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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Describe the signs and symptoms of attention-deficit hyperactivity disorder (ADHD) as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5.

  • Differentiate treatment options for ADHD with regard to effectiveness, tolerability, safety, monitoring parameters, and potential for drug interactions.

  • Compare the advantages and disadvantages of once-daily stimulant preparations with immediate-release stimulants.

  • Develop useful dosing schedule strategies that may be employed in the management of patients with ADHD to enhance medication adherence.

  • Perform patient assessment to determine efficacy with selected therapy and appropriate monitoring for any adverse effects.

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PATIENT PRESENTATION

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Chief Complaint

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“My son has trouble focusing and sitting still while completing his afternoon homework.”

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HPI

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David Handlon is a 10-year-old boy who returns for a routine visit to his psychiatrist with his mother. He was diagnosed 2 years ago with ADHD and is currently being treated with Adderall XR 20 mg every morning. His mother states that during the last parent–teacher meeting, his teacher indicated that David’s behavior is well controlled during the day. Despite David’s good behavior during the day, his mother reports difficulty getting David to complete any afternoon tasks or assignments after school. David’s rules include no playtime activities until he has completed his afternoon homework assignments. Instead of focusing on homework, David insists on playing Guitar Hero® in his room, and he sometimes carelessly throws his guitar. David has also exhibited impulsive and reckless behavior when interacting with his younger 8-year-old brother. Initially David’s mother thought the medication was working. However, within the past year, David’s afternoon antics have progressively gotten worse. Mrs Handlon is afraid that uncontrolled afternoon antics will have serious repercussions on David’s daytime behavior and grades. She questions, “What are my options?”

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PMH

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  • Asthma × 3 years

  • ADHD × 2 years

  • Tonsillectomy (1 year ago)

  • Broken wrist at age 8 (fell from tree)

  • Vaccinations up to date

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FH

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Both father and uncle have a history of hyperactivity and are currently receiving treatment as adults

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SH

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Lives with both parents and younger brother in the suburbs

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Meds

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  • Adderall XR 20 mg daily (given every morning at 7:00 am)

  • Albuterol inhaler two puffs Q 4–6 H PRN shortness of breath

  • Singulair 5 mg PO daily

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All

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NKDA

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ROS

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Physical assessment was difficult to assess in David as he could not sit still for more than 30 seconds and was jumping off of the exam table. Asthma symptoms appear controlled with PRN inhaler use at bedtime only and daily Singulair.

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Physical Examination

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