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Decision #3After four weeks of being on Adderall XL, Katie’s parents are delighted that her symptoms have improved while at the same time concerned about her daydreaming in the afternoons at school and her decreased appetite. Symptom improvement was the expectation of the PMHNP, and a reduced appetite is an expected side effect of psychostimulant. However, the PMHNP was not expecting Katie to be daydreaming in the afternoon. This is based on Stahl (2017), who reported that Adderall XR has up to eight hours of clinical action while the IR has a 3-5 hour duration of action. The next best decision at this point is to add a small dose of AdderallIR in the early afternoon. Adding Adderall IR would be a safe choice because the effect of the drug would wear off before bedtime if Katie would get her afternoon dose by noon to avoid insomnia. Moreover, this medication can therapeutically be increased for children age 6-12 between 5-40mg/day in divided doses for the Adderall IR. Considering Katie will already be taking the XR form, adding a small dose of the IR would be beneficial and well within the daily dose limits. As stated by Sadock, Sadock, and Ruiz (2014), parents of children who are prescribed psychostimulants for ADHD should be educated on the common side effect of appetite suppression at the initiation of treatment. While it is necessary to educate Katie’s parents about the appetite suppressant effect of Adderall XL, this option was not chosen because Katie is benefiting from the Adderall as reported by her parents. Phillips (2014) reported that some parents and children might decide to continue the psychostimulant if they determine that the
PRACTICUM: WEEK 3 DECISION TREE6benefit of improved ADHD symptoms outweighs the decreased appetite. The PMHNP would then reassure Katie’s parents that Katie’s weight and height would be monitored closely and thenrefer Katie to a dietitian if weight loss would be a concern. Phillips (2014) further reported that dietitians help families and their children with nutrition strategies to overcome the suppressed appetite when weight and growth are affected. Additionally, Bhat and Hechtman (2016) advise practitioners to encourage increased food intake when the medication is not operative such as early in the morning before the drug is taken and before bedtime when the medication has worn off. This helps maintain a 24-hour calorie intake. The option to augment medication with family therapy was not chosen because it is not likely to address Katie’s inattentiveness in the afternoon. Felt and Biermann (2014) stated that medication management should be the first-line treatment for children six years and older, even though behavioral therapy might help. Ethical Considerations Impacting Communication and Treatment PlanThe practitioner must obtain informed consent from the parents of the child when treatingchildren and adolescents. The privacy of the patient should also be maintained, and information released only to authorized recipients. In Katie’s situation, the PMHNP must understand that Katie’s teacher may not be permitted to receive information even though she provided Conner’s teacher’s rating scale form. Another consideration for the PMHNP regarding psychostimulants is that the American Heart Association recommends a comprehensive physical assessment before initiating stimulants (Southammakosane & Schmitz, 2015). A family history of cardiac history