Effective Management of ADHD During Patient Transitions
Effective Management of ADHD During Patient Transitions

From Medscape Psychiatry & Mental Health

Effective Management of ADHD During Patient Transitions

Attention-deficit/hyperactivity disorder (ADHD) is well described and frequently successfully treated with behavioral and/or pharmacologic interventions. Presentations of ADHD are not necessarily straightforward, however. The following patient simulations represent common scenarios for the clinician. Behavioral comorbidities may resolve with successful treatment of ADHD or may require further intervention. Concomitant substance abuse may likewise improve with treatment of ADHD or may require additional intervention. Finally, initially successful treatment may require reassessment when a patient's life transitions to a new environment or new phase of development. In each case, participants have the opportunity to seek diagnostic clues, review case histories, and make therapeutic decisions.

Patient Name: Michael O., 9
Description: Michael is a 9-year-old Caucasian male whose classroom teachers have grown increasingly concerned about his behavior and academic performance over the past school year. Michael is in the second half of his 3rd grade year and attends school at a public elementary school. Michael's parents report that starting in kindergarten through 2nd grade, his teachers often commented on his activity level and talkativeness, but that his academic performance had been adequate. Since the beginning of the current academic year, however, Michael's behavior has grown consistently more disruptive and his grades have been declining.

One of Michael's teachers (he has 3) has recently moved his desk to the front of the classroom due to excessive talking and missing homework. His other teachers have also sent reports home to Michael's parents with concerns about similar behaviors. Michael's parents report that his behavior has been challenging since he was a toddler. He has often been impulsive, highly active, and forgetful. He also has difficulty managing his emotions when he becomes frustrated or upset. His parents report, however, that they have usually been able to manage this behavior by taking away privileges for negative behavior and by limiting the settings in which his behavior could cause problems (i.e., not going out to dinner as a family, not going to unstructured social events like birthday parties). Although this has disrupted family functioning, Michael's parents say they are used to it and its better than the alternative.

Based on her 23 years of experience, one of Michael's teachers suggests that he be evaluated for ADHD. The parents are unsure of whether to see psychologist or psychiatrist for evaluation and are reluctant to initiate an evaluation since they have heard many negative things about ADHD and treatment with medication. Michael has never before been evaluated for psychiatric or emotional problems and he has never received any psychological or medical treatment for these problems. Michael's parents discuss all of this information with his pediatrician.


Patient Name: Brittany M., 16
Description: Brittany is a 16-year, 7-month-old Caucasian female who is reporting difficulty keeping up with her academic work, organizing her application materials for colleges, and preparing for her impending driver's license examination. Brittany was diagnosed with ADHD by her pediatrician at age 7 due to disruptive and inattentive behavior in the classroom, which led to poor academic performance. At the time of her diagnosis, Brittany was also having difficulty in the home environment, during her dancing lessons, and in her Sunday school classes. Following her diagnosis, Brittany was prescribed several different stimulant medications over the course of 3 years, until she stabilized on a regimen of 18 mg (qd) osmotic-release methylphenidate (OROS;Concerta). She remained on this dose for 3 years until she and her parents reported that it had begun to lose efficacy. Specifically, Brittany was experiencing increasing problems completing schoolwork, following instructions at home, and managing her responsibilities both at home and in school. As a result of this, her medication dose was increased first to 36 mg (qd) and then to 54 mg (qd). Brittany and her parents reported that his dose helped with some of her difficulties, but also resulted in significant appetite loss and subsequent weight loss. Since Brittany was already underweight for her age and height, the decision was made to discontinue medication in consultation with the pediatrician. At this time, Brittany was referred to a clinical psychologist who has been working with her since that time on behavioral and cognitive strategies to manage her ADHD symptoms. This approach to treatment has been moderately effective, although Brittany's academic performance is still below what she and her parents feel she is capable of. Also, Brittany reports that her friends often tease her for being a "chatterbox" or an "airhead" on a frequent basis. Given the modest gains made in psychological treatment and her increasing impairments related to important milestones (i.e., driving, college applications, etc.), Brittany's psychologist, Dr. Evans, has referred her to a psychiatrist for a new medication consult.


Patient Name: Tom K., 28
Description: Tom is a 28-year-old African-American man who comes to your office (accompanied by his wife of two years) at the urging of his supervisor at the outside sales firm where he has been for the last 12 months. Tom's career in sales has spanned 5 years over which he has sold everything from cars to mortgages but his career has been up and down with 3 employers in the last 2 years. His present employer runs a home improvement concern for which Tom both gets new business and estimates new jobs and, while he has been productive overall, in the last 6 weeks Tom has missed work 10 days and was caught by his boss with alcohol on his breath at their noon-time sales meeting. Tom was reprimanded and sent to seek professional counseling. Tom's employee assistance program (EAP) counselor evaluated Tom for alcohol problems and conducted a careful substance use history. In the process of his counseling sessions, Tom was administered the Adult ADHD Self-Report Scale as a screener (ASRS) (see attached). Tom scored very high (total 54, scale of 0-4 per item) with 4 or more marks in the shaded area for Part A, which is highly consistent with adult ADHD requiring further evaluation. It was in this context that the EAP counselor has referred Tom to his (Primary Care Physician) PCP three months ago, for evaluation and management of possible ADHD. The PCP treated him with atomoxetine, a non-stimulant medication for ADHD, but it did not help the patient's symptoms and caused an unacceptable increase in the patient's blood pressure.

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