Case Vignettes ANSWER KEY

Case Vignettes ANSWER KEY CASE 1 Cesar, an 8 year old, 38 kg Hispanic boy, presents to your office, transferring care from another PCP across town. He presents with complaints of significant hyperactivity, impulsivity, and defiance that are problematic at home and school. Records have yet to be received from his previous provider s office but reportedly previously diagnosed with ADHD and ODD at 6 ½ years of age. Mom expresses disappointment with previous medication trial of methylphenidate that was ineffective. She recalled he had been prescribed a once daily medication and he had to swallow the capsule whole. Dose was started at 18 mg but even at 27 mg it was still ineffective so mom stopped giving it. She wants to consider another trial of medication since he is still performing poorly in school and behaving badly both at home and school. 1) What is the most likely reason that initial trial of MPH failed? He was likely underdosed and MPH can be titrated all the way to 2 mg/kg/day. If MPH was adequately tolerated previously would you retry it? Yes. If MPH was not adequately tolerated is it time to consider a nonstimulant option? Not yet since generally need failed trials with both MPH and AMP (secondary to unsatisfactory symptoms response at MAXIMUM dosage or intolerable side effects). 2) Review of parent and teacher Vanderbilt rating scales revealed the following? VANDERBILT REPORT: PARENT: Symptoms of Inattention (i.e., items with score = 2 or 3): 6 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 7 out of 9 TOTAL SCORE: 13 (4 symptoms of ODD) TEACHER: Symptoms of Inattention (i.e., items with score = 2 or 3): 8 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 5 out of 9 TOTAL SCORE: 13 (0 symptoms of ODD) Which is the most accurate diagnostic impression based on data gathered? a) Cesar continues with to evince both features of ADHD and ODD at home and school. b) Cesar continues to evince features of ADHD both at home and school but the more disruptive behaviors exclusive to domestic settings. c) Cesar s ADHD symptomatology appears subthreshold to meet criteria for formal diagnosis. 3) Mother expresses some hesitancy about medication use and asks you if it is necessary. Review of Vanderbilt rating scales from both parent and home reveal functional impairment due to ADHD related behaviors appears to be significant both at home and school to warrant medication management. Above Somewhat of a Classroom Behavioral Performance Excellent Average Average Problem Problematic Relationship with peers 1 2 3 4 5 Following directions 1 2 3 4 5 Disrupting Class 1 2 3 4 5 Assignment completion 1 2 3 4 5 Organizational Skills 1 2 3 4 5 PERFORMANCE SEVERE MODERATE MILD NOT AT ALL Academic Work 3 2 1 0

Study Habits 3 2 1 0 Attitude Towards Teacher 3 2 1 0 Peer Relationships 3 2 1 0 a) True b) False 4) Upon further inquiring about his academic struggles, you discover that Cesar failed last years end of grade testing in reading and he passed to the third grade because of summer school. Currently, teacher responses on modified Vanderbilt indicate? Circle all that apply IEP Y N or 504 Y N EC Pullout to: Inclusion Self Contained For what purpose? Title 1 OT PT ST RtI : Tier 1 Tier 2 Tier 3 Has child had educational testing? Comments: a) No Section 504 Plan has been formulated for ADHD related behaviors. b) No prior psychoeducational evaluation has been completed to rule out learning issues. c) Currently no RtI for academic intervention has been implemented 5) Based on Cesar s current weight and previously reported adequate tolerance to medication, you recommend retrying once daily formulation of MPH at higher dosing so as to continue titration of dose for optimal effect. You prescribe Concerta 27 mg once daily for 1 week and then increase to 54 mg once daily thereafter. Based on follow up Vanderbilt rating scales, there is notable improvement at school but home is another matter. He is also now experiencing mild insomnia. VANDERBILT REPORT: PARENT: Symptoms of Inattention (i.e., items with score = 2 or 3): 4 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 4 out of 9 TOTAL SCORE: 8 (2 symptoms of ODD) TEACHER: Symptoms of Inattention (i.e., items with score = 2 or 3): 2 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 2 out of 9 TOTAL SCORE: 4 (0 symptoms of ODD) Academic Performance 2 years below grade level 1 2 years below grade level At grade level 1 2 years above grade level 2 years above grade level

Reading Writing Spelling Math Above Somewhat of a Classroom Behavioral Performance Excellent Average Average Problem Problematic Relationship with peers 1 2 3 4 5 Following directions 1 2 3 4 5 Disrupting Class 1 2 3 4 5 Assignment completion 1 2 3 4 5 Organizational Skills 1 2 3 4 5 Comments : IEP Y N or 504 Y N EC Pullout to: Inclusion Self Contained For what purpose? Title 1 OT PT ST RtI : Tier 1 Tier 2 Tier 3 Has child had educational testing? Your next recommendations include: a) MPH is quite efficacious for school but still not lasting full 10 12 hours and so decide to prescribe short acting MPH booster dose for after school hours, especially since tolerance of MPH at robust dosing has not been an issue. b) Refer parent to behavioral therapist for parent management training to better address anger management and the persistent defiant behaviors still demonstrated at home. c) Academically, there is minimal improvement despite adequately controlled ADHD symptoms and so you help parent advocate for school proceeding with full psychoeducational evaluation since there may be underlying learning disability. d) You review sleep hygiene and consider OTC melatonin for initial sleep aid. 6) On the third follow up visit, Vanderbilt teacher and parent rating scales reflect notable improvement. However, his appetite has markedly diminished but mom is reluctant to make any changes at this time since efficacy is quite good. Consequently, your next recommendations may include the following statements:

a) Counsel on high protein and high calorie nutrition to help him regain his weight loss. b) Initially review his growth curve and though he has lost 4 pounds reassure parent he remains overweight between 90 to 95 th percentile. c) Discuss with parent that if weight decreases to the point of crossing significant weight percentiles, may need to consider alternative medication management. 7) On the fourth follow up visit, parent and teacher Vanderbilt rating scales reflect continued efficacy but weight loss has continued and he has now lost total of 12 pounds which is now worrying parent. Mom worried lowering his total daily dose of MPH will lose efficacy. Hence at this juncture remaining medication management options include: a) Trial of Vyvanse since also 10 12 hour duration of effect and may be better tolerated and equally or better efficacious. b) Present again option of augmenting with guanfacine ER to allow for dose reduction in total daily dose of MPH. c) Adjunctive use of Risperdal to help him gain weight. 8) Mom opted to try Vyvanse as monotherapy. On the fifth follow up visit, parent and teacher rating scales reflect satisfactory ADHD symptom management. She brings copy of his school testing results and they revealed the following: WISC IV with Verbal IQ SS 94 Perceptual Reasoning SS 100 Working Memory SS 78 Processing Speed 80 (mean is 100). Academic Achievement testing on WJ III were as follows Reading Composite 80 (Basic reading 83, Fluency 78, Reading comprehension 82), Math 92, and Writing 91 (mean is 100). You discuss results with parent and school IEP team has appeared to recommend and IEP under Specific Learning disability for which subject? a) Reading b) Math c) Writing 9) What is striking about his Working Memory management and Processing Speed in comparison to his Verbal and Nonverbal IQ scores? Is this normal?

10) What other categories of IEP eligibility may be considered for a youngster with ADHD? OHI and Emotional Disturbed CASE 2 Owen is a former 33 week preterm infant with previously diagnosed ADHD in 2013. He is new to your practice following a change in family s insurance coverage, his prior PCP had provided medication management starting since 2014 but no longer in network. Owen s mom reported unsuccessful past trials with Vyvanse and Intuniv. Side effects with Focalin XR were reported including rash around lips, onset of motor tics

and throat clearing, and compulsive smelling of self. Now at 7 years of age, weighing 31 kg, and he most recently had been prescribed Adderall 15 mg BID and review of behavior rating scales reveal it has been partially efficacious. A mild rash to lips was reported to recur but with notable decrease in appetite and recent weight loss of 8 pounds. At home he remains impulsive and loud; he is still easily distracted, and moody sometimes (i.e. angry and emotional); OC tendencies and motor and vocal tics began with stimulant medication and have persisted even off the stimulants along with some compulsive behaviors. Gathered behavior rating scales indicate mild breakthrough of ADHD related behaviors on his current medication regimen. On a DSM-oriented rating scale, parent endorsed 3/9 symptoms of inattention and 4/9 symptoms of hyperactivity/impulsiveness. No other behavior management concerns reflected on screening behavioral inventory, including no symptoms of ODD, no depression, and no overt anxiety at home. However, he is fearful about certain things and hypervigilant about police following a break in at his GF's neighbor's house. He is also fearful of thunderstorms. On gathered behavior rating scales, his teacher endorsed 5/9 symptoms of inattention and 6/9 symptoms of hyperactivity and impulsivity. His first grade teacher reported relationship with peers, following direction, and disruptiveness in class are all still problematic. Teacher s recorded responses also seem to perceives Owen as anxious in classroom. There are also ongoing academic struggles and currently failing math. 1) Along with ADHD combined subtype, what other co morbid conditions should be screened given clinical history already provided? 2) Given his prematurity, is there increased risk for neurodevelopmental disability? If, so what kind of problems are often encountered? 3) Do stimulant cause tics? Are they not contraindicated? If tics become problematic what recommendations would you consider giving to parent about her son s ADHD management? 4) Given his ongoing academic struggles what should you recommend to this parent to help with management of ADHD in classroom setting and academics? 5) Vanderbilt parent and teacher rating scales reflected partial efficacy with Adderall but given side effect complaints of appetite suppression and weight loss, mom is receptive to trying alternative stimulant medication. Which long-acting stimulant medication would you select next? 6) What instrument for further assessment at the primary care level should you consider to help better assess degree of anxiety? 7) Four weeks later with Ritalin LA dose titrated to 40 mg, parent and teacher Vanderbilt scores endorse satisfactory ADHD symptom management. However, he is demonstrating rebound moodiness that occurs after school hours. Generally, he has a window of about an hour to finish homework before

medication completely wears off. Mom completed SCARED and ends up revealing minimal of anxiety related behaviors. Owen also broke out with "allergy" around his mouth just like before with stimulants. Further inquiry reveals he is frequently licking his lips. VANDERBILT REPORT: PARENT: Symptoms of Inattention (i.e., items with score = 2 or 3): 4 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 2 out of 9 TOTAL SCORE: 6 TEACHER: Symptoms of Inattention (i.e., items with score = 2 or 3): 2 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 1 out of 9 TOTAL SCORE: 3 SCREEN FOR CHILDREN'S ANXIETY RELATED DISORDERS (SCARED): The SCARED is a questionnaire comprised of 41 statements about how people feel. Each statement is rated according to how true it has been over the preceding 3 months. Possible responses for each statement are: 0 (Not True or Hardly Ever True) 1 (Somewhat True of Sometimes True), or 2 (Very True or Often True). One form is designed for the child to complete; a separate form is for a parent to complete. Significant Total Score (>25) indicates high likelihood of an anxiety disorder. Subtypes of anxiety are assessed by tallies of specific questions; risk of having each subtype is considered high if the cutoff (in parentheses) for that subtype is exceeded. Parent's ratings: Panic/Somatic (7): 1 Gen. Anxiety Disorder (9): 6 Separation Anxiety (5): 3 Social Anxiety (8): 1 School Avoidance (3): 1 TOTAL (25): 12

What changes in any in medication management would you consider at this juncture? What is the general maneuver from a medication standpoint to help with rebound moodiness? Is it surprising with stimulants for kids with anxious disposition or OCD tendencies to experience exacerbation of anxiety/ocd tendencies? Mom pleased with efficacy and overall tolerance to MPH compared to other stimulants previously tried and so discussed options with dosing. Can lower MPH dose to help reduce the compulsive lip licking and add guanfacine for adjunctive dose to help make up the difference in ADHD symptom control or can try different MPH formulation and switch from Ritalin LA (50/50) to Metadate CD (30/70). 8) Mom opted to first try Metadate CD formulation before having to add a second ADHD medication for augmentation. There was adequate tolerance to medication, and tics seem to persist intermittently but with slight increase observed at this visit. He seemed to do very well with Metadate CD 40 for first 2 weeks and now seeing steady increase of breakthrough ADHD related behaviors. Comparing Ritalin LA to Metadate CD, mom thought Owen did better in school performance with the 50/50 distribution but appetite was much more significantly diminished at the 40 mg/day of Ritalin LA. Mom completed Vanderbilt in follow up visit today and brought updated one from teacher. Now what do you recommend? VANDERBILT REPORT: PARENT: Symptoms of Inattention (i.e., items with score = 2 or 3): 5 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 4 out of 9 TOTAL SCORE: 9 TEACHER: Symptoms of Inattention (i.e., items with score = 2 or 3): 3 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 3 out of 9 TOTAL SCORE: 7 Although stimulants are first-line treatment of ADHD based on established robust efficacy, there are various indication for the use of FDA-approved nonstimulant medications for children aged > 6 years. In this case an alpha-adrenergic agonist may be prescribed as monotherapy, or in cases of partial stimulant response, guanfacine can be used as augmentative to stimulant medication. So monotherapy even at robust MPH dosing was not enough to adequately sustained ADHD symptom control. Consequently mom was ready to proceed with adjunctive use of guanfacine to better target ADHD related behaviors and once at maintenance dose can consider switching back to Ritalin LA formulation at even possibly at reduced dose for less impact on appetite. May need to consider swapping out MPH for another stimulant which worked well in past until developed tachyphylaxis if it appears same is occurring with MPH. Vocal tics were more continue to monitor and might even garner further reduction of tics with guanfacine on board. His anxiousness is stable and if can ultimately back down on stimulant dose, likely will see less of his compulsive behaviors. Plan is to continue Metadate CD 40 mg/day. Due to cost at this time, added guanfacine 1/2 tabs in AM and PM to better target ADHD related behaviors.

9) At his now fifth follow up visit, Mom reports improved target symptoms with the addition of guanfacine, but ADHD symptom control is not yet optimal in classroom setting. Metadate CD typically lasts long enough for HW time before wearing off so that the 1/2 mg of guanfacine near dinner time is sufficiently helpful but not enough for school. Vocal tics have increased in frequency and teacher complaining they are distracting to other children in classroom. Owen is fearful he will get in trouble in school for being disruptive. Mom inquiring if she should pursue behavioral therapy to help him with self-regulation and further reduction of impulsiveness. On gathered behavior rating scales, his teacher endorsed 6/9 symptoms of inattention and 5/9 symptoms of hyperactivity and impulsivity. He continues to rush through his work, he remains disorganized, and requiring lots of redirection to remain on task. Academically he continues to struggle and he is performing 1 to 2 years below grade level. Still no RtI or Section 504 plan in place. Now what would you recommend? VANDERBILT REPORT: PARENT: Symptoms of Inattention (i.e., items with score = 2 or 3): 3 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 2 out of 9 TOTAL SCORE: 5 TEACHER: Symptoms of Inattention (i.e., items with score = 2 or 3): 6 out of 9 Symptoms of Hyperactivity/Impulsivity (i.e., items with score = 2 or 3): 5 out of 9 TOTAL SCORE: 13 Keep Metadate CD at 40 mg, switch short acting guanfacine to ER formulation and get PA. Would continue with titration of Intuniv to better target ADHD symptom control and help further reduce tic frequency. Agree with behavioral therapy but to also address increased anxiousness, coping strategies the promote increased relaxation and self-regulation. CBT for habit reversal is evidence based to help with tic reduction. Monitor level of anxiety and consider having him complete SCARED child version for further assessment if needed. Help advocate for formulation of Section 504 Plan to help with ADHD related behaviors in class and request RtI Tier 2 level of intervention. Ultimately, he may need full IEP and can be considered under OHI secondary to ADHD diagnosis. 10) Two months later with Metadate CD maintained at 40 mg/day and Intuniv titrated to 4 mg, gathered parent and teacher Vanderbilt scores endorse satisfactory ADHD symptom management. Section 504

Plan is in place with RtI at Tier 2 and academically appreciating improved progress. ARD meeting is in 2 weeks. Mom s only concern is noticing increased daytime somnolence corroborated by teacher comments on Vanderbilt since dose of Intuniv was increased from 3 to 4 mg/day. He had been taking dose in AM along with his stimulant. What one change would you recommend? Given complaints of increased daytime somnolence experienced with higher dosing of Intuniv at 4 mg, would switch to dinner time or bedtime before considering dose reduction.