Ptx Ii Final - Adhd

Front 1

M.P. is a 7 year old African American male who was diagnosed with ADHD 9 months ago by his pediatrician using the AAP Clinical Practice Guideline for evaluation and diagnosis. At diagnosis, he was prescribed a low dose of short-acting methylphenidate, 5mg BID (6:30am and 3:00pm). M.P. attends school from 8:30am until 2:30pm. M.P. rides the bus home from school where his grandmother stays with him until his parents arrive home from work. A.P. has football practice four nights per week from 6:00-8:00pm. At the 6 month visit, parent rating scales show improvement in 30% of his targeted outcomes. Teachers’ rating scales show improvement in 35% of the targeted outcomes. The dose was changed at that time to methylphenidate 10mg BID (6:30 and 3:00pm) M.P. is now at the 9 month visit. Parent rating scales show improvement in 75% of her targeted outcomes. Teachers’ rating scales show improvement in 45% of the targeted outcomes. The most appropriate course of action at this visit would be:
a. Continue short-acting methylphenidate 10mg BID
b. Change medication to short-acting dextroamphetamine 10mg BID
c. Change medication to atomoxetine 10mg QD
d. Increase dose of short-acting methylphenidate to 15mg at 6:30am, 15mg at 3:00pm.
e. Refer patient to a specialist

Back 1

d. Increase dose of short-acting methylphenidate to 15mg at 6:30am, 15mg at 3:00pm.

A, Incorrect. Stated in lecture ‘The first dose that a child responds to may not be the best dose to improve function.” Start with low dose and titrate upwards. Reduce dose when side effects are seen or no further improvement is achieved.
B, Incorrect. There is no need to change to another stimulant at this point. You have not optimized therapy with the first stimulant tried.
C, Incorrect. There is no need to change to another drug class at this point. You have not optimized therapy with the first stimulant tried and you have not experienced adverse effects.
D, Correct. A.P. is showing response to the medication, increasing the dose is the next step. Since the targeted outcomes have not improved as much in the school environment (mornings), increasing the dose at that time would be appropriate. Although 75% of the target outcomes have been achieved by the parent scales, there is a possibility that you can still do better, so increasing the afternoon dose is warranted also.
E, Incorrect. The patient does not need to be referred to a specialist unless they have a treatment failure, or have a complicated diagnosis due to a co-existing condition.

Front 2

J.T. is a 15 year old Hispanic male who was diagnosed with ADHD 7 years ago. He has been successfully treated with dextroamphetamine, with his most recent dosage being intermediate-acting dextroamphetamine, 15mg QD (taken in the morning). According to parent and teacher rating scales, he has been stable on this dose for almost 2 years. J.T. recently started playing hockey at the local YMCA after school. J.T.’s father has noticed that he has a hard time interacting with the other team members, and is quickly becoming discouraged. This is the first time that he has participated in any after school type activities. The most appropriate course of action to address this concern at this visit would be:
a. Continue intermediate-acting dextroamphetamine, 15mg QD
b. Increase dose of intermediate-acting dextroamphetamine, 15mg BID
c. Change medication to intermediate-acting methylphenidate 15mg QD
d. Change medication to low-dose imipramine 2mg/kg/day
e. Refer patient to a specialist

Back 2

b. Increase dose of intermediate-acting dextroamphetamine, 15mg BID

ANSWER: B.
REASON: J.T. is now involved in additional afternoon activities, which results in a new targeted outcome, management of his ADHD symptoms in the afternoon during hockey practice. His daytime symptoms are still under control, so there is no need to change his morning dose. The addition of a later dose in the day (BID therapy) or the use of a longer acting dextroamphetamine, would provide afternoon coverage during these new activities. Changing medications at this point is unnecessary. The patient does not need to be referred to a specialist unless they have a treatment failure, or have a complicated diagnosis due to a co-existing condition.

Front 3

AP is an 8 year old Hispanic female who was diagnosed with ADHD 6 months ago by her pediatrician using the AAP Clinical Practice Guideline for evaluation and diagnosis. At diagnosis, she was prescribed a low dose of short-acting methylphenidate, 5mg BID (6:30am and 3:00pm). AP attends elementary school from 8:00am until 2:00pm. The family has a babysitter who picks up AP and her brother from school and stays with them at home until the mother comes home from work, usually around 6:00pm. AP has soccer practice two nights per week at 7:00pm. At the 3 month visit, parent rating scales show improvement in 45% of her targeted outcomes. Teachers’ rating scales show improvement in 30% of the targeted outcomes. The dose was changed at that time to methylphenidate 10mg BID (6:30 and 3:00pm) A.P. is now at the 6 month visit. Parent rating scales show improvement in 80% of her targeted outcomes. Teachers’ rating scales show improvement in 50% of the targeted outcomes. Which of the following is the most appropriate course of action at this visit?
a. Continue short-acting methylphenidate 10mg BID
b. Change medication to short-acting dextroamphetamine 10mg BID
c. Change medication to atomoxetine 10mg QD
d. Increase dose of short-acting methylphenidate to 15mg at 6:30am, 15mg at 3:00pm.
e. Refer patient to a specialist

Back 3

d. Increase dose of short-acting methylphenidate to 15mg at 6:30am, 15mg at 3:00pm.

A, Incorrect. Stated in lecture ‘The first dose that a child responds to may not be the best dose to improve function.” Start with low dose and titrate upwards. Reduce dose when side effects are seen or no further improvement is achieved.
B, Incorrect. There is no need to change to another stimulant at this point. You have not optimized therapy with the first stimulant tried.
C, Incorrect. There is no need to change to another drug class at this point. You have not optimized therapy with the first stimulant tried and you have not experienced adverse effects.
D, Correct. AP is showing response to the medication, increasing the dose is the next step. Since the targeted outcomes have not improved as much in the school environment (mornings), increasing the dose at that time would be appropriate. Although 80% of the target outcomes have been achieved by the parent scales, there is a possibility that you can still do better, so increasing the afternoon dose is warranted also.
E, Incorrect. The patient does not need to be referred to a specialist unless they have a treatment failure, or have a complicated diagnosis due to a co-existing condition.

Front 4

SF is a 4 year old Caucasian male who presents to his pediatrician for an annual exam. His mother reports that SF just got asked today to leave the daycare that he is attending and the mother “just does not know what to do with him.” This is the fourth daycare that SF has attended this year, and the mother reports that he was “kicked out” of the last three as well. The mother reports that SF just never slows down, doesn’t listen to anyone and does not get along well with the other kids. SF’s mother reports that she has tried enrolling SF in soccer and T-ball, so that he could “get rid of some energy”, but SF has been unable to get along with the other kids and was asked to leave those activities as well. Which of the following statements about ADHD in preschoolers is true?

a. There are no rating scales available to evaluate ADHD symptoms in a 4 year old child
b. If SF is diagnosed with ADHD, there is no need to consider or evaluate for comorbid conditions since preschoolers do not have comorbid conditions with ADHD
c. If SF is diagnosed with ADHD, drug therapy cannot be initiated because there are no pediatric dosage forms available for a 3 year old
d. All of the above
e. None of the above

Back 4

e. None of the above


A, Incorrect. As stated in lecture, there are rating scales (such as Conner’s) that are valid in children 3 years of age and up.
B, Incorrect. Studies estimate that at least 50% of preschoolers with ADHD also have a comorbid condition.
C, Incorrect. Methylphenidate is now available is a liquid dosage form as well as chewable tablets.
D, Incorrect.
E, Correct.

Front 5

A.P. is a 6 year old Caucasian male who was diagnosed with ADHD 6 months ago by his pediatrician using the AAP Clinical Practice Guideline for evaluation and
diagnosis. At diagnosis, he was prescribed a low dose of short-acting methylphenidate (Ritalin), 5mg BID (7:00am and 2:30pm). A.P. attends elementary school from 8:30am until 2:00pm, and then attends an after school
program at a local daycare until his father picks him up around 5:30pm. At the 3
month visit, parent rating scales show improvement in 25% of her targeted
outcomes. Teachers’ rating scales show improvement in 25% of the targeted
outcomes. The dose was changed at that time to methylphenidate 10mg BID (7:00AM and 2:30pm) A.P. is now at the 6 month visit. Parent rating scales show
improvement in 75% of his targeted outcomes. Teachers’ rating scales show
improvement in 50% of the targeted outcomes. The most appropriate course of
action at this visit would be:
a. Continue short-acting methylphenidate 10mg BID
b. Increase dose of short-acting methylphenidate to 15mg at 7:00am,
15mg at 2:30pm.
c. Change medication to short-acting dextroamphetamine (Dexedrine) 10mg
BID
d. Change medication to atomoxetine (Strattera) 10mg QD

Back 5

b. Increase dose of short-acting methylphenidate to 15mg at 7:00am,
15mg at 2:30pm.

“A” is incorrect. Stated in lecture ‘The first dose that a child responds to may not be the best dose to improve function.” Start with low dose and titrate upwards. Reduce dose when side effects are seen or no further improvement is achieved.
“B” is correct. M.H. is showing response to the medication, increasing the dose is the next step. Since the targeted outcomes have not improved as much in the school environment (mornings), increasing the dose at that time would be appropriate. Although 75% of the target outcomes have been achieved by the parent scales, there is a possibility that you can still do better, so increasing the afternoon dose is warranted also.
“C” is incorrect. There is no need to change to another stimulant at this point. You have not optimized therapy with the first stimulant tried.
“D” is incorrect. There is no need to change to another drug class at this point. You have not optimized therapy with the first stimulant tried and you have not
experienced adverse effects.

Front 6

T.S. is an 11 year old Hispanic female who was diagnosed with ADHD 3 months ago by her pediatrician using the AAP Clinical Practice Guideline for evaluation and diagnosis. At diagnosis, she was prescribed a low dose of short-acting methylphenidate, 5mg BID (6:30am and 2:00pm). M.H. attends elementary school from 8am until 1:30pm, and spends the afternoon at home with her mother. At this visit, 3 months later, parent rating scales show improvement in 75% of her targeted outcomes. Teachers’ rating scales show improvement in approximately half of the targeted outcomes. The most appropriate course of action at this visit would be:
a. Continue short-acting methylphenidate 5mg BID
b. Change medication to short-acting dextroamphetamine 10mg BID
c. Increase dose of short-acting methylphenidate to 10mg at 6:30am, 5mg at 2:00pm.
d. Change medication to low-dose imipramine 2mg/kg/day
e. Refer patient to a specialist

Back 6

c. Increase dose of short-acting methylphenidate to 10mg at 6:30am, 5mg at 2:00pm.

ANSWER C, REASON: Stated in lecture ‘The first dose that a child responds to may not be the best dose to improve function.” Start with low dose and titrate upwards.
Reduce dose when side effects are seen or no further improvement is achieved.

M.H. is showing response to the medication, increasing the dose is the next step. Since the targeted outcomes have not improved as much in the school environment (mornings), increasing the dose at that time would be appropriate. There is no need to change to another stimulant at this point, and the patient has not failed stimulant therapy, so there is no need to proceed to a second-line agent (imipramine). The patient does not need to be referred to a specialist unless they have a treatment failure, or have a complicated diagnosis due to a co-existing condition.