Case 2: Volume 1 Case #14
Case 2: Volume 1 Case #14
To prepare for this Discussion:
Note: To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number. (Already attached with this posting)
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Case 2: Volume 1, Case #14: The scatter-brained mother whose daughter has ADHD, like mother, like daughter
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.
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.
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.
By Day 3
Post a response to the following:
Provide the case number in the subject line of the Discussion.
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. Case 2: Volume 1 Case #14
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.
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Clancy, C.M., Change, S., Slutsky, J., & Fox, S. (2011). Attention deficit hyperactivity disorder: Effectiveness of treatment in at-risk preschoolers; long-term effectiveness in all ages; and variability in prevalence, diagnosis, and treatment. Table B. KQ2: Long-term(>1 year) effectiveness of interventions for ADHD in people 6 years and older.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 12, “Attention Deficit Hyperactivity Disorder and Its Treatment”
Stahl, S. M., & Mignon, L. (2012). Stahl’s illustrated attention deficit hyperactivity disorder. New York, NY: Cambridge University Press.
To access the following chapter, click on the Illustrated Guides tab and then the ADHD tab.
Chapter 4, “ADHD Treatments”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
Review the following medications:
For ADHD
armodafinil
amphetamine (d)
amphetamine (d,l)
atomoxetine
bupropion
chlorpromazine
clonidine
guanfacine
haloperidol
lisdexamfetamine
methylphenidate (d)
methylphenidate (d,l)
modafinil
reboxetine
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Optional Resources
Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. doi:10.2165/11599630-000000000-00000
Psychiatric Times. (2016). A 5-question quiz on ADHD. Retrieved from http://www.psychiatrictimes.com/adhd/5-question-quiz-adhd?GUID=AA46068B-C6FF-4020-8933-087041A0B140&rememberme=1&ts=22072016
Course Texts
These course texts are available through Stahl Online Resources http://ezp.waldenulibrary.org/login?url=http://stahlonline.cambridge.org/
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
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nurs_6630_interventions_for_adhd.pdf
Table B. KQ2: Long-term (>1 year) effectiveness of interventions for ADHD in people 6 years and
older Conclusion
Medication Treatment
Level of EvidenceIntervention SOE: Low Very few studies include untreated controls.
Studies were largely funded by industry. SMD: -0.54 (95% Cl, -0.79 to -0.29)
MPH:
Psychostimulants continue to provide control of ADHD symptoms and are generally well tolerated for months to years
ATX: at a time. The evidence for MPH use in the context of careful SMD: -0.40 (95% medication monitoring shows good evidence for benefits for Cl, -0.61 to -0.18) symptoms for 14 months.
ATX is effective for ADHD symptoms and well tolerated over 12 months.
SOE: Insufficient Only one study of GXR monotherapy is available. It reports reduced ADHD symptoms and global improvement, although less than a fifth of participants completed 12 months.
Monitoring of cardiac status may be indicated since approximately 1% of participants showed EGG changes judged clinically significant.
Combined The results from 2 cohorts indicate both medication (MPH) and Psychostimulant
SOE: Low combined medication and behavioral treatment are effective in
Medication and SMD: -0.70 (95% treating ADHD plus ODD symptoms in children, primarily boys Behavioral ages 7-9 years of nomnal intelligence with combined type of Treatment
Cl, -0.95 to -0.46) ADHD, especially during the first 2 years of treatment.
Several reports from one high-quality study suggest that combined medication and behavioral treatment improves outcomes more than medication alone for some subgroups of children with ADHD combined type and for some outcomes.
Behavioral/ There is not enough evidence to draw conclusions for persons Psychosocial
SOE: Insufficient 6 years and older with a diagnosis of ADHD.
Parent Behavior There is not enough evidence to draw conclusions for persons Training
SOE: Insufficient 6 years and older with a diagnosis of ADHD.
Academic Interventions One good-quality study and its extension showed that classroom-based programs to enhance academic skills are effective in improving achievement scores in multiple domains, but following discontinuation, the benefits for sustained growth in academic skills are limited to the domain of reading fluency. All other domains show skill maintenance but not continued growth.
SOE: Insufficient
.. Note: ADHD- attention defictt hyperactlvtty dtsorder, ATX- atomoxetine, ECG- electrocardiOgram, GXR- guanfacme extended release; KQ =Key Question; MPH= methylphenidate; ODD= oppositional defiant disorder; SMD =standardized mean difference; SOE =strength ofevidence.
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Pharmacological Interventions Multiple short-term studies document that psycho stimulant medications, either MPH,
dextroamphetamine (DEX), or mixed amphetamine salts (MAS), effectively decrease the core symptoms of ADHD and associated impairment. 10 A review of the mechanisms of action of pharmacological interventions for ADHD is beyond the scope of this report. Some preparations last only a few hours, with symptoms returning as the medication wears off. Many families choose to use medication primarily on school days, and these medications have primarily been studied in school-aged children and youth aged 6 years and older. Psychostimulants, most connnonly MPH and DEX, are generally safe and well tolerated. Common side effects include poor appetite, insomnia, headaches, stomachaches, and increased blood pressure and heart rate. Prolonged use may result in a decreased rate of growth, generally considered clinically insignificant.n8 Concerns have been raised from postmarketing surveillance suggesting a rare incidence of sudden death, perhaps associated with pre-existing cardiac defects, however, the rate does not appear to exceed that of the base rate of sudden death in the population. 118 As noted earlier, approximately 2.5 million children in the United States, ages 4 to 17 years with a diagnosis of Attention Deficit Disorder (ADD) or ADHD, cunently take medication.4
Several extended release preparations of psychostimulants have been developed in recent years aimed at improved adherence and symptom control throughout the day as well as decreased abuse potential. 120 Non-stimulants (e.g., alpha adrenergic agents and atomoxetine (A TX)) have also been developed and found to be helpful in controlling symptoms with few adverse events. 121 However, in general, the benefits ofmedications wear offwhen they are discontinued. Since ADHD is a chronic disorder, many children, teens, and adults stay on medications for years at a time. Given the possibility of cumulative effects over time, a review of evidence regarding benefits and risks ofprolonged medication use for ADHD is indicated. Case 2: Volume 1 Case #14
Nonpharmacological Interventions In the area of nonpharmacologic interventions, behavior training has been found to be
helpful, primarily for disruptive behaviors that frequently coincide with ADHD. 122 Since ADHD may begin before school age, using the precedent of older children, increasing numbers of preschoolers are being identified and treated, sometimes with medications. However, the most commonly used psychostimulant, MPH, does not yet have government regulatory approval for use in children less than 6 years of age, while MAS has been granted aEproval by the FDA in the United States for children under 6 years, but older than 3 years of age. 2 Recent reviews of treatments for preschoolers with ADHD emphasize the use ofparenting interventions prior to medication based on general clinical consensus. 124 Indeed, the Preschool ADHD Treatment Study (PATS), funded by the U.S. National Institute for Mental Health (NIMH), included parent behavior training (PBT) as the first phase for all children recruited into the study prior to randomization for the purpose of evaluating efficacy and safety ofpsychostimulant medication.125 While the few studies available suggest stimulant medications are effective for the core symptoms of inattention, hyperactivity, and impulsiveness in very young children, psychostimulants also appear to cause more adverse events in preschool children than in older children.54 Beyond the PATS, little information exists to document effectiveness of either medication or non-medication interventions specifically for ADHD in this age group. Part ofthe difficulty has been lack of clarity regarding reliability and validity of diagnostic criteria and therefore lack ofwidespread application of the ADHD diagnosis for children under 6 years.n 9
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