon and into the early evening when she must do her homework. This
would also address Katie’s parents and teacher’s concerns of Katie’s ADHD symptoms coming
back in the afternoon (AAP, 2019, Laureate Education, 2017b, Sadock, Sadock & Ruiz, 2014,
Stahl, 2013, Stahl, 2014b).
Although augmenting medication with family therapy is an option that I considered as an
appropriate addition to her treatment with medications, I decided against using it as on only
option because it would not address Katie’s parent’s and teacher’s concerns of Katie’s ADHD
Practicum: Decision Tree 6
symptoms coming back in the afternoon. Although weight loss is common with stimulant
medications, I decided against assuring Katie’s parents that weight loss is common with
stimulant medications used to treat ADHD as an only option as it would not address their
concerns of Katie’s ADHD symptoms coming back in the afternoon (AAP, 2019, Laureate
Education, 2017b, Sadock, Sadock & Ruiz, 2014, Stahl, 2013, Stahl, 2014b).
Ethical Considerations
The American Nurses Association’s [ANA] (2001) code of ethics for nurse’s provision #
2.1 which notes that it is the responsibility of the treating psychiatric mental health nurse
practitioner (PMHNP) to understand that he/she has a primary commitment and an ethical
requirement to treat his/her clients whether individuals or families. Treating Katie who is a minor
would require the parent’s participation in her care. While treating Katie, it would therefore be
important for the PMHNP to have an ethical consideration to involve Katie’s parents in all
aspects of her care especially relating to educating the parents on administration of medications.
The treating PMHNP would also have an ethical responsibility to educate Katie and her parents
about any side effects that could arise from use of medications (ANA, 2001, Laureate Education,
2017b).
Practicum: Decision Tree 7
References
American Academy of Pediatrics [AAP]. (2019). Clinical Practice Guideline for the Diagnosis,
Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and
Adolescents. Pediatrics. Official Journal of the American Academy of Pediatrics.
Retrieved from
https://pediatrics.aappublications.org/content/pediatrics/144/4/e20192528.full.pdf
American Academy of Child & Adolescent Psychiatry [AACAP]. (2012a). Practice parameter
for psychodynamic psychotherapy with children. Journal of the American Academy of
Child & Adolescent Psychiatry, 51(5), 541-557.
American Nurses Association [ANA]. (2001). Code of Ethics for Nurses with Interpretive
Statements. Silver Spring. MD. Nursesbooks.org.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington
Chung, J., Tchaconas, A., Meryash, D., & Adesman, A. (2016). Treatment of
attention-Deficit/Hyperactivity disorder in preschool-age children: Child and adolescent
psychiatrists' adherence to clinical practice guidelines.#Journal of Child and Adolescent
Psychopharmacology,#26(4), 335-343.
doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1089/cap.2015.0108
Practicum: Decision Tree 8
Conners, C. K., Sitarenios, G., Parker, J. D. A., & Epstein, J. N. (1998). Conners’ Teacher Rating
Scales--Revised. Journal of Abnormal Child Psychology, 26, 279–291. Retrieved from
https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?
direct=true&db=hpi&AN=HaPI-163279&site=eds-live&scope=site
Heldt, J. (2017). Memorable Psychopharmacology. Test Review for medicine, Nursing, and
Psychology. Columbia, SC:
Huang, Y., & Tsai, M. (2011). Long-term outcomes with medications for attention-deficit
hyperactivity disorder.#CNS Drugs,#25(7), 539-54.
doi:http://dx.doi.org.ezp.waldenulibrary.org/10.2165/11589380-000000000-00000
Laureate Education (Producer). (2017b). A young girl with difficulties in school [Multimedia
file]. Baltimore, MD: Author.
National Institute for Children’s Health Quality [NICHQ]. (n.d.). Vanderbilt Assessment Scales
Used for diagnosing ADHD. Retrieved from
https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_S
cales.pdf
Prescribers’ Digital Reference. (2019). Methylphenidate hydrochloride – Drug Summary.
Retrieved from: https://www.pdr.net/drug-summary/Ritalin-LA-methylphenidate-
hydrochloride-1003
Sadock, B. J., Sadock V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical
applications (4th ed.). New York, NY: Cambridge University Press.
Practicum: Decision Tree 9
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University
Press.
