Stahl Case 14: Scatter-Brained Mother Whose Daughter Has ADHD, Like Mother, Like Daughter

Stahl Case 14: Scatter-Brained Mother Whose Daughter Has ADHD, Like Mother, Like Daughter

ADHD has a high probability of coming from a genetic inheritance. According to studies, genetically inherited ADHD cases account for over 75% of cases in the United States. Therefore, mental health professions need to carefully consider conducting a genetic test when they suspect the presence of this condition. In the present case, the 26-year-old mother of two revealed the symptomatology of ADHD during the assessment of her own daughter. Such a scenario implies that nurse practitioners should keenly and comprehensively examine family members in instances wherein one of them presents with ADHD symptoms. The paper will thus look to analyze the patient from the perspective of the present nurse and then use the information to formulate an effective psychopharmacological intervention.

Clinical Interview Questions for the Patient

            The DSM-IV diagnostic criteria provides that nine core symptoms always present in patients with ADHD. According to the criteria, questions offered to the patient need to center around revealing those symptoms. Thus, in the present case, the mother of two will answer the questions below as per the DSM-V criteria (American Psychiatric Association, 2013):

1. In a scale of 1-10, how many times would you struggle to finish the final project, after the most difficult parts have been addressed?
2. In a scale of 1-10, how many times do you find it challenging to focus on a repetitive or boring work?
3. How often does your body feel restless or fidgety?

The fundamentality of the above questions draws from the fact that they allow the nurse an opportunity to diagnose not only the symptoms but also the severity of the same. The first two questions play an integral role in the determination of the existence of attention-deficit. The last one will help the nurse to analyze if the patient has hyperactivity symptom. In fact, the last question will allow the nurse to probe further so as to gain a more comprehensive insight into the hyperactivity part of ADHD.

Questions to Other People in the Patient’s Life

Given the ethical considerations concerning the assessment and treatment of ADHD patients, the nurse practitioner will seek permission from the patient to interview other people in her life. Since the patient has an unknown family history, the present nurse will interview her psychiatrist and immediate boss. The psychiatrist will be asked if they did a genetic test on the child to determine the present of the ADHD-causing gene (Kooij, 2013). The test has a substantial value in the assessment of the patient as it will either confirm or deny the presence of ADHD genes in the family line of the patient.

On the other hand, the immediate boss of the patient will have to reveal about her ability to meet deadlines- does she submit assignments or projects on time? The answer provided by the supervisor to the above question will help the present nurse to gain more insight into the workplace behavior of the patient. Additionally, the specific objective of the question involves the identification of attention issues with regard to the patient vis-à-vis her work.

Physical Exams and Diagnostic Tests

According to literature, no single test has the ability to reveal the presence of ADHD. However, a nurse practitioner has to order for these tests so as to eliminate other conditions. Particularly, the patient will have to undergo a test that will measure her electrical activity in her brain. Additionally, she will also have to undergo an MRI or CT scan to rule out brain damage. The above physicals will precede a blood test for analyzing lead levels. The nurse will also order for a complete blood test so as to eliminate the possibility of thyroid conditions as the causative diseases for the ADHD condition.

Differential Diagnosis

Attention-deficit hyperactivity disorder always occurs alongside other mental conditions. The most common conditions that co-occur with ADHD include stress, generalized anxiety disorder and substance abuse disorder (Frances, 2013). Whereas the doctor has already established the presence of ADHD as the primary condition, the existence of constant worry, fatigue, edgy feeling, irritability, insomnia, and challenging concentration point to the existence of generalized anxiety disorder (American Psychiatric Association, 2013). Thus, the nurse will diagnose the condition as ADHD and GAD.

Pharmacologic Agents

The treatment of ADHD has received significant attention from scientists across the world. All of them concur that amphetamine XR salts and methylphenidate have become the preferable molecules in the management of ADHD symptomatology. The nurse practitioner can prescribe amphetamine at a starting dose of 5 mg all the way to 40 mg per day depending on the patient’s clinical response (Stahl, 2013). Nevertheless, Stahl (2013) avers that she can similarly prescribe methylphenidate starting at a dose of 5 mg up to a clinical maximum of 60 mg per day.

The drugs normally gain favor from mental health professions due to their impressive pharmacodynamics and pharmacokinetic properties. For instance, amphetamine stimulates the central nervous system by changing the utilization of monoamines as neuronal signals (Stahl, 2014). It starts its action 30-60 minutes after administration. Additionally, the molecule has a 3-6 hours regarding its duration of action but the extended release nature of the present drug extends it. The molecule has a bioavailability rate of over 75% and a half-life of 9-14 hours depending on the present isomer.

The pharmacodynamics and pharmacokinetic properties of methylphenidate have also undergone extensive analysis. The molecule principally inhibits the reuptake of norepinephrine and dopamine. It has a duration of peak action of 2-4 hours for instant release. Methylphenidate also has a half-life of 2-3 hours but this depends on a patient (Stahl, 2013). At around 2 hours, the drug achieves its peak plasma concentration. Therefore, the drugs have similar mechanisms of action, pharmacodynamics and pharmacokinetics. However, from purely the pharmacodynamics perspective, the present nurse practitioner will elect to prescribe methylphenidate.

Contraindications/ Dosing Adjustment

            Genetic factors play a fundamental role regarding the modulation of the response to stimulant drugs such as methylphenidate. Association research works have analyzed the impacts of polymorphism in particular genes on chronic and acute responses to stimulant drugs. The presence of genetic variations in the CYPD26 gene impacts the dosage of administration as it influences the metabolism of the drug. Studies have revealed that people of Caucasian origin possess variants of the gene such as CYP2D*10 and their dosing can change based on this (Tan-Kan et al., 2016). However, a certain study revealed that the CYPD6 enzyme does not impact the metabolism of methylphenidate, implying that drugs that inhibit the enzyme, when administered concurrently with CYP2D6 do not impact its plasma concentration hence dose-adjustment.

Checkpoint Data

            As mentioned, methylphenidate dosages may start from 5 mg per day. However, given that the case involves an adult, the nurse practitioner will start at 10 mg per day and monitor the clinical response of the patient. The drug’s dosage will incrementally go up by 10 mg after every check point provided the patient reports a positive clinical response (Stahl, 2013). The nurse will undertake these increases so as to determine the optimal dosage of the drug that will lead to remission of ADHD symptoms.

Lessons Learned from the Case

            The case has revealed several important facts that can influence the future practice of the present nurse. It has supported literature assertions that ADHD has genetic linkages and the nurse will always pursue that path during assessment. Moreover, the case has revealed that ADHD mostly occurs alongside other mental health disorders and the treatment option adopted should seek to combat it before turning to the comorbid condition. Indeed, the case has shown that one needs to start by giving a patient stimulants before using SSRIs or SSNIs to treat the comorbid conditions. Lastly, the present nurse practitioner has learnt that the consideration that a treatment regimen for ADHD has succeeded can only occur when the symptoms undergo full-remission and not when a patient starts feeling better.

Therefore, the above lessons will substantially influence the future practice of the present nurse. As a consequence of the knowledge gained from the lessons, the nurse will always seek to quickly diagnose ADHD and the accompanying comorbid condition. Additionally, the nurse practitioner will adopt the usage of nonpharmacological therapy such as cognitive based therapy as the first line of treatment before resorting to stimulants. Lastly, the nurse will look to treat the conditions on a case-by-case basis as different patients have varied clinical responses to stimulants.

Reference

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Arlington, VA: American Psychiatric Association.

Frances, A. (2013). Essentials of psychiatric diagnosis. New York: Guilford Press.

Kooij, J. J. S. (2013). Adult ADHD [recurso electrónico]: Diagnostic Assessment and Treatment.

Stahl, S. M. (2014). Essential psychopharmacology: The prescriber’s guide, 5^th ed. Cambridge, NY: Cambridge Univ. Press.

Stahl, S.M. (2013).Stahl’s Essential Psychopharmacology, 4th ed. New York, NY: Cambridge University Press.

Tan-kam, T., Suthisisang, C., Pavasuthipaisit, C., Limsila, P., Puangpetch, A., & Sukasem, C. (2013). Importance of pharmacogenetics in the treatment of children with attention deficit hyperactive disorder: a case report. Pharmacogenomics and Personalized Medicine, 6, 3–7.

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