Volume 2 Case Number 21 Attention Deficit Hyperactivity Disorder (ADHD) affects clients across the lifespan, although it is more common in children. Data from the Center for Diseases Prevention and Control (CDC) indicates that approximately 6.1 million children in the US had ADHD in 2016 (CDC, 2019). In some cases, however, ADHD is not detected early and progresses into adulthood, where it affects an individual’s ability to run a household, maintain employment, and care for children. The presenting client is a 30-year old female diagnosed with post-traumatic stress disorder (PTSD), poly-substance abuse, and long-standing schizoaffective bipolar-type disorder. The client reports involvement in criminal activity, impulsiveness, hallucinations, difficulty managing anger, persecutory ideation, poor academic performance, and self-mutilatory behavior. This text seeks to develop an individualized treatment plan for the client with co-occurring ADHD and PTSD.

Questions to Ask the Client

Clinical interviews are crucial for effective treatment. A fundamental question to ask the client is whether they have a history of vocal and motor tics. Tics are a symptom of Tourette Syndrome, which is prevalent among ADHD patients (Kolar et al., 2008). The FDA approves stimulants as first-line treatments for adults with ADHD. However, stimulants are associated with a risk of exacerbating tics in clients with tic disorders (Kolar et al., 2008). Identifying whether Tourette Syndrome exists would help the PMHNP determine the appropriate dosage of stimulants to prescribe to minimize the risk of tics. It would also be crucial to ask whether the client has a history of cardiovascular problems. Stimulants have been associated with a high risk of cardiovascular disease in patients with ADHD, and the PMHNP may need to decide whether or not to prescribe stimulants for the client (Dalsgaard, 2014). Lower doses of FDA-approved non-stimulants may be a better option for clients with a heightened potential for cardiovascular disease (Dalsgaard, 2014). Finally, there is a need to ask the client what their specific treatment targets are. Identifying what the client expects to gain from the treatment is a crucial influencer of the most relevant treatment plan.

For the presenting client, the PMHNP could obtain feedback from their spouse, their college professor, and colleagues at work. Specific questions could include: i) what types of behavior impair the client’s learning? In what circumstances is the client disruptive and when are they not disruptive? In what types of activities does the client seem much focused on, and when are they not focused at all? These questions would provide a view of specific activities that trigger certain behaviors such as disruptiveness and self-mutilatory tendencies. Cognitive-behavioral therapy could then focus on helping clients deal with negative behaviors that could trigger disruptive tendencies. Further, identifying specific activities that keep the client focused could form a basis for educating family members, college professors, and colleagues on how to engage the client so that they are kept focused. Finally, understanding when the client is most disruptive would help the PMHNP advise the relevant parties on how to identify at-risk situations and what strategies to use to minimize the risk...…in extra neuronal catecholamines (Kolar et al., 2008). There are two primary classes of stimulants – methylphenidate and amphetamine (Kolar et al., 2018). Amphetamine increases dopamine release from presynaptic storage vesicles, but at the same time blocks the uptake of the same into neural vessels, which makes dopamine more available in the presynaptic neuron (Kolar et al., 2018). The FDA approves an initial dosage of 5mg once or twice daily for Amphetamine, with daily increases of 5mg to a maximum dosage of 40mg daily (CMS, 2016).
Conversely, methylphenidate, while still inhibiting the reuptake of norepinephrine, does not affect dopamine levels, making it possible for the drug to achieve high levels of efficacy at low doses (Kolar et al., 2018). Trials have associated stimulant use with an increased risk of cardiovascular disease. Methylphenidate is preferred to Amphetamine for the presenting client owing to its ability to realize high efficacy levels in low dosages, hence a lower risk of cardiovascular disease. The FDA approves an initial dosage of 10mg of Methylphenidate daily taken in the morning, with weekly increases of 10mg to a maximum of 60mg daily (CMS, 2016).

Conclusion

The FDA approves stimulants and non-stimulants for the treatment of ADHD in adults. However, most ADHD cases are diagnosed in childhood, with diagnoses in adulthood often hampered by similarities in symptoms with other common disorders. For instance, adults with PTSD present with symptoms similar to those of ADHD patients, signifying the need for clinicians to carry out multiple diagnostic tests as a way of increasing the accuracy of their diagnoses.

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