NURS 6521 Attention Deficit Hyperactivity Disorder

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NURS 6521 Attention Deficit Hyperactivity Disorder

NURS 6521 Attention Deficit Hyperactivity Disorder
Attentiondeficit hyperactivity disorder (ADHD) is one of the most prevalent neuropsychiatric disorders of childhood and adolescence and is associated with significant impairment in academic, social, and occupational functioning (Ng, 2017). “Neuroimaging studies indicate structural and functional abnormalities in multiple brain areas, including the frontal cortez, basal ganglia, brainstem, and cerebellum- regoins involved with regulating attention , impulsivity, and motor activity” (Rosenthal & Burchum, 2021, p. 250-251).
Case Scenario
My selected scenario describes an eight year old girl (Katie), who was referred to psychiatry by her primary care provider to be evaluated for ADHD. Background information consists of a completed Conner’s Teacher Rating Scale-Revised along with the teacher’s report. Katie exhibited inattention, forgetfulness, was easily distracted, had poor follow through, and struggled in spelling and math. The diagnosis is confirmed as attention deficit hyperactivity disorder-predominantly inattentive type.
First medication to be prescribed would be Ritalin 10mg chewable tablet every morning. Stimulants are the first line choice for treatment of ADHD (Rosenthal & Burchum, 2021). Intuniv would not be my choice for the patient as it is a nonstimulant medication. On the same lines, Wellbutrin XR is not considered a stimulant and has not been well studied in its safety and efficacy in children (Ng, 2017). Nonstimulants are less affective that stimulants and are considered second –choice drugs (Rosenthal & Burchum, 2021). The search for nonstimulant alternatives for the management of ADHD in children is ongoing. As many as 20% of patients do not respond to stimulants, and stimulants may also worsen comorbid sleep, mood, and anxiety disorders and lead to problems of misuse and diversion (Ng, 2017).

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NURS 6521 Attention Deficit Hyperactivity Disorder

NURS 6521 Attention Deficit Hyperactivity Disorder

At the four week follow up visit, the teacher reports seeing improvement in her behavior and performance during the morning hours but little improvement through the afternoon. Katie also reports a “funny feeling in her chest” with a heart rate in the 130’s. Stimulants will produce a small increase in heart rate and blood pressure at recommended doses. In the absence of cardiovascular disease, this increase in heart rate and blood pressure lacks clinical significance (Rosenthal & Burchum, 2021). A provider at this point could do additional testing to rule out any heart defects or heart disease. Additionally, obtaining an EKG could be done to confirm rhythm and rate.
My choice would be to continue with the Ritalin in an extended release form. I would then change the medication to Ritalin LA 20mg to be taken in the morning. Taking a long acting form of the medication will enable Katie to have positive effects for a longer duration which will sustain her focus and academic success throughout the school day.
The four week follow up with the Ritalin LA shows the medication is helping Katie throughout her school day and heart rate is within normal limits. I would maintain this current dosing of medication as it seems to be effective with no reported negative side effects at this time.
Other Considerations
As a provider, I would want documentation of testing done to rule of a learning disorder as some of Katie’s symptoms could also be attributed to this. Identifying a learning disorder in the presence of ADHD could change the course of treatment. Attention deficit hyperactivity disorder–predominantly inattentive presentation and specific learning disorder (SLD) are commonly co-occurring conditions (Friedman et al., 2019). Children with ADHD and SLD are poorer responders to psychostimulant medications than those with ADHD alone (Friedman et al., 2019).
There also needs to be additional education for Katie’s parents, explaining the diagnosis of ADHD and the differences between the sub classifications; the predominately hyperactive-impulsive type, predominately inattentive type, or combined type. The parents currently deny the idea of ADHD because they do not have an accurate understanding of an ADHD diagnosis and that it can exist without the presence of hyperactivity.

References
Friedman, L. M., McBurnett, K., Dvorsky, M. R., Hinshaw, S. P., & Pfiffner, L. J. (2019). Learning disorder confers setting-specific treatment resistance for children with ADHD, predominantly inattentive presentation. Journal of Clinical Child & Adolescent Psychology, 49(6), 854-867. https://doi.org/10.1080/15374416.2019.1644647
Ng, Q. X. (2017). A systematic review of the use of Bupropion for attention-deficit/Hyperactivity disorder in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 27(2), 112-116. https://doi.org/10.1089/cap.2016.0124
Rosenthal, L., & Burchum, J. (2021). Lehne’s Pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier Health Sciences.

 

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