Attention deficit hyperactivity disorder case studies and clinical presentations

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.
Apart from the client, the PMHNP also needs to conduct interviews with other parties who closely interact with the presenting client to further assess their situation. 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 of negative behaviors.
Diagnostic and Physical Tests
Physical tests conducted on the client could include checking for hearing impairment, visual impairment, malnutrition, and evidence of abuse (Smucker & Hedayat, 2001). However, these physical tests need to be complemented with diagnostic tests approved for use on adult patients. Self-rating scales recommended for adults such as the presenting client include the Wender-Utah rating scale for ADHD and the Adult ADHD Self-Report Scale. The Wender-Utah rating scale is a 25-item scale that assesses ADHD in adults based on childhood symptoms. Respondents are called upon to specify the extent to which they agree with each of the 25 items on a scale of 0 to 4. ADHD is believed to be present if the client reports a score of at least 46 points.
The Adult ADHD Self-Reporting Scale consists of the 18 DSM-IV-TR criteria for ADHD (ADDA, 2015). A positive screening test for ADHD is given if the client reports a score of at least four points on the six-item part A of the scale, which measures how often a client feels compelled or overly active to do things, squirms or fidgets, delays getting started on tasks requiring a lot of thought, and how often they have trouble wrapping up a project’s final details, getting things in order, and remembering appointments (ADDA, 2015). The results obtained from these screening tests could inform a more in-depth clinical interview such as the DSM-V structured interview to provide an accurate ADHD diagnosis. The DSM-V criteria diagnose ADHD by assessing symptoms or behaviors that have persisted for at least 6 months in 2 settings that are essentially diverse – such as school, work, and church. For an adult client to receive a positive ADHD diagnosis, they need to demonstrate at least five of the diagnostic symptoms and/or behaviors.
Differential Diagnoses for the Client
Differential diagnoses for the presenting client include post-traumatic stress disorder, depression, and mood disorder. The client exhibits both behavioral and psychological symptoms of bipolar disorder. Behavioral symptoms exhibited include irritability, agitation, risk-taking behavior such as self-harm, and impulsivity - while psychological symptoms include depressed mood and hallucinations (APA, 2013). The client further exhibits depressive symptoms including agitation and irritability, low memory ability, and persecutory ideation that leads to the infliction of self-harm (APA, 2013). However, PTSD is the most common differential diagnosis because it shares the largest number of symptoms with ADHD. Symptoms common to both PTSD and ADHD in the presenting client include a lack of concentration, evidenced in the inability to focus on tasks and remember things due to memory problems, impulsive behaviors leading to engagement in risky tendencies such as self-harm, and hyperactivity/agitation – emotional outbursts leading to violence, and hallucinations (APA, 2013). Further, of the three differential diagnoses, only PTSD manifests in the form of hyperactivity leading to violent tendencies against others, which is one of the key symptoms exhibited by the presenting client.
Treatment
The FDA approves stimulant and non-stimulants for the treatment of ADHD in adults. Several studies have in the past shown that stimulants are an effective treatment option for ADHD, with a responsiveness range of between 70 and 80 percent (Kolar et al., 2008). Stimulants work by inhibiting the presynaptic neuron’s reuptake of dopamine and norepinephrine, leading to an increase 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.











References
APA (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (5th ed.). Washington, DC: American Psychiatry Association.
ADDA (2015). Adult ADHD Self-Report Scale: Symptom Checklist Instructions. Attention Deficit Disorder Association. Retrieved from https://add.org/wp-content/uploads/2015/03/adhd-questionnaire-ASRS111.pdf
CDC (2019). Data and Statistics about ADHD. Center for Diseases Prevention and Control (CDC). Retrieved from https://www.cdc.gov/ncbddd/adhd/data.html
CMS (2016). Stimulant and Related Medications: US Food and Drug Administration – Approved Indications and Dosages for Use in Adults. Center for Medicare and Medicaid Services. Retrieved from https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Pharmacy-Education-Materials/Downloads/stim-adult-dosingchart11-14.pdf
Dalgaard, S., Kvist, A., Leckman, F. J., Nielsen, H., & Simonsen, M. (2014). Cardiovascular Safety of Stimulants in Children with Attention –Deficit/Hyperactivity Disorder: a Nationwide Perspective Cohort Study. Journal of Child and Adolescent Psychopharmacology, 24(6), 302-10.
Kolar, D., Keller, A., Golfinopoulos, M., Cumyn, L., Syer, C., & Hechtman, L. (2008). Treatment of Adults with Attention-Deficit/ Hyperactivity Disorder. Neuropsychiatric Disease and Treatment, 4(2), 389-403.
Smucker, W., & Hedayat, M. (2001). Evaluation and Treatment of ADHD. American Family Physician, 64(5), 817-30.