Attention Deficit Hyperactivity Disorder
A Young Girl With ADHD

A Young Girl With ADHD

 

Decision Point One


Begin Wellbutrin (bupropion) XL 150 mg orally daily

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what you should do next:


Educate the parents that Bupropion sometimes causes suicidal ideation in children and that this is normal, and re-start the drug at the previous dose

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie's parents again report that after about a week of treatment with the Bupropion, Katie began telling her parents that she wanted to hurt herself and began having dreams about being dead. This scared her parents and they stopped giving her the medication
  • At this point, they are quite upset with the results of their daughter’s treatment and are convinced that medication is not the answer
Decision Point Three
Select what you should do next:


Refer the parents to a pediatric psychologist who can use behavioral therapy to treat Katie’s ADHD
Guidance to Student

Bupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.

At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.

In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.

You should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow you to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.


Do nothing, and explain to the parents that Katie’s ADHD will most likely improve with age as her prefrontal cortex grows and matures
Guidance to Student

Bupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.

At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.

In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.

You should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow you to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.


Discuss the use of a medication such as Adderall and its evidence for treating ADHD
Guidance to Student

Bupropion is used off-label for ADHD and is used more commonly in adults. It’s mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, (which largely lacks dopamine transporters) bupropion can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Bupropion as well as other antidepressants have been linked to suicidal ideation in children and adolescents- despite the fact that it was being used initially to treat ADHD, it is still an antidepressant.

At this point, the parents are probably quite frustrated as no parent wants to hear their child talking about hurting themselves or having dreams about being dead. If the parents are adamant about no more medications, referral to a pediatric psychologist or similar therapist skilled in the use of behavioral therapies to treat ADHD in children. However, it should be noted that behavioral therapies work best when combined with medication, however, if the parents are insistent, then behavioral therapy may be the only alternative left in the treatment of Katie.

In terms of the pathophysiology of ADHD, whereas it may be true that increasing age may demonstrate some improvement in symptoms (some people will actually experience complete resolution of symptoms by adulthood), it is not helping Katie in the here and now. Katie still needs help with her symptoms which are causing academic issues.

You should attempt to repair the rupture in the therapeutic alliance (the parents now believe that medications are not the answer) by explaining rationale for the use of Bupropion (many people like to start with Bupropion because it has a low-risk for addiction). The family should be encouraged to allow you to initiate Adderall as it has a very good track record in terms of its efficacy in treating ADHD.


Discontinue Wellbutrin and begin Strattera (atomoxetine) 10 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are getting a bit better
  • They are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three
Select what you should do next:


Maintain current dose of Strattera and reevaluate side effects at next office visit in 4 weeks
Guidance to Student

Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.

After discontinuing the Wellbutrin and beginning Strattera (atomoxetine), a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but you will need to monitor it. Keep in mind that if you decides to increase the dose at this point, the side effects may worsen. Additionally, Strattera can take up to 8 to 12 weeks to demonstrate the full therapeutic actions of the drug; therefore, it may be prudent at this point to maintain the current dose.

The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.


Discontinue Strattera and begin Intuniv extended release, 1 mg orally daily
Guidance to Student

Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.

After discontinuing the Wellbutrin and beginning Strattera (atomoxetine), a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but you will need to monitor it. Keep in mind that if you decides to increase the dose at this point, the side effects may worsen. Additionally, Strattera can take up to 8 to 12 weeks to demonstrate the full therapeutic actions of the drug; therefore, it may be prudent at this point to maintain the current dose.

The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.


Increase Strattera to 25 mg orally daily and reevaluate at next office visit in 4 weeks
Guidance to Student

Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.

After discontinuing the Wellbutrin and beginning Strattera (atomoxetine), a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but you will need to monitor it. Keep in mind that if you decides to increase the dose at this point, the side effects may worsen. Additionally, Strattera can take up to 8 to 12 weeks to demonstrate the full therapeutic actions of the drug; therefore, it may be prudent at this point to maintain the current dose.

The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.


Discontinue Wellbutrin and begin Adderall (amphetamine d, l) extended release 5 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Katie’s parents report that they spoke with Katie’s teacher who notices that her symptoms are getting a bit better
  • They are very concerned, however, about Katie’s decreased appetite. They say that Katie was never a “big eater” but have become concerned that her appetite has worsened
Decision Point Three
Select what you should do next:


Maintain current dose of Adderall and re-evaluate side effects at next office visit in 4 weeks
Guidance to Student

Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.

After discontinuing the Wellbutrin and beginning Adderall, a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but you will need to monitor it.

Increasing the dose of Adderall may worsen this side effect; however, if symptoms are still severe enough, an increase in dose may be warranted. At this point, you need to know what symptoms have improved and—based on overall functioning—must then determine whether or not there is an indication to increase the current dose of the medication.

The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.


Discontinue Adderall and begin Intuniv extended release, 1 mg orally daily
Guidance to Student

Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.

After discontinuing the Wellbutrin and beginning Adderall, a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but you will need to monitor it.

Increasing the dose of Adderall may worsen this side effect; however, if symptoms are still severe enough, an increase in dose may be warranted. At this point, you need to know what symptoms have improved and—based on overall functioning—must then determine whether or not there is an indication to increase the current dose of the medication.

The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.


Adderall to 10 mg extended release daily and reevaluate at next office visit in 4 weeks
Guidance to Student

Wellbutrin is used off-label for ADHD but is used more commonly in adults. Its mechanism of action results in increasing the neurotransmitters norepinephrine/noradrenaline and dopamine. Since dopamine is inactivated by norepinephrine reuptake in frontal cortex (which largely lacks dopamine transporters), Wellbutrin can increase dopamine neurotransmission in this part of the brain, which may explain its effectiveness in ADHD. However, Wellbutrin, as well as other antidepressants, has been linked to suicidal ideation in children and adolescents. Despite the fact that it is being used to treat ADHD, it is still an antidepressant.

After discontinuing the Wellbutrin and beginning Adderall, a decrease in symptoms was noted by Katie’s teacher. This indicates that the drug is working. However, the parents are concerned about Katie’s decreased appetite. This side effect may improve with the passage of time, but you will need to monitor it.

Increasing the dose of Adderall may worsen this side effect; however, if symptoms are still severe enough, an increase in dose may be warranted. At this point, you need to know what symptoms have improved and—based on overall functioning—must then determine whether or not there is an indication to increase the current dose of the medication.

The development of common side effects are not an indication to discontinue one drug and begin a different medication unless they are severe enough to warrant intervention (i.e., they are severe or incapacity for the individual); therefore, it would not be appropriate to discontinue Strattera and begin Intuniv.