Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree
Practicum: Decision Tree
For this Assignment, you examine the client case study in this week’s Learning Resources. Consider how you might assess and treat pediatric clients presenting with symptoms noted in the case.
Note: This Assignment is the first of three assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients. Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree
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Learning Objectives
Students will:
• Evaluate clients for treatment of mental health disorders
• Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders
The Assignment:
Examine Case 1. You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.
At each Decision Point, stop to complete the following:
• Decision #1: Differential Diagnosis
o Which Decision did you select?
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the Decision. Why were they different?
• Decision #2: Treatment Plan for Psychotherapy
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the Decision. Why were they different?
• Decision #3: Treatment Plan for Psychopharmacology
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
• Also include how ethical considerations might impact your treatment plan and communication with clients and their families.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
Below is a sample paper for this assignment, use it as a guide.
Clinical Judgement on Katie’s Disorder
One of the vital roles of nurse practitioners is formulating the appropriate diagnosis whenever they encounter clients with symptoms that resemble different disorders. When such situations arise, it becomes imperative for the practitioners to develop the right diagnosis by utilization of the standardize diagnostic tools to rule out other differential diagnoses which will assist practitioners in the initiation of the treatment plan that will lead to a favorable outcome as well as increase patient satisfaction. The focus in this paper is about an eight-year-old girl Katie that was brought to the clinic by her parents due to the child is suspected of suffering from attention deficit hyperactive disorder (ADHD) from the assessment her teacher performed with the assessment tool called Conners’ Teacher Rating Scale. While inside the practitioner’s office, Katie was exhibiting some behavior that aligns with ADHD for example, inability to pay attention or sit still, continually interrupting the parents and the practitioner. She also revealed that she has difficulty paying attention in class or complete her school work. It is the responsibility of the mental health nurse practitioner that is managing this client to perform further diagnostic evaluations to establish the appropriate diagnosis and treatment plan. Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
Decision Point One
After evaluating all the information provided including the independent and objective evidence, the carefully chosen judgement for Katia is 314.00 Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation. An additional diagnostic evaluation tool to use to assess the Katia and her parents are the Child Behavior Check List (CBCL) since the teacher has already evaluated the child with Conners’ Teacher Rating Scale. CBCL is a user-friendly, cost-effective, reliable, and valid standardized assessment tool that is generally used in mental health services, schools, medical settings, child and family services, public health agencies, child guidance, and training programs for assessing children’s behavioral/emotional problems from the perspectives of multiple informants including parents, caregivers, and teachers (Mazefsky, Anderson, Conner, & Minshew, 2014).
The reason for choosing the above diagnosis is due to the symptoms the client exhibited in concurrent with the criteria for the selected diagnosis as listed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: (DSM-5). The requirements to make the determination is when the client meets up to six or more of the rules, for example, exhibits concentration difficulty, inability to complete a task promptly, difficulty retaining simple instructions, avoids activities that require cognition, and paying attention to unnecessary distractions (American Psychiatric Association [APA], 2013). The target outcome is to link the symptoms to the right diagnostic criteria in DSM-5 before establishing the appropriate treatment plan, and that matches with the expected result.
Decision Point Two
The initial pharmacological agent to use for the client is Adderall XR 10mg by mouth every day. The medication is also known as Amphetamine is an approved medication to treat kids from six to 17 years with ADHD and it belongs to the group of drugs called stimulants that functions by improving the chemical irregularity in the brain which is prompting the symptoms (Stahl, 2014). The basis behind this judgment is that it reduces the symptoms of inattentiveness, motor hyperactivity, and impulsiveness that interrupt social, school, and occupational functioning which is the goal of treatment for this client. The common side effects of Adderall XR to explain to the parents of the client includes; insomnia, shivering, vertigo, dehydrated mouth, constipation, diarrhea, reduced appetite, and weight loss (Felt, Biermann, Christner, Kochhar, & Harrison, 2014). The effectiveness of the medication can be apparent right after the first dose while in some patients, it can take several weeks to achieve the most therapeutic effect.
After four weeks of initiating this choice of medication, the parents of the client and the teacher noted some positive changes in the morning but not so much improvement in the afternoon and also complained of reduced appetite. The updates from the parents and teacher are the regular occurrence that is associated with medication which was explained to the parents at the initial visit, and the full effect of the drug takes several weeks in some individuals. Therefore, the result at hand is not different from what the practitioner expected. Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
Decision Point Three
Although the client has shown some improvement in the morning, modification in her attentiveness in the afternoon is yet to be achieved. Therefore, the next action is to supplement Adderall XR with a minute dose of instant release Adderall for the client to take in the afternoon that will sustain the client in the afternoon to complete her homework as well. The reason is that the overall result for initiating treatment is to improve the client’s attentiveness and concentration in school work including homework. At this point, the practitioner will schedule a follow-up visit in four weeks to assess for the effectiveness of the instant release on the client’s symptoms. American Academy of Pediatrics (2017), recommends that Continuous monitoring of the client’s behavior and medications are necessary to assess if the treatment strategy is functioning and one of the ways to achieve it is by follow-up visits.
Ethical Consideration
The dominant interest of mental health practitioner that is managing the mental health of children and adolescents is the safety of the child while upholding the moral principle of doing no harm and also address the rights and privileges of both children and their parents/legal caregivers, interpret consent as well as confidentiality (Jackson, Burns, & Richter, 2014). Therefore, mental health practitioners to should be watchful of different forces that could play roles in the diagnostic method while preserving the knowledge that their attempts will significantly reshape the near- and likely longer-term expectations of their child patients. Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
Conclusion
When practitioners encounter a patient with symptoms that resemble other conditions, establishing the appropriate diagnosis by ruling out other possible conditions becomes imperative like the case of Katie who was accompanied to the clinic by her parents. Therefore, it is the sole obligation of the mental health practitioner that is managing this client to perform further diagnostic evaluations to establish the appropriate diagnosis and treatment plan. They should also remember the importance of maintaining confidentiality and ensuring that the authorized person signs the treatment consent before initiating treatment.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
American Academy of Pediatrics. (2017). Treatment & Target Outcomes for Children with
ADHD. Retrieved from https://www.healthychildren.org/English/health-issues/conditions/adhd/Pages/Treatment-of-ADHD-and-Related-Disorders.aspx
Felt, B. T, Biermann, B., Christner, J. G., Kochhar, P. & Harrison, R. V. (2014). Diagnosis and
management of ADHD in children. American Family Physician, 90(7), 456-464.Retrieved from https://www.aafp.org/afp/2014/1001/p456.html
Jackson, M. K., Burns, K. K., & Richter, M. S. (2014). Confidentiality and treatment decisions
of minor clients: a health professional’s dilemma & policy makers challenge. Springer Plus, 3, 320. https://10.1186/2193-1801-3-320 Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
Mazefsky, C. A., Anderson, R., Conner, C. M., & Minshew, N. (2014). Child Behavior Checklist
Scores for School-Aged Children with Autism: Preliminary Evidence of Patterns Suggesting the Need for Referral. Journal of psychopathology and behavioral assessment, 33(1), 31-37. https://doi.org/10.1007/s10862-010-9198-1
Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New
York, NY: Cambridge University Press.
Practicum: Decision Tree
Introduction
Nurse practitioners have the role of making a suitable diagnosis for the clients and prescribing the appropriate treatment regimen. The diagnosis should be performed using suitable diagnostic tools in order to exclude other differential diagnoses in order to facilitate appropriate treatment and ensure better health outcomes for the patient/client. This case study presents an 8-year-old female client, who presented after being suspected of having ADHD. The “Conner’s Teacher Rating Scale-Revised” showed that the client was forgetful, inattentive, distractible easily, and poor in reading, spelling, and math. The teacher further reported that the client had short attention span, did not have interest in schoolwork, left school work uncompleted, and did not follow instruction. After the mental status exam, her mood was euthymic while the clinical interview indicated that her concentration and attention were fairly limited. Accordingly, this paper will present three decisions made about the diagnosis and treatment choices for this client and the rationale behind the selected decisions. The paper will conclude by discussing ethical considerations during the client’s treatment. Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
Decision Point One
From the provided information and the findings of the mental status exam, the diagnosis of the client is attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation. The Child Behavior Check List (CBCL) can be used to further evaluate the client and her parents because the reliability and validity of the tool in evaluating mental health issues in children have been verified. The rationale for selecting the diagnosis, attention deficit hyperactivity disorder (ADHD) is because the client manifests symptoms consistent with clinical symptoms listed within the DSM-5 diagnostic criteria. As per the DSM-5 criteria for ADHD, individuals with ADHD manifest hyperactivity-impulsivity or/and inattention that affect an individual’s development or functioning (American Psychiatric Association, 2013). For inattention, children should manifest 6 or more inattention symptoms for a minimum of 6 months and the symptoms include: lack of attention to details and mistakes in classwork and other activities; lack of attention during play/tasks; inability to listen directly; inability to follow instructions; failure to finish classwork or assigned chores; disorganization; avoiding activities needing mental effort; losing essential things such as books; forgetfulness; and being easily distracted (Tong et al, 2016). On the other hand, hyperactivity/impulsivity is characterized by fidgeting; running/climbing inappropriately; inability to play quietly; excessive talking; blurting out answers prior to question completion; problem waiting for ones turn, and interrupting/intruding others. The client manifests more than six symptoms of inattention and hence fits the diagnosis of attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation American Psychiatric Association, 2013). Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
With this decision, the hope was that the appropriate diagnosis would lead to the appropriate treatment for this client, and hence ensure better health outcomes.
Decision Point Two
The first treatment choice is for the client to start Adderall XR 10 mg orally every day. The reason for choosing Adderall is because evidence shows the efficacy of the pharmacological agent in the treatment of ADHD. Adderall is FDA approved for treatment of children aged from 6-17 years. The medication is a stimulant and works by improving stimulation within the prefrontal cortex; specifically, Adderall is a competitive inhibitor of dopamine and hence acts on the dopamine and norepinephrine transporters and hence boosts neurotransmission of both dopamine and norepinephrine within the prefrontal cortex, improving the symptoms of ADHD such as inattentiveness, impulsivity, and hyperactivity (Brown et al, 2018). Side effects that have been reported in Adderall include increased aggressiveness, appetite suppression, sleeplessness, weight loss, mouth dryness, diarrhea, vertigo and constipation (Weyandt et al,2018).
The expected outcome was that there will be significant symptom improvement because the pharmacological agent has been demonstrated to be effective in improving ADHD symptoms. It was also hoped that she would not experience side effects after initiation of the medication. Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
Comparable with the expected outcome, after four weeks of starting Adderall, there was significant symptom improvement for the client in the morning. However, there was no significant improvement during the afternoon hours because the client was unable to maintain attention in the afternoon. This is attributable to the Adderall being an immediate release amphetamine pharmacological agent and thus the medication was short-acting, leading to decreased effectiveness to last for the whole day (Weyandt et al, 2018). In addition, the client reported appetite loss which is a major side effect in amphetamines.
Decision Point Three
The third decision is the addition of a slight dose of Adderall during the early afternoon. The reason for this decision is to make sure that the client will be able to maintain attention even during the afternoon because, with the previous decision, the client was not able to achieve attention in the afternoon (Huss et al, 2017).
By adding a small dose in the afternoon, it is hoped that the client will maintain attention throughout the day and thus she will concentrate on her school work and other activities (Huss et al, 2017). The client will be monitored by a PMHNP after every four weeks in order to have her progress assessed. In addition, the assessment will be able to inform the ability of the client to tolerate the additional dose.
Ethical Considerations
Medications such as stimulants like Adderall have various side effects and hence the PHHNP should ensure no harm to the client. In addition, informed consent is an important ethical aspect during the treatment of this client. Therefore, it is the duty of the PMHNP to explain to the parents of Katie regarding the available treatment options, including the side effects associated with stimulants such as Adderall (Committee on Bioethics, 2016). This will ensure that the parents of the client make an informed decision prior to selecting any treatment option.
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Conclusion
According to the presented symptoms, the diagnosis for this client was attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation. The first pharmacological agent for the client was Adderall XR 10 mg because Adderall is approved for treatment of the pediatric population and its efficacy in treating ADHD has been demonstrated. Even though, the symptoms improved, the client was not able to maintain attention in the afternoon. Accordingly, the third decision was addition of a slight dose of Adderall during the early afternoon in order to ensure that she was able to maintain attention even in the afternoon hours. In conclusion, it is important for the PMHNP to ensure that the selected treatment regimen does not cause harm to the client and also seek informed consent from the parents of Katie prior to starting any treatment. This will ensure the parents make an informed choice, regarding their daughter’s treatment. Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th edition. Arlington: American Psychiatric Publishing.
Brown K, Samuel S & Patel D. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Transl Pediatric. 7(1): 36–47.
Committee on Bioethics. (2016). Informed Consent in Decision-Making in Pediatric Practice. American Academy of Pediatrics. 96(5):981.
Huss M, Duhan P, Gadhi P, Chen C, Carsten S & Kumar V. (2017). Methylphenidate dose optimization for ADHD treatment: a review of safety, efficacy, and clinical necessity. Neuropsychiatr Dis Treat. 1(13), 1741–1751.
Tong L, Xiong X, Tan H (2016) Attention-Deficit/Hyperactivity Disorder and Lifestyle-Related Behaviors in Children. PLoS ONE. 11(9): e0163434.
Weyandt L, White T, Gyda B, Adam N, Leon K & Bjorn S. (2018). Neurocognitive, Autonomic, and Mood Effects of Adderall: A Pilot Study of Healthy College Students. Pharmacy (Basel). 6(3): 58. Katie’s attention deficit hyperactive disorder (ADHD) Practicum: Decision Tree.