ADHD Discussion Board
Chief Complaint
“My son has trouble focusing and sitting still while completing his afternoon homework.”
HPI
David Handlon is a 10-year-old boy who returns for a routine visit to his psychiatrist with his mother. He was diagnosed 2 years ago with ADHD and is currently being treated with Adderall XR 20 mg every morning. His mother states that during the last parent–teacher meeting, his teacher indicated that David’s behavior is well controlled during the day. Despite David’s good behavior during the day, his mother reports difficulty getting David to complete any afternoon tasks or assignments after school. David’s rules include no playtime activities until he has completed his afternoon homework assignments. Instead of focusing on homework, David insists on playing Guitar Hero® in his room, and he sometimes carelessly throws his guitar. David has also exhibited impulsive and reckless behavior when interacting with his younger 8-year-old brother. Initially David’s mother thought the medication was working. However, within the past year, David’s afternoon antics have progressively gotten worse. Mrs Handlon is afraid that uncontrolled afternoon antics will have serious repercussions on David’s daytime behavior and grades. She questions, “What are my options?”
PMH
Asthma × 3 years
ADHD × 2 years
Tonsillectomy (1 year ago)
Broken wrist at age 8 (fell from tree)
Vaccinations up to date
FH
Both father and uncle have a history of hyperactivity and are currently receiving treatment as adults.
SH
Lives with both parents and younger brother in the suburbs
Meds
Adderall XR 20 mg daily (given every morning at 7:00 AM)
Albuterol inhaler two puffs Q 4–6 H PRN shortness of breath
Montelukast 5 mg PO daily
All
NKDA
ROS
Physical assessment was difficult to assess for David as he could not sit still for more than 30 seconds and was jumping off of the exam table. Asthma symptoms appear controlled with PRN inhaler use at bedtime only and daily montelukast.
PE
Gen
Well-nourished, healthy-appearing male child, normal physical development
VS
BP 110/72 mm Hg, P 82 bpm, RR 25, T 37.5°C; Wt 50 kg, Ht 5′2″
Skin
No signs of rash, skin irritation, or bruising noted. Scar noticed on left wrist from where he fell from tree. Minor cuts on knees from frequent falls on school playground.
HEENT
Unable to assess
Neck/Lymph Nodes
Unable to assess
Lungs/Thorax
No rales, rhonchi, or wheezing
CV
RRR
Abd
Deferred
Genit/Rect
Deferred
MS/Ext
Unable to assess
Neuro
A&O × 3; no underlying tics noted
Labs
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Na 138 mEq/L
K 3.8 mEq/L
Cl 106 mEq/L
CO2 23 mEq/L
BUN 18 mg/dL
SCr 0.8 mg/dL
Glu 110 mg/dL
Hgb 14 g/dL
Hct 44.5%
RBC 4.6 × 106/mm3
Plt 278 × 103/mm3
MCV 85 μm3
MCHC 33 g/dL
WBC 9 × 103/mm3
Neutros 66%
Bands 2%
Eos 3%
Lymphs 24%
Monos 5%
Mag 1.8 mg/dL
Serum iron 95 mcg/dL
TSH 3.6 mIU/L
ECG
NSR; changes not clinically significant
Assessment
ADHD
Mild-persistent asthma, well controlled with PRN albuterol and daily montelukast
Discussion: Make sure to utilize and cite primary literature and guidelines. If you are going to speak from personal experience, support your clinical practice with scholarly resources.
Create an individualized, patient centered, team based care plan to optimize medication therapy for this patient’s ADHD and other drug problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Considerations:
What subjective and objective information indicates the presence or severity of ADHD? What additional information is needed to fully assess this patient’s ADHD?
What nondrug therapies might be beneficial for those diagnosed with ADHD?
What are the goals of pharmacotherapy in this case? What feasible pharmacotherapeutic alternatives are available for the treatment of ADHD?
What alternatives would be appropriate if the initial care plan fails or cannot be used?
What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
Describe how care should be coordinated with other healthcare providers.
Monitoring and Evaluating Therapy: Provide a summary that addresses the long-term effect stimulants have on growth and appetite, cardiovascular risks, sleep, and any psychiatric or behavioral effects.
Considerations:
What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects?
Develop a plan for the follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
Many parents are apprehensive about starting stimulants in children because of abuse warnings in the prescribing information and media reports. What is the relationship between both untreated and treated ADHD and drug abuse? Does stimulant treatment for ADHD increase the risk of drug abuse?
4. Develop an appropriate recommendation for product conversion in a patient who is switching from oral methylphenidate (Concerta) 36 mg PO daily to methylphenidate (Daytrana) transdermal patch. Also, convert doses of mixed amphetamine salts (Adderall IR/Adderall XR) to lisdexamfetamine (Vyvanse).
Perform a literature search and defend or refute the role of modafinil, selective serotonin reuptake inhibitors, tricyclic antidepressants, and atypical antipsychotics in the treatment of ADHD.
