The process of diagnosing patients with neurodevelopmental disorders is critical due to the diverse symptoms. Psychiatric and Mental Health Nurse Practitioners (PMHNP) have a responsibility to assess the patients to determine their sickness. Collaboration with various stakeholders such as parents and teachers is essential to determine the behavior of a child. The paper explores a case study of Katie an 8-year old female child who is believed to have ADHD. The PCP referred Katie for a psychiatric analysis to determine the diagnosis. The role of a PMHNP is to evaluate the subjective and objective data to determine the diagnosis according to the DSM-5 criteria. The paper will examine the psychotherapeutic and psychopharmacologic interventions and ethical considerations during the care delivery.
# Decision One
The first decision is to diagnose the client with Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation (314.00). DSM-5 criteria indicate that patients with Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation should have at least six symptoms that interfere with the developmental and functional aspects of a child (Cortese et al., 2018). Another requirement is that the symptoms should persist for at least six months. The condition should cause an impediment to the academic and social functioning of a child (Cortese et al., 2018). In the current case study, Katie meets all the criteria according to the DSM-5. For instance, she has had trouble with poor academic performance and relationships with others. She confesses to losing concentration in class and having an imaginary friend.
The patient has a poor concentration which leads to recurrent and unexpected mistakes in her classwork and homework. The symptoms include the inability to pay attention to detail, paying close attention for a limited time, and the inability to complete schoolwork tasks (Clark & Bélanger, 2018). Other symptoms involve hyperactivity which includes talking excessively, fidgeting, bursting answers, and talking without giving other people an opportunity to speak. The symptoms are detrimental to the social and academic life of Katie. According to the DSM-criteria, six symptoms are needed for children below 12 years, and five are needed for children above 17 years (Clark & Bélanger, 2018). The symptoms hint that Katie could be suffering from Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation.
The diagnosis involves the collaboration of teachers who should fill the Conner’s teacher rating scale. According to the teacher’s report, the child is inattentive forgets things, is easily distracted, has careless mistakes, and performs poorly in arithmetic, reading, and spelling. The report shows she has a short concentration span and only pays attention to the things she is interested in. The symptoms undermine the ability to interact or play with peers. Studies show that inattentive ADHD is common in girls than boys, making it a more accurate diagnosis for the case study (Clark & Bélanger, 2018). The teacher indicates that she has poor concentration, interrupts the conversation, and is fidgety.
The diagnosis involves refuting other conditions such as autism spectrum disorder, and social anxiety disorder based on the presenting symptoms. Studies show that autism presents poor social interaction, verbal communication, difficulty in sleeping, and poor appetite (Hoogman et al., 2017). The condition leads to poor relationships and an inability to respond to body language. The patient is not likely suffering from a learning disorder since the symptoms affect social life (Hoogman et al., 2017).
The expectation was that the patient was suffering from Attention Deficit Hyperactivity Disorder, predominantly inattentive presentation. The reason is due to the presenting symptoms. The other two options do not meet the DSM-5 criteria such as autism and specific learning disorder (Hoogman et al., 2017). The expectations were similar to the results since the presenting symptoms indicate the patient is suffering from ADHD inattentive type.
# Decision Two
Katie returns to the clinic after four weeks. The best decision is to prescribe Adderall XR 10mg orally daily. The decision is based on evidence-based practice recommended by Stahl (2017) that the drug is a dopamine norepinephrine reuptake inhibitor and releaser that is effective for the treatment of ADHD in children between 6 and 17 years. The goal of the treatment is to reduce poor concentration which affects learning and social interaction (Engelking et al., 2018). According to the Food and Drug Administration, stimulants are effective first-line treatment drugs for children with ADHD. Psychostimulants are the preferred method of treatment for children with ADHD (Engelking et al., 2018). The expectation is that the child will gradually improve concentration both in school and social settings.
The other two treatment options including Wellbutrin 75mg orally daily and Strattera 25mg orally daily are not effective options for the treatment of ADHD inattentive type (Naguy et al., 2021). Wellbutrin is an antidepressant that is used as an off-label drug to treat ADHD among children. Studies show that antidepressants are the second line of treatment for children who cannot take stimulants (Naguy et al., 2021). Findings indicate that the benefits of taking stimulants are far beyond those antidepressants among children with ADHD (Naguy et al., 2021). According to Stahl (2017), Strattera is a non-stimulant that cannot be chosen as the first line of treatment for children with the inattentive type of ADHD. Although Strattera has a low potential of abuse as compared to Adderall XR, it is considered as the first line of treatment compared to Adderall XR (Naguy et al., 2021). The drug would only be a preference if the stimulant drug, Adderall XR, is not generating quality results.
During the clinic with the parents, they indicate that their child has improved although she can still do better. For instance, Katie can concentrate and complete her homework. The parents indicate that she has been asking strange questions such as where people go when they die and if people meet their pets after death. The parents confess they have never had such questions from Katie.
The expected outcome is that Katie will improve on her concentration after taking the medication. However, additional improvement is needed to realize full recovery (Naguy et al., 2021). One of the unexpected outcomes is that the child started asking strange questions to the parents.
# Decision Three
The third decision is to prescribe an additional dose of Adderall IR since changing the medication can affect the patient. Stahl (2017) states that polypharmacy is not an effective approach in the treatment of mental conditions. One of the precautions that a healthcare practitioner should take is to educate the parents about the side effects of the drug such as daydreaming and poor appetite (Naguy et al., 2021). According to the questions that Katie is asking, she is expressing symptoms close to those of death ideation. It is important to add the dose to ensure the patient will have a sustained period of suppressing the symptoms (Engelking et al., 2018). The decision should comprise adding a small dose of Adderall IR, which will wear off before bedtime to avoid insomnia. The patient should take the drug in the afternoon since it has a half-life of 3-5hours, unlike XR which has up to eight hours (Engelking et al., 2018). The IR dosage can be increased without any harm to Katie.
The expected outcome is that the patient may experience side effects such as low appetite. PMHNP has a responsibility to educate the parents about the side effects of the drug on their children (Hoogman et al., 2017). A referral to a dietician would be important if the weight of the child is affected by the poor appetite. Dieticians can help children cope with a lack of appetite. Taking heavy meals early in the morning before taking the drug and in the evening when the drug has worn off is essential in maintaining the calorie intake (Hoogman et al., 2017).
Psychotherapy was not chosen as a line of treatment since it might not address the inattentiveness of the child. Medication is the first line of treatment for ADHD in children (Hoogman et al., 2017). Behavioral therapy can be used if the child has a poor response to the medication. Behavioral therapy can be used to provide treatment for children taking stimulants.
The first ethical consideration is obtaining informed consent from the parent since the child is below 18 years. The information about the treatment of the child should remain confidential despite the various stakeholders such as her teacher participating in the treatment (McDermott-Levy et al., 2018). Beneficence is another consideration that involves taking due diligence to prevent harm. For instance, a comprehensive physical assessment is necessary before prescribing stimulants since they can affect the cardiovascular system (McDermott-Levy et al., 2018). It is important to educate the parents about the side effects of the drugs to avoid cause for alarm.
PMHNP has the responsibility to provide treatment to children using the best available options. The case study of Katie involves the prescription of medication that are considered the first line of treatment. A practitioner should assess the condition of the patient and make the appropriate decisions. Adherence to the ethical considerations is effective in providing safe and effective care.
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