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USE 5 REFERENCES 

TOPIC – ADHD

SAMPLE INCLUDED

NRNP 6665

WK3 PRESCRIBING MEDICATIONS

Learning Resources

Required Readings (click to expand/reduce)

Hilt, R. J., & Nussbaum, A. M. (2016). DSM-5 pocket guide for child and adolescent mental health. American Psychiatric Association Publishing.

· Chapter 14, “Psychosocial Interventions”

· Chapter 15, “Psychotherapeutic Interventions”

· Chapter 16, “Psychopharmacological Interventions”

Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Wiley Blackwell.

· Chapter 43, “Pharmacological, Medically-Led and Related Treatments”

Walden University. (n.d.). Developing SMART goals. https://academicguides.waldenu.edu/ld.php?content_id=51901492

Zakhari, R. (2020). The psychiatric-mental health nurse practitioner certification review manual. Springer.

· Chapter 5, “Psychopharmacology”

Required Media (click to expand/reduce)

CriticalThinkRx. (2019, June 9). Module 5: Specific drug classes: Focus on adverse effects [Video]. YouTube. https://youtu.be/Gbq6RnOsGKQ

CriticalThinkRx. (2019, June 9). Module 2: Use of psychotropics with youth_prevalence and concerns [Video]. YouTube. https://youtu.be/NRef-g4Ding

Assignment 1: Prescribing for Children and Adolescents

Off-label prescribing is when a physician gives you a drug that the U.S. Food and Drug Administration (FDA) has approved to treat a condition different than your condition. This practice is legal and common. In fact, one in five prescriptions written today are for off-label use.

—Agency for Healthcare Research and Quality

Photo Credit: Getty Images/Ingram Publishing

Psychotropic drugs are commonly used for children and adolescents to treat mental health disorders, yet many of these drugs are not FDA approved for use in these populations. Thus, their use is considered “off-label,” and it is often up to the best judgment of the prescribing clinician. As a PMHNP, you will need to apply the best available information and research on pharmacological treatments for children in order to safely and effectively treat child and adolescent patients. Sometimes this will come in the form of formal studies and approvals for drugs in children. Other times you may need to extrapolate from research or treatment guidelines on drugs in adults. Each individual patient case will need to be considered independently and each treatment considered from a risk assessment standpoint. What psychotherapeutic approach might be indicated as an initial treatment? What are the potential side effects of a particular drug?

For this Assignment, you consider these questions and others as you explore FDA-approved (“on label”) pharmacological treatments, non-FDA-approved (“off-label”) pharmacological treatments, and nonpharmacological treatments for disorders in children and adolescents.

Reference:

Agency for Healthcare Research and Quality. (2015). Off-label drugs: What you need to know. 
https://www.ahrq.gov/patients-consumers/patient-involvement/off-label-drug-usage.html

To Prepare

· Your Instructor will assign a specific disorder for you to research for this Assignment.

· Use the Walden library to research evidence-based treatments for your assigned disorder in children and adolescents. You will need to recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating this disorder in children and adolescents.

The Assignment (1–2 pages)

· Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your assigned disorder in children and adolescents.

· Explain the risk assessment you would use to inform your treatment decision making. What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?

· Explain whether clinical practice guidelines exist for this disorder and, if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.

· Support your reasoning with at least three scholarly resources, one each on the FDA-approved drug, the off-label, and a non-medication intervention for the disorder. Attach the PDFs of your sources.

In 1–2 pages, address the following:

• Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating your assigned disorder in children and adolescents.–

Excellent 23 (23%) – 25 (25%)

Good 20 (20%) – 22 (22%)

Fair 18 (18%) – 19 (19%)

Poor 0 (0%) – 17 (17%)

• Explain the risk assessment you would use to inform your treatment decision making. What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?–

Excellent 23 (23%) – 25 (25%)

Good 20 (20%) – 22 (22%)

Fair 18 (18%) – 19 (19%)

Poor 0 (0%) – 17 (17%)

• Explain whether clinical practice guidelines exist for this disorder and, if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.–

Excellent 23 (23%) – 25 (25%)

Good 20 (20%) – 22 (22%)

Fair 18 (18%) – 19 (19%)

Poor 0 (0%) – 17 (17%)

• Support your reasoning with at least three scholarly resources, one each on the FDA-approved drug, the off-label, and a non-medication intervention for the disorder. Be sure they are current (no more than 5 years old). Attach the PDFs of your sources.–

Excellent 9 (9%) – 10 (10%)

Good 8 (8%) – 8 (8%)

Fair 7 (7%) – 7 (7%)

Poor 0 (0%) – 6 (6%)

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3.5 (3.5%) – 3.5 (3.5%)

Poor 0 (0%) – 3 (3%)

Written Expression and Formatting – English Writing Standards:

Correct grammar, mechanics, and proper punctuation–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3.5 (3.5%) – 3.5 (3.5%)

Poor 0 (0%) – 3 (3%)

Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/narrative in-text citations, and reference list.–

Excellent 5 (5%) – 5 (5%)

Good 4 (4%) – 4 (4%)

Fair 3.5 (3.5%) – 3.5 (3.5%)

Poor 0 (0%) – 3 (3%)

USE 5 REFERENCES FOR THIS ASSIGN

TOPIC – ADHD

1

Week 3-Prescribing for Children and Adolescents

Holly Bowling

Walden University

NRNP 6665: PMHNP Care Across the Lifespan I

Dr. Pamela Mokoko

March 21, 2021

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2

Week 3-Prescribing for Children and Adolescents

There are many different treatment options for those suffering from ADHD including

medication management, counseling, and behavioral treatment, with sometimes a combination of

all three being necessitated for many clients. However, the overall goal of any treatment for

someone with ADHD is to help increase their attention span, slow their activity level, and

decrease their impulsiveness to help them perform better in school, and build better relationships

with their family and peers (Krull, 2019). Because not all drugs for ADHD are approved by the

FDA for adolescents, some practitioners may choose to avoid using such medications in their

treatment regimens for children, as there is typically not as much research done, however, that

does not necessarily mean the drug is not safe. It is up to the advanced practitioner to know what

drugs FDA and non-FDA are approved, as well as understanding the potential risk and benefits

of both. With that being said, the following paper will discuss FDA and non-FDA-approved

medications for the use of ADHD, with risks and benefits, as well as nonpharmacological

treatment options that may prove to be beneficial.

FDA-Approved Drug/Risk and Benefits

One FDA-approved medication I would suggest would be that of Methylphenidate

(MPH), with the trade name of Ritalin or Concerta. MPH is a stimulant and is considered a first-

line pharmacological agent in the treatment of ADHD in children and adolescents (Inglis et al.,

2016). MPH is one of the most commonly used stimulants for the treatment of ADHD and has

been shown to have positive effects on the core symptoms of ADHD, such as an increase in

concentration, attention, and focus (Inglis et al., 2016). MPH and other stimulants have also been

shown to help reduce the risk of subsequent cigarette smoking and alcohol and substance use

disorders, as well as be positively associated with improved academic achievement in elementary

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school children, improved health-related quality of life in children and adolescents, and

improved brain dysfunction (Shier, Reichenbacher, Ghuman, & Ghuman, 2012). Some common

adverse effects that can be seen with stimulants include appetite suppression, stomachache,

insomnia, and headache, however, these are generally tolerable enough to continue taking the

medication (Shier et al., 2012). There has however been some investigation into the effect

stimulants have on the growth of a child, as well as the potential for sudden death even though

the risk is below that of the general population (Inglis et al., 2016). As a stimulant, there is a high

risk for abuse, especially in those who already have an addiction problem. Therefore, it is

important to monitor the risk for abuse before starting and during treatment (Stahl, 2014).

Keeping the risk and benefits in mind is important to assess growth parameters with children and

adolescents before any stimulant treatment with periodic monitoring through repeated

measurements of weight and height and their changes over time, as well as pretreatment

checking and monitoring of pulse and blood pressure with frequent monitoring (Inglis et al.,

2016). It is also important to obtain a carefully targeted cardiac history including history of

cardiac problems and family history of sudden death in children or young adults. And for any

child or adolescent with known serious structural cardiac abnormalities, cardiomyopathy, serious

heart rhythm abnormalities, or other serious cardiac problems, stimulant treatment should be

contraindicated (Shier et al., 2012).

Off-Label Drug/Risk and Benefits

Bupropion is a dopamine and norepinephrine reuptake inhibitor (NDRI), and an off-label

drug commonly indicated for depression and smoking cessation but has also shown to be a

promising non-stimulant alternative with several reports of positive outcomes for treatment of

ADHD in adolescents (Ng, 2017). One systematic review reported that bupropion had efficacy

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comparable to stimulants and that bupropion was equally efficacious to methylphenidate. It also

showed that bupropion was better tolerated than methylphenidate; in a head-to-head trial,

headaches were observed more frequently in the methylphenidate-treated group, whereas the

frequency of other side effects, for example, decreased appetite did not differ significantly

between the bupropion-treated and the methylphenidate-treated groups (Ng, 2017). Other studies

have also found bupropion beneficial in children and adolescents with comorbid ADHD and

conduct, substance use, and depressive disorders, further supporting bupropion in the

management of ADHD, as there is an incidence of high comorbidity (Ng, 2017). Some common

adverse effects noted with Buproprion include dizziness, constipation, nausea, weight loss,

anorexia, headache, myalgia, anxiety, sweating, tinnitus, and hypertension, however, most of

them spontaneously resolve (Kweon & Kim, 2019). Due to no efficacy and safety being

established, as with any antidepressant, it is important to monitor for suicidal ideation, and

inform the parents of the risk so they can observe them as well, as suicide is a big risk factor for

adolescents taking antidepressants (Kweon & Kim, 2019).

Nonpharmacological Intervention

Many types of non-pharmacological interventions may be utilized in the treatment of

ADHD in children and adolescents. However, there are suggested uses of treatment depending

on the age group specified. The American Academy of Pediatrics (AAP) guidelines suggest that

first-line treatment for children 4-5 years old include evidence-based parent training in behavior

management (PTBM) and/or behavioral classroom interventions, and that methylphenidate may

be considered if there is no improvement (Shrestha, Lautenschleger, & Soares, 2020). Children

6–11 years should receive medications approved by the FDA along with PTBM and/or

behavioral classroom interventions. And adolescents 12–18 years should receive FDA-approved

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medications as first-line treatment, along with the encouragement of Evidence-based training

interventions and/or behavioral interventions (Shrestha et al., 2020). One of the most common

behavioral interventions is parent training in behavior management (PTBM), which encourages

parent-child therapy, and helps parents to enhance their parenting techniques and foster a better

relationship with their children. Parents are taught to recognize problematic behaviors in their

children and discourage unwanted behaviors through nonphysical means like timeouts and

reward positive behaviors through positive attention and praise (Shrestha et al., 2020). The

examination of fifty-five studies involving PTBM showed an overall strength of evidence that

was high for improved child behavior in children and adolescents with ADHD (Shrestha et al.,

2020)

Clinical Practice Guidelines

There are several key components to the clinical practice guidelines for the diagnosis,

evaluation, and treatment of ADHD, which also help in justifying such treatment options

suggested. Initiation of evaluation for ADHD should begin between the ages of 4-18, with

treatment recommendations varying depending on the child’s age, and if medication is

prescribed, it should be titrated to ensure the child receives the maximum benefit with the least

degree of adverse effects (Wolraich et al., 2019). A diagnosis of ADHD should follow established

guidelines in the DSM-V, with the evaluation including assessment of other conditions which

commonly co-occur with ADHD, such as emotional and behavioral conditions, and should be

treated as a chronic condition with the use of chronic care (Wolraich et al., 2019).

Conclusion

In conclusion, many different treatment options can be utilized for the management of

ADHD. However, the advanced practitioner needs to understand the risk and benefits of the

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different medication options, as well as best practice guidelines when administering certain

medications to different age groups, as not all medications are appropriate for everyone. It is also

important to remember as well that medication management may not be the first option or the

best option depending on age and symptoms, and that with the younger preschool children, non-

pharmacological treatments might be a better option, and for other children, a combination of

medication management and behavioral therapy might be the best fit. Regardless of the treatment

option, a risk assessment should be a priority before starting any medication, as well as

explaining any potential adverse effects to the client and family.

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References

Inglis, S. K., Carucci, S., Garas, P., Haege, A., Banaschewski, T., Buitelaar, J. K., Dittmann, R.

W., Falissard, B., Hollis, C., Kovshoff, H., Liddle, E., McCarthy, S., Nagy, P., Neubert,

A., Rosenthal, E., Sonuga-Barke, E., Wong, I., Zuddas, A., Coghill, D. C., & ADDUCE

Consortium. (2016). Prospective observational study protocol to investigate long-term

adverse effects of methylphenidate in children and adolescents with ADHD: the Attention

Deficit Hyperactivity Disorder Drugs Use Chronic Effects (ADDUCE) study. BMJ

OPEN, 6(4). https://doi-org.ezp.waldenulibrary.org/10.1136/bmjopen-2015-010433

Krull, K. (2019). Attention deficit hyperactivity disorder in children and adolescents:

Clinical features and diagnosis. Retrieved

from https://www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-

children-and-adolescents-clinical-features-and-diagnosis

Kweon, K., & Kim, H.-W. (2019). Effectiveness and safety of bupropion in children and

adolescents with depressive disorders: A retrospective chart review. Clinical

Psychopharmacology and Neuroscience, 17(4), 537–541. https://doi-

org.ezp.waldenulibrary.org/10.9758/cpn.2019.17.4.537

Ng, Q. X. (2017). A Systematic Review of the Use of Bupropion for Attention-

Deficit/Hyperactivity Disorder in Children and Adolescents. Journal of Child and

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Adolescent Psychopharmacology, 27(2), 112–116. https://doi-

org.ezp.waldenulibrary.org/10.1089/cap.2016.0124

Shier, A. C., Reichenbacher, T., Ghuman, H. S., & Ghuman, J. K. (2012). Pharmacological

treatment of attention deficit hyperactivity disorder in children and adolescents: clinical

strategies. Journal of Central Nervous System Disease, 5, 1–17. https://doi-

org.ezp.waldenulibrary.org/10.4137/JCNSD.S6691

Shrestha, M., Lautenschleger, J., & Soares, N. (2020). Non-pharmacologic management of

attention-deficit/hyperactivity disorder in children and adolescents: a

review. Translational Pediatrics, 9(Suppl 1), S114–S124.

https://doi.org/10.21037/tp.2019.10.01

Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Wolraich, M. L., Hagan, J. F., Jr, Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn,

S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R.,

Okechukwu, K., Pierce, K. L., Winner, J. D., Zurhellen, W., & SUBCOMMITTEE ON

CHILDREN AND ADOLESCENTS WITH ATTENTION-DEFICIT/HYPERACTIVE

DISORDER (2019). Clinical Practice Guideline for the Diagnosis, Evaluation, and

Treatment of Attention-Deficit/Hyperactivity Disorder in Children and

Adolescents. Pediatrics, 144(4), e20192528. https://doi.org/10.1542/peds.2019-2528

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