Attention Deficit Hyperactivity Disorder

Review this week\’s Learning Resources and reflect on the insights they provide.
• Go to the Stahl Online website and examine the case study you were assigned Attention Deficit Hyperactivity Disorder .
• Take the pretest for the case study.
• Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.
• Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).
• Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.
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• Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.
• Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.
• Review the posttest for the case study.
QUESTION
Post a response to the following:
• Provide the case number in the subject line of the Discussion AS SHOWN BELOW
Case 2: Volume 1, Case #14: The scatter-brained mother whose daughter has ADHD, like mother, like daughter
SEE ATTACHED ABOVE CASE 2

• List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s ADHD therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other Attention Deficit Hyperactivity Disorder .
• If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.
Attention deficit hyperactivity disorder (ADHD) is a chronic neuro-developmental mental disorder characterized by inattentive, hyperactivity /impulsive behaviors or a combination of both (American Psychiatric Association, 2013). It’s a genetic disorder that tends to run in families. ADHD is associated with co morbid disorders such as; generalized anxiety disorder, mood disorders, a learning disorders, oppositional defiant disorder and autism (Treuer, Gau, Mendez, et al., 2013). Also, it adversely affects the academic, occupational, and social life of an individual. Comprehensive evaluation of the patient is important in accurately diagnosing ADHD. Pharmacotherapy and psychosocial therapy through educational remediation and cognitive-behavior therapy have proved effective in the management of ADHD. The case presentation is a 26-year-old woman in case number 2, volume 1, case 14 of the scatter-brained mother whose daughter has ADHD, like mother, like daughter.

List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions
How often do you find it difficult to finish up final details of an activity or project once u have dealt with the challenging parts of the projects have been dealt with?

When dealing with tasks that require a lot of thinking and involvement, how often do you avoid or delay working on the task?

How often do you feel overly active, restless and strongly compelled to do certain activities?

These questions help in the accurate diagnosis of ADHD.

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Obtaining information from the parents and the spouse is important. Inquire about how often they forget appointments. Are they ready to support the patient in the treatment? This will help determine whether the patient will be reminded and adhere to drug regimen.

Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
There is no single specific test for diagnosing ADHD. However, interviews with the parents/guardians and teachers, and watching the child or adult helps in the diagnosis. Moreover, use of various aids in evaluation and recognizing symptoms of ADHD. These include; Adult Self Report Scale, Brown Attention scales for adults and Conners Adult ADHD Scales. Also, Vanderbilt Assessment Scale which consists of a set of 55-questions for reviewing ADHD symptoms. It helps to rule out anxiety, depression, conduct disorder, and oppositional-defiant disorder. The Child Attention Profile (CAP filled by teachers to track symptoms of ADHD.Behavior Assessment System for Children (BASC) done to check for hyperactivity and aggressivity, anxiety, mood disorders, and learning problems. Child Behavior Checklist/Teacher Report Form (CBCL that detects physical complaints, or delinquent behaviors. Others tests include Neuropsychiatric EEG-Based Assessment Aid (NEBA) which is a brain wave test. It picks higher brain waves in individuals especially between 6-17 years with ADHD (Barkley., 2014). List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why Attention Deficit Hyperactivity Disorder .

The differential diagnosis for the case presentations are ADHD, conduct disorder or Oppositional Defiant Disorder, Bipolar Mood Disorder, and anxiety disorders( Grogan, Gormley, Claire, Rooney, Brendan & Whela et al., 2017). ADHD is the likely diagnosis because the patient manifested the symptoms of DSM-5 Criteria for ADHD which are inattentive, hyperactivity /impulsive behaviors (Barkley., 2014). This was clearly seen in the psychiatry history where she misses or delays appointments, she is disorganized, found it hard to keep regular schedule and time, poor academic performance, intimidated by any testing, worries of her future and has mental freezes when things seem too much (Stahl., 2014b).

List two pharmacologic agents and their dosing that would be appropriate for the therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent
Administer Amphetamine (d) 5-30 mg twice or thrice a day. Amphetamine is a stimulant used in first-line treatment of ADHD for pediatric and adult patients due to its efficacy and safety index. It’s a sympathomimetic drug that increases dopamine and norepinephrine and helps release presynaptic catecholamines. It’s well tolerated in adult patients.

Give Guanfacine 0.5-1mg TID OR 1-4 mg daily. Guanfacine is an alpha 2a agonists that have proved effective in attention and impulsive behavior management (Treuer, Gau, Mendez , et al. 2013).

Amphetamine (d) is preferred over Guanfacine because it’s a first line treatment effective in all age group. Guanfacine is an antihypertensive that can have rebound hypertension in cases of abrupt stoppage and sedation side effects unlike Amphetamine (Treuer, Gau, Mendez, et al., 2013).

Lessons learned from the case study

ADHD is a progressive condition commonly in children and persists o adulthood. It had has multi-factorial causation, though genetics play a great role in ADHD (Centers for Disease Control and Prevention (CDC)., 2017). Compressive history and diagnostics tests for adults are important in the diagnosis of ADHD.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Barkley, RA. (2014). Attention-deficit hyperactivity disorder, fourth edition: A handbook for diagnosis and treatment. New York, NY: Guilford Press.

Centers for Disease Control and Prevention (CDC).(2017). Attention-Deficit/Hyperactivity Disorder. www.cdc.gov/ncbddd/adhd/diagnosis.html

Grogan, Katie & I. Gormley, Claire & Rooney, Brendan & Whelan, Robert & Kiiski, Hanni & Naughton, Marie & Bramham, Jessica. (2017). Differential diagnosis and comorbidity of ADHD and anxiety in adults. British Journal of Clinical Psychology. 57.Attention Deficit Hyperactivity Disorder .10.1111/bjc.12156.

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Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Treuer T, Gau SS, Mendez L, et al.( 2013).A Systematic Review of Combination Therapy with Stimulants and Atomoxetine for Attention-Deficit/Hyperactivity Disorder, including Patient Characteristics, Treatment Strategies, Effectiveness, and Tolerability. Journal of Child and Adolescent Psychopharmacology; 23:179-193.

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