Posted: December 20th, 2021

The 8-Year-Old Girl Who Was Naughty

Main Question Post.
NURS 6630N-08: Therapy for Clients with Sleep/Wake Disorders.
Week 7
Case 1: Volume 2, Case #16: The woman who liked the late-night TV
The 70-year-old woman shows several signs and symptoms related to mental illness such as depression. She is often sad due to her loneliness. Her husband died years ago, and the son no longer lives with her. Also, she experiences several unexplained pains and aches in different parts of her body. Her movement is substantially limited thus denying her a chance to join other people in society and participate in communal activities. Besides losing interest in doing things that she previously liked, she is also experiencing insomnia. She also admitted having experienced symptoms of Major Depression Disorder; thus indicating that she had historical family depression. Her mother suffered from the disease, despite the external family having the issues of Alcohol Use Disorder. The recent development of the hearing problem due to Major Depression Disorder (MDD) for both of her ears has dramatically affected her ability to communicate and interact with others. MDD has contributed to her sadness and the choice to remain alone rather than in a crowd (Stahl, 2013).
Questions and Rationales
Given the explanation of the signs experienced by the woman, the following are some of the questions the psychiatric mental health nurse practitioner (PMHNP) would consider asking patient as a way of establishing the cause and extent of her illness.
1. Have you been diagnosed with depression before? This way, it is easy to conclude whether the woman has a mental disorder or not (Ball, Dains, Flynn, Solomon, & Stewart, 2015).
2. Any other member of the family, apart from your mother, both nuclear and extended suffering or who have ever suffered from depression? The question is to help establish if the disease is genetic or not. Again, it would be the best way to develop the most effective medication to give to the patient, probably those that might have worked for the family members before. For instance, in the case of Major Depression Disorder (MDD), treatment is likely to be based on the medication that seemed useful for the family (Dains, Baumann, & Scheibel, 2016).
3. Do you suffer from any drug abuse? The family has a history of continued drug use disorder that might influence the development of depression due to inability to access the drugs (Ball et al., 2015). Therefore, it will be easy to draw a base and ground from which one can help uplift her spirit on awful days.
People in Patient’s Life to Give a Feedback
The first person that the psychiatric mental health nurse practitioner (PMHNP) would consider to reach and ask questions about the patient is the son (Stahl, 2013). Despite not being around his mother on a daily basis, he is the only family support that she has. Therefore, it is possible that he knows his mother’s condition in-depth. Again, he always accompanies her to her regular clinics for checkups. What this means is that the doctor keeps him updated on the improving or deteriorating state of his mother. He is a reliable source as the mother is also unlikely to hide any kind of pain and discomfort that she feels. The specific question to ask the son will be, when did you first notice a change in behavior in mother? The rationale is to establish a time frame of illness and to determine if the mother is an excellent historian and if what she said tallies with what happened. Another question will be what do you think may have triggered this behavior? Rationale, to assess if the trauma of losing her spouse engendered current illness and do you notice at any time if your mother used or is using street drugs or abusing any other substance? The reason is to rule our substance induced illness. Tell the PMHNP more about your mother? An open-ended question and answer that is free-flowing may reveal truths that the PMHNP may never have thought of asking (Ball et al., 2015). Another credible person as well is the home caretaker who takes care of the patient. He/she is responsible for catering to all the needs of the patient, thus understanding the progress of the woman regarding the mental sickness. The helper can also Help in identifying other psychological symptoms that the patient might have forgotten to mention. The PMHNP, without violating patient’s privacy will ask the caretaker, at any point in your care of the patient have you ever stumbled across any paraphernalia suggesting substance use by the patient? The PMHNP is still in search of the cause of patient’s illness to know how to Help client further. What does patient do during in her leisure time if any? The PMHNP want to gain insight into the patient’s daily behavior to determine the intensity of depression (Dains et al., 2016). The last individual the PMHNP will approach as he tries to understand the problems of the woman is the personal therapists who help her to fight against the mental disorder. Specific questions like what are the things you two talk about that change the patient’s mood from sad to happiness? There is a possibility of indicating activities and topics that they consider enjoyable to engage in that may be helpful to the PMHNP come up with a successful care plan. Also as the being the healthcare provider who has been caring for the patient, the therapist might be aware of the issues that might be considered to trigger the problem or even a medication that can help diagnose the further diseases. The progress of her illness is also essential since the therapist is always in constant communication with the patient. Therefore, the therapist might know more than anyone else could. People tend to be open with their health care providers because they tend to understand them better than all others (Davidson, 2016).
Physical Exams and Diagnostic Tests
The PMHNP will recommend for in-depth scrutiny of the patient’s well-being. Patient’s continued fatigue, especially in the morning, has not yet been established (Stahl, 2013). Therefore, it is difficult to prescribe any medication to her without the accurate medical information. In this case, the patient needs to be investigated in the affairs of obstructive sleep apnea. Lack of adequate sleep may result in patient always exhausted. Other examples like snoring and day-time sleeping are among the obstructive sleep apnea (OSA) that she experiences. Although there are high chances of concluding that she was suffering from the disease, there is a need for the physicians to conduct in-depth research on the same (Stahl, 2013).
Also, there should be implantation of the cochlear implant to help in depressing the major depression disorder (MDD). The confusion is stated to have not been under medication, thus the eternal suffering as a result of the illness. The use of the implant will help to regulate the level and impact of the disorder the patient experiences from time to time (Stahl, 2013).
The introduction of the Actigraphy to measure the movements made by the patient may also be an excellent way to monitor her sleep and wake cycles (Ancoli-Israel, Cole, Alessi, Chambers, Moorcroft, & Pollak, 2003). The device, worn on the wrist, records all the activities including the physical movement of the patient. It will show the resting and activity cycle of the patient. For that reason, it will be easy to assess the severity of insomnia (Stahl, 2013). Lastly, Polysomnography test (sleep study) should be conducted to establish the advancement of the sleeping disorder (Ancoli-Israel et al., 2003). The equipment is used to measure and record the brain activities that influence the sleeping ability of individual and other issues in the body such as breathing. The study examines the availability of oxygen in the body, heart rate, eye movement, as well as leg movement (Ancoli-Israel et al., 2003). With the study on the sleep patterns and cycles, it will be possible to establish the further cause of sleeplessness in the patient.
Differentiates Diagnoses
1. Major Depressive Disorder, Recurrent Episode severe (American Psychiatric Association, 2013; DSM-5, 2018).
2. Generalized Anxiety Disorder (American Psychiatric Association, 2013; DSM-5, 2018).
3. Obstructive Sleep Apnea (OSA) (American Psychiatric Association, 2013; DSM-5, 2018).
From the review of the case study, there are two significant illnesses. First, the patient is suffering from the major depression disorder (MDD) specified under the DSM-5 (American Psychiatric Association, 2013). People were suffering from the condition exhibit the symptoms of both mania and depression. For a patient who experiences mixed features, she needs to be diagnosed and treated with an antidepressant to suppress the disorder (Stahl, 2014b). In addition to the antidepressant that might work or not work on its own, there is a need to accompany the medication with more drugs. Typical antipsychotics such as Saphris, Latuda, Zyprexa, and Seroquel can help to effectively bring down the effects of the depression that is running in her family (Stahl, 2014b). Another reason for deciding to combine the medication is due to the (tenacity) stubbornness of the illness towards common drugs. Mood stabilizers like lithium and Depakote should be used to ensure that it sustains the spirit of the patient thus dealing with the issues of sadness and frequent cries. It should minimize the down periods and instead promote happiness from a few things that they enjoy doing.
Further diagnosis will be Generalized Anxiety Disorder (GAD) (DSM-5, 2018). Stillness and spending times all alone were the causes of anxiety and stress which later became the depression. Valium, a sedative will be used to help her with the sleep (Stahl, 2014b). Despite the previous medication being effective in promoting sleep, she still cannot help sleeping early. Therefore, she needs to use sleeping pills to encourage more rest.
Patient Medication
The use of the Citalopram (Celexa), an SSRI, 10 mg/d to suppress the depression symptoms have been quite successful (Stahl, 2014b). Although she has not started sleeping completely, the rate of sadness in her has reduced implying that it is useful in suppressing the mood instability (Stahl, 2014b). Increasing the amount of the SSRI intake would help improve the status of the patient even more (Stahl, 2014b). Replacing the drug with another medication has a high likelihood of causing a relapse on the user. During a decline, the condition of the patient goes back to the original status or even worse. Stopping the generation of the chemical in the body means that the antibodies responsible for the well-being will be defeated. The inclusion of the noradrenergic or dopaminergic to the antidepressant would help to treat the fatigue she experienced (Stahl, 2014b). Hypnotic drugs will be used to treat the lack of sleep which the SSRI failed to address (Drugbank, 2018). Also, the auto-titrating continuous positive airway pressure (CPAP) will also enhance the ability to curb the sleep disorder. Therefore, the goal is that the patient will experience fewer occurrences of insomnia. Continued use of the Zaleplon (Sonata) 5 mg will supplement the ability of the rest of the drugs in curbing lack of sleep (Stahl, 2014b).
Posttest
Ramelteon and doxepin are the hypnotic drugs that are considered to have no effects on the functionality of the psychomotor, the respiratory process or even become addictive. The two belong to the class of tricyclic antidepressants which increases the brain level of serotonin and norepinephrine. The two are the neurotransmitters used to transmit messages in the brain (Davidson, 2016). They are positive allosteric modulators (PAMs) used to relieve muscle spasm as well as providing medical sedation before performing medical procedures. Either of the two is an excellent choice to give the patient to stimulate sleeping cycles during the night. Unlike other drugs, the users are not expected to experience any after use adverse effects. Therefore, one will be sure on the treatment of the actual disease without side effects that tend to affect people differently. Augmenting the two drugs with the medications previously given the patient will help to increase her chances of sleeping. As a result, she will gain relief from the leg pain.
Check Points
The case study indicated positive responses to facsimiles received back and forth with the therapist (Stahl, 2013). In enhancing patient’s ability to associate with people and engage in everyday activities, cochlear implantation is necessary so the patient can hear others easily hence ending her frustration. Patient ability to hear will further motivate her to engage with others in different activities with peers along with pharmacologic and non-pharmacologic intervention (Sadock, 2015).
Lessons learned
The PMHNP knows that in this patient, the use of anti-stimulant is contraindicated. Instead, hypnotics augmented with SSRIs SNRIs may be prescribed. Additionally, for the neuropathic pain, gabapentin may be prescribed. The PMHNP due diligence in prescribing right drugs and making changes in medication where and when necessary will result in a patient living a more healthier, productive and fruitful life.
 
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Ancoli-Israel, S., Cole, R., Alessi, C., Chambers, M., Moorcroft, W., Pollak, C. P. (2003). The role of actigraphy in the study of sleep and circadian rhythms. American Academy of Sleep Medicine Review Paper. SLEEP 2003;26(3):342-92.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby
Dains, J. E., Baumann, L. C., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MO: Elsevier Mosby
Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16-e18. i:10.1192/bjpo.bp.116.003707. Retrieved from http://bjpo.rcpsych.org/content/2/6/e16
Drugbank. (2018). Hypnotics medications. Retrieved from https://www.drugbank.ca/drugs/DB00402
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia: Wolters Kluwer.
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.

Week 9: Therapy for Clients with ADHD
Tyler, a 9-year-old third grader, had always been an energetic child with a short attention span. For years, his mother attributed his behaviors to him being “all boy” and assumed it would improve as he grew older. Instead, daily tasks like chores and homework became increasingly overwhelming for Tyler, resulting in disruptive behaviors at home and school. After being evaluated by his healthcare provider, Tyler was diagnosed with and treated for attention deficit hyperactivity disorder (ADHD).
ADHD is a prevalent disorder for clients across the lifespan, as more than 6 million children (CDC, 2016) and 8 million adults (ADAA, 2016) have been diagnosed with the disorder. Like Tyler, individuals of all ages find that symptoms of ADHD can make life challenging. However, when properly diagnosed and treated, clients often respond well to therapies and have positive health outcomes.
This week, as you study ADHD therapies, you examine the assessment and treatment of clients with ADHD. You also explore ethical and legal implications of these therapies.
Photo Credit: [kristian sekulic]/[E+]/Getty Images
________________________________________
Discussion: Presentations of ADHD
Although ADHD is often associated with children, this disorder is diagnosed in clients across the lifespan. While many individuals are properly diagnosed and treated during childhood, some individuals who have ADHD only present with subsyndromal evidence of the disorder. These individuals are often undiagnosed until they reach adulthood and struggle to cope with competing demands of running a household, caring for children, and maintaining employment. For this Discussion, you consider how you might assess and treat individuals presenting with ADHD.
Learning Objectives
Students will:
• Assess client factors and history to develop personalized therapy plans for clients with ADHD
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for ADHD
• Evaluate efficacy of treatment plans
• Apply knowledge of providing care to adult and geriatric clients presenting for antidepressant therapy

To prepare for this Discussion:
Case 1: Volume 1, Case #13: The 8-year-old girl who was naughty
• Review this week’s Learning Resources and reflect on the insights they provide.
• 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.

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: 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.
Note: Retrieved from Walden Library databases.
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 https://monkessays.com/write-my-essay/psychiatrictimes.com/adhd/5-question-quiz-adhd?GUID=AA46068B-C6FF-4020-8933-087041A0B140&rememberme=1&ts=22072016

PATIENT FILE
133
The Case: 8-year-old girl who was naughty
The Question: Do girls get ADHD?
The Psychopharm Dilemma: How do you treat ADHD with oppositional
symptoms?
Pretest Self Assessment Question (answer at the end of the case)
What is true about oppositional symptoms in patients with ADHD
A. They can be part of the diagnostic criteria for ADHD in children
B. They can be confused with impulsive symptoms of ADHD
C. They can be part of oppositional defi ant disorder (ODD) which can be
comorbid with ADHD
D. They can be part of conduct disorder (CD) which can be comorbid
with ADHD
Patient Intake
• 8-year-old girl brought to her pediatrician by her 26-year-old mother
• Chief complaint: fever and sore throat
Psychiatric History
• While evaluating the patient for an upper respiratory infection, the
pediatrician asks if school is going well
• The patient responds “yes” but in the background the mother shakes
her head “no”
• The mother states that her daughter is negative and defi ant at home
and she has similar reports, mostly of disobedience, from her teacher
at school
• The patient has had temper tantrums since age 5 but these have
decreased over the past 3 years, especially the past year
• Still angry and resentful since her little sister was born 6 years ago
• Academic problems
• Fights with other children, mostly arguments and harsh words with
other girls at school
Social and Personal History
• Goes to public school
• Has a younger sister age 6
• Does not see her father much, lives in a nearby city
• Not many friends
• Spends most of her time with her sister and either her mother or her
maternal grandmother who helps with after school supervision and
baby sitting
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PATIENT FILE
134
Medical History
• None
Family History
• None known for medical or psychiatric disorders other than the father
who drinks a bit too much and his father (paternal grandfather) who
some think might be an alcoholic
• Mother was adopted and no family history known
Pediatrician’s Notes: Initial Assessment
• Not enough time to do any more Assessment
• Instead, the mother is given the parent and teacher version of the
Conners ADHD rating scale and is instructed to bring the completed
forms to the followup visit
• A variety of rating scales are available, some without charge (see
https://monkessays.com/write-my-essay/neurotransmitter.net/adhdscales.html).
• The Connors scale charges a fee but other rating scales available at
this link, or listed in the Two-Minute Tute below are free.
Pediatrician’s Notes: Followup Visit Week 3
• At the followup visit, the mother admits to having been too busy to fi ll
out the parent form
• Also admits to having forgotten to send the rating form to the teacher
• Mother acknowledges being more disorganized since her second
child started school this year
• Since then it has also been extremely diffi cult to keep the patient
organized and focused on school
• The mother is on the verge of tears
• “Two children are too much for a single mother”
• The pediatrician offers to send the teacher form to the school and
gives the mother tips on how to remember to fi ll out her own form
• When the teacher form is sent back to the pediatrician’s offi ce the
mother will be contacted for a followup visit
Pediatrician’s Notes: Followup Visit Week 6
• At the followup visit, the mother comes alone
• Teacher’s ADHD rating scale responses state that the patient has
signifi cant problems with
– Talking excessively
– Sustaining attention
– Being organized
– Being distracted
– Being forgetful
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PATIENT FILE
135
– Following instructions
– Making careless errors (except when it comes to her homework)
• The teacher also complains of the patient being more argumentative and
disobedient than the other children in her class
• The mother’s responses on the ADHD rating scales are similar to the
teacher’s but she endorses only fi ve symptoms as signifi cantly impairing
• Checked “severe” for ability to listen (rated only mild by the teacher)
• Upon further questioning by the pediatrician, it becomes clear that the
mother is compensating for her daughter by
– Double checking her homework
– Making sure homework is in her backpack
– Helping the patient be organized
• Eventually, symptoms that were originally determined to be “mild” by the
mother are changed to “signifi cantly impairing”
• Mother confi rms that the patient argues a lot with her, especially when
the mother is trying to oversee her work, and that the patient still
occasionally has temper tantrums similar to when she was fi ve years
old, but milder
Based on just what you have been told so far about this patient’s history
what do you think is her diagnosis?
• ADHD
• ODD (oppositional defi ant disorder)
• CD (conduct disorder)
• ADHD comorbid with ODD
• ADHD comorbid with CD
• A child acting out again her mother’s divorce and against having to
share her mother with her sister
• Other
Pediatrician’s Mental Notes: Followup Visit, Week 6, Continued
• The patient is diagnosed with ADHD, mostly inattentive type,
comorbid with symptoms of oppositional defi ant disorder
– ADHD symptoms include inattention but not hyperactivity
– Some of her impulsive symptoms such as being argumentative
and disobedient overlap with her ODD symptoms but the ODD
symptoms seem to be willful and on purpose rather than truly
thoughtlessly impulsive
• To be diagnosed with conduct disorder, the patient would need to
exhibit symptoms similar to ODD plus have aggression towards
animals, destruction of property, deceitfulness or theft, and serious
violations of rules, symptoms of a type and severity that neither the
teacher nor the mother brought up
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PATIENT FILE
136
How would you treat her?
• Cognitive behavioral therapy
• Parent training
• d-methylphenidate XR (Focalin) 5 mg once daily in the morning
titrated in 5 mg increments each week to optimization
• OROS methylphenidate (Concerta) 18 mg once daily in the morning
titrated in 18 mg increments each week to optimization
• Mixed salts of amphetamine XR (Adderall XR) 10 mg once daily in the
morning titrated in 10 mg increments each week to optimization
• Lisdexamfetamine (Vyvanse) 30 mg once daily in the morning titrated
in 10–20 mg increments a week to optimization
• Other
Pediatrician’s Mental Notes: Followup Visit Week 6, Continued
• Mother is initially uncomfortable with the diagnosis of ADHD with
ODD and is far from ready to accept medication treatment for her
daughter
• Wants different options
• Pediatrician suggests cognitive behavioral therapy and parent
training
• Pediatrician also offers to write a letter to the school to implement
strategies to help her daughter such as
– Allowing extra time on tests and assignments
– Placing child nearest to the teacher
– Devising signals between teacher and child to redirect child’s
attention without embarrassing the child
Pediatrician’s Mental Notes: Followup Visit Week 10
• Mother learns that closest CBT specialist is one-hour drive away from
their home so this option falls through
• Also, while the teacher is happy to implement the strategies
suggested by the pediatrician, she admits to already using them with
the patient, given her experience with other ADHD students
• The lack of non-pharmacological treatment options helps the mother
reconsider the risks versus the benefi ts of ADHD medications
• All the options listed as stimulants in the list above, plus some
nonstimulants, are approved for the treatment of ADHD and have
shown some effi cacy for ODD symptoms
• D-methylphenidate XR is chosen
Pediatrician’s Mental Notes: Followup Visits Weeks 12 and 14
• The dose of d-methylphenidate is titrated to 20 mg/day with some
improvement in classroom behavior according to the teacher
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PATIENT FILE
137
• However, the patient develops problems with initial insomnia
– Sometimes the effects of stimulants later in the day can actually
improve sleep, especially in hyperactive individuals who have
problems slowing down for bedtime routines
– Some studies suggest that OROS methylphenidate lasts even
longer (up to 12 hours) compared to d-methylphenidate XR,
which seems to be more effective in the fi rst 8 hours; thus OROS
methylphenidate would be a potential option in such cases
– However, this is not this patient’s presentation
– Since this patient did not have problems with sleep prior to
starting d-methylphenidate XR, the initial insomnia is likely due to
the stimulant
• Also, even though classroom behavior seems to be improving
according to the teacher, the patient remains defi ant with the mother,
tears up some toys of her younger sister to upset her and screams
more than ever at her mother while doing homework, seeming
delighted when her mother gets upset and yells back
• The mother is instructed to give the medication another month to see
if the improvements in the classroom begin to be seen in the home
and is instructed about sleep hygiene including
– Keeping regular schedules for going to bed and waking up
– Avoiding the patient’s favorite caffeinated sodas, especially in the
late afternoon
– Providing quiet activities as part of a bedtime routine
– Having the patient leave her room to do another quiet activity if she
does not fall asleep within 30 minutes
Pediatrician’s Mental Notes: Followup Visit Week 18
• The mother herself is often overwhelmed and disorganized and so
has a diffi cult time keeping regular schedules for going to bed and
waking up, even during the week but especially on weekends
• Despite trying the behavioral approach, the initial insomnia remains a
problem
• So does the defi ant behavior at home
• Also, reports last week that the patient shoved somebody who she
said was crowding in line, causing her classmate to cut her knee,
requiring stitches/sutures
• Was not sorry or remorseful
How would you treat her now?
• Refer to a psychiatrist for further Assessment and
psychopharmacological management
• Refer to a psychologist for therapy
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PATIENT FILE
138
• Switch to dl-methylphenidate immediate release (classical Ritalin) 10
mg twice daily, then titrate to optimized dose
• Switch to the methylphenidate transdermal patch (Daytrana) starting
at 10 mg, then titrate to optimized dose
• Switch to the prodrug lisdexamfetamine (Vyvanse) starting at 30 mg
once in the morning, then titrate to optimized dose
• Switch to atomoxetine (Strattera) 10–18 mg per day, then titrated to
optimized dose
• Switch to guanfacineXR (Intuniv) 1 mg/day, then titrated to optimized
dose
• Other
Pediatrician’s Mental Notes: Followup Visit Week 18, Continued
• Each treatment option has specifi c considerations to take into account:
– In general, the active d enantiomer of methylphenidate (which
the patient was originally prescribed) may be slightly more
than twice as potent as racemic d,l-methylphenidate; so, if side
effects persist on d-methylphenidate it may be useful to switch
to immediate release d, l methylphenidate which might require a
“sculpted dose” with a higher morning than afternoon dose
– The methylphenidate patch needs to have the patient and mother
follow instructions and in this patient’s case, may need to remove
the patch before the suggested nine-hour wear time is over, if
insomnia or other adverse events emerge; the patch should not be
cut as a way to lower the dose
– Lisdexamfetamine should be titrated by increasing the dose in
10–20 mg increments each week; 10–12 hours of clinical action
can be expected, so might be less favorable in patients who
already have problems with insomnia
– Atomoxetine can have a longer onset of action but does not cause
insomnia
– Guanfacine/guanfacineXR should start at 1 mg and titrate by 1 mg
increments to a maximum of 4 mg/day but an 8 year old will not
likely need or tolerate the highest dose, which may cause sedation
• The mother prefers the methylphenidate patch approach, as it seems
to be the most convenient way to address the sleep problems
• Additionally, sometimes the patient refuses to swallow pills and will
take the medication only if convinced to do so, or possibly if sprinkled
on food. This confrontation over medications adds too much extra
time to the mother’s already hectic morning schedule
• The patient likes the novelty of the patch, which reminds her of a
sticker
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PATIENT FILE
139
Pediatrician’s Mental Notes: Followup Visit Week 20
• The 10 mg patch with an eight hour or shorter wear time addresses
the classroom ADHD symptoms without causing insomnia
• However, on the days when the mother forgets to remove the patch
before 3 pm, insomnia returns
• That is resolved by setting her cell-phone alarm to remind her to
remove the patch every day at 3 pm after applying it at 7 am
• At fi rst the patient and her mother are impressed with the novelty of
the patch and its fl exibility and the resolution of the patient’s insomnia
• However, she is still argumentative, including some evenings at
bedtime, and this can interfere with getting to bed on time even
though the patient no longer has insomnia
• The patient scratched her sister’s face last week with her fi ngernails
because her sister was playing with the patient’s dolls
• Thinks it is funny that her sister’s face is scratched
• “She looks like she has warpaint on her cheek”
• The pediatrician feels like only a bit of progress has been made with
several months of medication treatment, including two different
stimulants
• Even though inattentive symptoms in the classroom are reportedly
improved, oppositional symptoms both at school and at home are not
improved and if anything, are the main problem now
• Furthermore, the patches are expensive, not covered well by the
mother’s insurance and frequently are pulled off by the patient or her
classmates tormenting her in response to her fi ghting/arguing with
them
• Refers the patient and her mother to a psychiatrist
Attending Psychiatrist’s Mental Notes: Initial Psychiatric
Assessment
• Seems like the patient needs more stimulant during the day and less
at night
• Also, seems like the oppositional symptoms may require special
therapeutic focus
• Considerations include:
– Developing a platform of stimulant to optimize treatment with
another oral medication
– Increasing the dose during the day to see if oppositional
symptoms will respond to this
– If not, consider augmentation strategies for the oppositional
symptoms
– Psychotherapy (too expensive and too time consuming, mother
cannot miss work, and too far away)
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PATIENT FILE
140
– Atypical antipsychotic (controversial, for use of atypical
antipsychotics is not approved for ADHD or for oppositional
symptoms of ADHD/ODD
– guanfacine XR – approved for ADHD with some evidence
for use in oppositional as well as inattentive/hyperactive
symptoms of ADHD but not approved for ODD
• Suggested switching back to an oral medication from the patch
• Trial of lisdexamfetamine 30 mg once in the morning
Attending Physician’s Mental Notes: First and Second Interim
Followups, Weeks 4 and 8
• Only partial effi cacy but no insomnia
• Rather than increase dose of lisdexamfetamine, added 5 mg of
dextroamphetamine at 7 am, then 10 mg, then 15 mg, became
nauseous, reduced to 10 mg on top of lisdexamphetamine 30 mg in
the morning
• Sometimes a second 5 mg dose of the dextroamphetamine after
school is necessary
• This regimen does not cause insomnia
• ADHD better but oppositional symptoms persist
• Augmentation with guanfacine XR 1 mg/day
Case Outcome: Followup Weeks 12 to 20
• No side effects
• Titration to 2 mg/day
• Continues lisdexamfetamine 30 mg in the morning
• Plus dextroamphetamine 5 mg in the morning
• Plus occasional dextroamphetamine 5 mg additional daytime dose
• Oppositional symptoms improved slowly but surely over 2 months
• Psychiatrist asks whether the patient’s sister has any problems
in school, and the mother states that she is “spacey” but not
oppositional
• Psychiatrist suggests to bring in the sister the next time the patient
comes and gives mother screening forms for ADHD and asks her
to consult with her other daughter’s teacher to see if there are
symptoms of ADHD in that daughter as well
• Psychiatrist asks mother to make an appointment for herself because
it is obvious that she has undiagnosed and untreated ADHD
– Given adult ADHD rating form for mother to fi ll out
– Symptoms of ADHD in the mother are obvious during various
interviews
– Mother misses appointments or is late for appointments
– Often appears disorganized
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PATIENT FILE
141
– Did not fi ll out her child’s forms on time
– Did not deliver forms to her child’s teacher, forgot, lost them
– Admits being very disorganized since her second child started
school
– Feels overwhelmed by two children and her life circumstances
– Could also have some signs of depression
– Can’t get organized to take her child to CBT
– Has a hard time keeping a regular schedule and also keeping her
daughter on a regular schedule of going to bed and waking up
– Was unable to remember to remove the daughter’s skin patch
unless she set a cell phone alarm
– All these suggest further Assessment of the mother is indicated
since ADHD commonly runs in families and has a very high
genetic contribution
– See the following Case 14, p 151 for presentation of the
mother’s case
Case Debrief
• The patient is an 8-year-old with ADHD, inattentive type with
comorbid ODD
• High doses of stimulants reduce inattention but cause insomnia and
do not adequately treat oppositional symptoms
• “Top up” with the alpha 2A selective noradrenergic agonist
(guanfacine XR) improves oppositional symptoms and the patient has
stabilized
Take-Home Points
• ADHD with ODD comorbidity can be a diffi cult combination of
behaviors to treat in children
• Combining stimulants with alpha 2A selective agonist actions may
be useful in some patients with this combination of symptoms not
adequately responsive to stimulants alone
Performance in Practice: Confessions of a
Psychopharmacologist
• What could have been done better here?
– Should the father have been included in the medical decisions?
– Whether or not he has legal medical rights, he has visitation rights
and could feel upset or vindictive if left out
– It is possible that the patient is still dealing with her parents’
divorce and still adjusting to her sister taking some of her
mother’s time and attention; some of the oppositional symptoms
may not be due to ODD but to family confl ict and possibly family
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PATIENT FILE
142
or individual psychotherapy involving the patient, her mother and/
or her sister could be productive here
• Possible action item for improvement in practice
– Make a concerted effort to involve the father
– Perhaps this patient should have been sent to a specialist
psychopharmacologist earlier and symptom improvement may
have occurred earlier
– Perhaps a trial of atomoxetine would have been benefi cial
Tips and Pearls
• Although guanfacine XR is approved as a monotherapy for ADHD,
some studies and clinical anecdotes suggest that it can be combined
with stimulatnts for patients with diffi cult oppositional comorbid
symptoms
• “Sculpted therapy” combining long acting with immediate acting
formulations of stimulants may optimize treatment for some cases
with inadequate responses to long acting formulations alone
Two-Minute Tute: A brief lesson and psychopharmacology
tutorial (tute) with relevant background material for this case
– Rating scales
– Oppositional Defi ant Disorder vs Conduct Disorder
– NE and DA in prefrontal cortex in ADHD
Table 1: ADHD Rating Scale-IV – home version
Child’s Name __________________________________________________
Child’s Age ______ Sex: M F Grade______ Child’s Race______
Completed by: Mother Father Guardian Grandparent
Circle the number that best describes your child’s home behavior over the
last 6 months
never sometimes often very
or rarely often
1. Fails to give close attention
to details or makes careless
mistakes in schoolwork. 0 1 2 3
2. Fidgets with hands or feet or
squirms in seat. 0 1 2 3
3. Has diffi culty sustaining
attention in tasks or play
activities. 0 1 2 3
4. Leaves seat in classroom or
in other situations in which
remaining seated is expected. 0 1 2 3
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PATIENT FILE
143
5. Does not seem to listen
when spoken to directly. 0 1 2 3
6. Runs about or climbs
excessively in situations in
which it is inappropriate. 0 1 2 3
7. Does not follow through on
instructions and fails to fi nish
work. 0 1 2 3
8. Has diffi culty playing or
engaging in leisure activities
quietly. 0 1 2 3
9. Has diffi culty organizing tasks
and activities. 0 1 2 3
10. Is “on the go” or acts as if
“driven by a motor.” 0 1 2 3
11.A voids tasks (e.g., schoolwork,
homework) that require
sustained mental effort. 0 1 2 3
12.T alks excessively 0 1 2 3
13. Loses things necessary for
tasks or activities. 0 1 2 3
14. Blurts out answers before
questions have been
completed. 0 1 2 3
15. Is easily distracted. 0 1 2 3
16. Has diffi culty awaiting turn. 0 1 2 3
17. Is forgetful in daily activities. 0 1 2 3
18. Interrupts or intrudes
on others. 0 1 2 3
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PATIENT FILE
144
Table 2: ADHD rating scale-IV – school version
Child’s Name __________________________________________________
Child’s Age ______ Sex: M F Grade______ Child’s Race______
Completed by: Mother Father Guardian Grandparent
Circle the number that best describes your child’s home behavior over
the last 6 months
never sometimes often very
or rarely often
1. Fails to give close attention
to details or makes careless
mistakes in schoolwork. 0 1 2 3
2. Fidgets with hands or feet
or squirms in seat. 0 1 2 3
3. Has diffi culty sustaining
attention in tasks or play
activities. 0 1 2 3
4. Leaves seat in classroom or
in other situations in which
remaining seated is expected. 0 1 2 3
5. Does not seem to listen when
spoken to directly. 0 1 2 3
6. Runs about or climbs
excessively in situations in
which it is inappropriate. 0 1 2 3
7. Does not follow through on
instructions and fails to fi nish
work. 0 1 2 3
8. Has diffi culty playing or
engaging in leisure activities
quietly. 0 1 2 3
9. Has diffi culty organizing
tasks and activities. 0 1 2 3
10. Is “on the go” or acts as if
“driven by a motor.” 0 1 2 3
11. Avoids tasks (e.g., schoolwork,
homework) that require
sustained mental effort. 0 1 2 3
12. Talks excessively 0 1 2 3
13. Loses things necessary for
tasks or activities. 0 1 2 3
14. Blurts out answers before
questions have been
completed. 0 1 2 3
15. Is easily distracted. 0 1 2 3
16. Has diffi culty awaiting turn. 0 1 2 3
17. Is forgetful in daily activities. 0 1 2 3
18. Interrupts or intrudes on
others. 0 1 2 3
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PATIENT FILE
145
Table 3: Oppositional defi ant disorder
• Aggressiveness
• Tendency to purposefully bother and irritate others
• Negativistic, hostile and defi ant behavior lasting at least 6 months
which according to DSM IV must have 4 or more of the following:
– Often loses temper
– Often argues with adults
– Often actively defi es or refuses to comply with adults’ requests
or rules
– Often deliberately annoys people
– Often blames others for his or her mistakes or misbehavior
– Is often touchy or easily annoyed by others
– Is often angry and resentful
– Is often spiteful and vindictive
Table 4: Conduct disorder
• Some think that conduct disorder is a worse version of ODD
• Approximately 6–10% of boys and 2–9% of girls
• Can be comorbid with ADHD
• Can go away by adulthood
• Can progress into antisocial personality disorder
• Can be comorbid with many other disorders including substance
abuse
• Violation of basic rights of others and rules of society, which
according to DSM IV at least three of the following must be
present in the last 12months and at least one in the last 6 months
– Aggression to people and animals
– Destruction of property
– Deceitfulness or theft
– Serious violations of rules
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PATIENT FILE
146
PPC strength
of output NE concentration
NE low-signal enhanced
DA low-noise increased PPC strength of output DA concentration
Figure 1. ADHD: Hypothetically Low Signals and/or High Noise in the
Prefrontal Cortex (PFC) in ADHD.
Theoretically, ADHD with inattention, hyperactivity and/or impulsiveness
is due to the prefrontal cortex being “out of tune” with both DA
(dopamine) and NE (norepinephrine) being too low, and causing signals
to be low and/or “noise” to be too high and drown out signals, thus
creating the symptoms of ADHD PPC strength of output NE concentration
NE optimized-signal increased
DA optimized-noise reduced PPC strength of output DA concentration
Figure 2. ADHD: Treatment to Increase NE, Increase DA.
Stimulants increase both NE (norepinephrine) and DA (dopamine) actions
in prefrontal cortex, increasing signals and reducing noise and thus
hypothetically reducing the symptoms of ADHD PPC strength of output PPC strength of output DA concentration
NE low-signal reduced
DA optimized-noise reduced
NE concentration
Figure 3. ADHD: Hypothetically Low Signals Due to Low NE.
Although many cases of ADHD may be due to low DA and NE as shown
in Figure 1, some may hypothetically be due to only low NE
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PATIENT FILE
147
PPC strength
of output NE concentration
NE optimized-signal increased
DA optimized-noise reduced PPC strength of output DA concentration
Figure 4. ADHD: Treatment with Alpha 2A Agonist.
In cases where ADHD is due predominantly to low NE activity, as shown
in Figure 3, selective NE enhancing agents such as the alpha 2A selective
noradrenergic agonist guanfacine XR may be helpful in treating ADHD
symptoms without necessarily needing to interact with DA PPC strength of output NE concentration
NE very low-signal much reduced
DA low-noise increased PPC strength of output DA concentration
Figure 5. ADHD and Oppositional Symptoms: Hypothetically Very Low
Signals in VMPFC (Ventromedial Prefrontal Cortex).
Cases of ADHD with comorbid ODD (oppositional defi ant disorder) may
differ from classical ADHD shown in Figure 1. With ADHD and ODD,
there may hypothetically be very low NE signals and low DA levels with
increased noise. PPC strength of output NE concentration
NE still low-signal still reduced
DA optimized-noise reduced PPC strength of output DA concentration
Figure 6. ADHD and Oppositional Symptoms: Treatment with a Stimulant.
When ADHD with ODD (Figure 5) is treated with a stimulant, this
improves both NE and DA levels, but is theoretically suboptimal tuning
of NE. Thus, NE is still low, signals still reduced while DA optimized
because noise is reduced. This may explain why stimulants can improve
some ADHD symptoms in patients with comorbid ADHD but not their
ODD symptoms. Raising the dose of the stimulant would put NE into
balance, but would put DA too high and thus out of balance
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PATIENT FILE
148
PPC strength
of output NE concentration
NE optimized-signal increased
DA optimized-noise reduced PPC strength of output DA concentration
Figure 7. ADHD and Oppositional Symptoms: Augment a Stimulant with
an Alpha 2A Agonist.
After treatment of ADHD comorbid with ODD (Figure 5) with stimulants
(Figure 6), the prefrontal cortex is still not adequately tuned (Figure 6),
so that ADHD symptoms may be improved but oppositional symptoms
persist. Adding an alpha 2A selective noradrenergic agonist such as
guanfacine XR to the stimulant will improve NE tone selectively, and
hypothetically enhance the therapeutic actions of the stimulant so that
both ADHD and ODD symptomst are improved
Posttest Self Assessment Question: Answer
What is true about oppositional symptoms in patients with ADHD
A. They can be part of the diagnostic criteria for ADHD in children
– False. The diagnostic criteria are inattentive, hyperactive and
impulsive, not oppositional; some patients have oppositional
symptoms insuffi cient to meet the criteria for ODD but they are not
part of the diagnostic criteria for ADHD
B. They can be confused with impulsive symptoms of ADHD
– True. Oppositional symptoms, however, are purposeful and
without remorse whereas impulsive symptoms are thoughtless
and cause remorse after the fact
C. They can be part of oppositional defi ant disorder (ODD) which can be
comorbid with ADHD
– True
D. They can be part of conduct disorder (CD) which can be comorbid
with ADHD
– Although true, oppositional symptoms are not suffi cient for the
diagnosis of conduct disorder which requires additional symptoms
as well for the diagnosis to be made
Answer: B, C and D
References
1. Franke B, Neale BM, and Faraone SV. Genome-wide association
studies in ADHD. Hum Genet 2009; 126(1): 13–50
2. Haberstick BC, Timberlake D, Hopfer CJ et al. Genetic and
environmental contributions to retrospectively reported DSM-IV
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childhood attention defi cit hyperactivity disorder. Psychol Med 2008;
38(7): 1057–66
3. McLoughlin G, Ronald A, Kuntsi J et al. Genetic support for the
dual nature of attention defi cit hyperactivity disorder: substantial
genetic overlap between the inattentive and hyperactive-impulsive
components. J Abnorm Child Psychol 2007; 35(6): 999–1008
4. Todd RD, Rasmussen ER, Neuman RJ et al. Familiality and
heritability of subtypes of attention defi cit hyperactivity disorder in
a population sample of adolescent female twins. Am J Psychiatry
2001; 158(11): 1891–8
5. Faraone SV, Advances in the genetics and neurobiology of attention
defi cit hyperactivity disorder, Biol Psychiatry 2006; 60: 1025–7
6. Stahl SM, Stahl’s Illustrated Attention Defi cit Hyperactivity Disorder,
Cambridge University Press, New York, 2009
7. Stahl SM, Attention Defi cit Hyperactivity Disorder and its Treatment,
in Stahl’s Essential Psychopharmacology, 3rd edition, Cambridge
University Press, New York, 2008, pp 863–98
8. Stahl SM, Lisdexamfetamine, in Stahl’s Essential
Psychopharmacology The Prescriber’s Guide, 3rd edition,
Cambridge University Press, New York, 2009, pp 271–6
9. Stahl SM, Atomoxetine, in Stahl’s Essential Psychopharmacology
The Prescriber’s Guide, 3rd edition, Cambridge University Press,
New York, 2009, pp 51–5
10. Stahl SM, Guanfacine XR, in Stahl’s Essential Psychopharmacology
The Prescriber’s Guide, 3rd edition, Cambridge University Press,
New York, 2009, pp 233–5
11. Stahl SM, d-Methylphenidate, in Stahl’s Essential
Psychopharmacology The Prescriber’s Guide, 3rd edition,
Cambridge University Press, New York, 2009, pp 323–7
12. Stahl SM, d,l Methylphenidate, in Stahl’s Essential
Psychopharmacology The Prescriber’s Guide, 3rd edition,
Cambridge University Press, New York, 2009, pp 329–35
13. Stahl SM, Mixed Salts of d,l amphetamine, in Stahl’s Essential
Psychopharmacology The Prescriber’s Guide, 3rd edition,
Cambridge University Press, New York, 2009, pp 39–44
14. Stahl SM, d-amphetamine, in Stahl’s Essential Psychopharmacology
The Prescriber’s Guide, 3rd edition, Cambridge University Press,
New York, 2009, pp 33–8
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