Post a brief explanation of the psychological disorder presented and the decision

Post a brief explanation of the psychological disorder presented and the decision steps you applied in completing the interactive media piece for the psychological disorder you selected. Then, explain how the administration of the associated pharmacotherapeutics you recommended may impact the patient’s pathophysiology. How might these potential impacts inform how you would suggest treatment plans for this patient? Be specific and provide examples with 3 cited references.

SCENARIO:

BACKGROUND

Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.

 

The parents give you a copy of a form titled “Conner’s Teacher Rating Scale-Revised”. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.

 

Katie’s parents actively deny that Katie has ADHD. “She would be running around like a wild person if she had ADHD” reports her mother. “She is never defiant or has temper outburst” adds her father.

SUBJECTIVE

 

Katie reports that she doesn’t know what the “big deal” is. She states that school is “OK”- her favorite subjects are “art” and “recess.” She states that she finds her other subjects boring, and sometimes hard because she feels “lost”. She admits that her mind does wander during class to things that she thinks of as more fun. “Sometimes” Katie reports “I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.” Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.

MENTAL STATUS EXAM

The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic. Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2’s and 5’s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.

 

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

 

Decision Point One:

Begin Intuniv extended release 1 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

 Client returns to clinic in four weeks

 Katie’s teacher reports no change in her classroom behaviors

 Katie's parents are reporting that Katie has become “impossible” to wake in the morning and that for the first few hours of the day, she seems “sluggish”

Decision Point Two:

Discontinue Intuniv and begin Focalin (dexmethylphenidate) XR 10 mg orally daily

RESULTS OF DECISION POINT TWO

 Client returns to clinic in four weeks

 Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are much better, and that her academic performance has improved considerably

 Katie’s parents are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened

Decision Point Three:

Maintain current dose of Focalin XR and re-evaluate at next clinic visit in 4 weeks

Guidance to Student

Focalin XR [Methylphenidate (d)] is a first line agent with strong evidence of efficacy in ADHD. Side effects such as decreased appetite are not unusual with stimulant medications. The side effect may not have been as pronounced with a starting dose of 5 mg daily, but since she was started on 10 mg daily, the most prudent course of action from the available choices would be to maintain the current dose of Focalin XR until the next visit in 4 weeks. At that time, appetite should be assessed. No action will be required if it stabilizes or improves. However, worsening of appetite may herald the need to decrease to 5 mg orally daily.

 

Increasing the dose to 20 mg orally daily would not be appropriate as it may increase the side effects- and since there is evidence of good efficacy at the 10 mg, there is no clinical indication to increase the dose (recall that with stimulants, you always want to use the smallest effective dose).

 

Common side effects are not an indication to discontinue the drug and begin a different medication, therefore, it would not be appropriate to discontinue Focalin XR and begin Strattera at this time.