NUR 7642 Module 5 Adult ADHD Case: ASRS Screening, Stimulant Choice and CBT for Lasting Skills Example

Forty Unread Claims: Screening, Confirming and Treating ADHD in a 35-Year-Old Insurance Adjuster

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7642: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Adult Population, Part B

Mentor Name

Month Day, Year

Forty Unread Claims: Screening, Confirming and Treating ADHD in a 35-Year-Old Insurance Adjuster

The Backlog

Derek, an invented patient, is 35 and adjusts auto insurance claims for a large insurer. Last year his job went fully remote. Since then he has fallen behind, with forty claims waiting, several missed deadlines and a written warning from his supervisor. He starts reports and leaves them half done, loses track of phone calls, forgets to send documents he promised and spends hours on news sites without noticing the time. In the office, coworkers and a fixed schedule kept him on track.

He says he has always been this way. He was called lazy in school, lost his keys constantly and drifted through college in six years. He fidgets in meetings and interrupts his wife. Weekends bring a few beers, smokes cannabis on Saturday nights and has never misused prescription drugs. He has high blood pressure, controlled on lisinopril. His mother says he "never sat still" as a boy.

His wife describes the cost at home. Bills are paid late, she manages the calendar for both of them, and he has forgotten to pick up their daughter from daycare twice. She is supportive but tired, and she worries he will lose his job. Derek says he feels ashamed, and that he has spent years believing he was simply not trying hard enough. Naming the condition, the paper notes, can ease that shame, and the plan builds on it.

Screening

Kessler et al. (2005) developed the World Health Organization Adult ADHD Self-Report Scale, with 18 questions on the frequency of current ADHD symptoms, and compared its answers with blind clinical ratings in 154 people from a national survey. Six questions were selected for a short screener. Surprisingly, the six-question screener performed better than the full eighteen, with a sensitivity of 68.7 percent, a specificity of 99.5 percent and total accuracy of 97.9 percent. The authors noted that the sample was small and called for calibration in larger groups.

Derek answers four of the six screener questions in the positive range, which is a positive screen. The paper notes that the screener misses about a third of true cases, so a negative result would not have ended the evaluation, and that a positive one requires a full interview.

Confirming the Diagnosis

Adult ADHD requires symptoms before age 12 in more than one setting. Derek's mother finds his third and fifth grade report cards, which note "does not finish work," "careless errors" and "out of seat often." A structured interview confirms six inattentive and five hyperactive-impulsive symptoms now, present at work and at home, with clear harm to his job. Depression and anxiety are screened and are mild, likely following his work problems. He is asked about sleep, since poor sleep mimics inattention; he sleeps seven hours and does not snore. His cannabis use is discussed, since it can worsen attention.

Choosing a Medicine

Cortese et al. (2018) pooled 133 blinded trials of ADHD drugs, 51 of which enrolled adults, with efficacy analyses including more than 8,100 adults. All the drugs studied reduced core ADHD symptoms in children compared with placebo. In adults, amphetamines showed the largest effect on clinician-rated symptoms, followed by methylphenidate, and both were reasonably tolerated. Balancing benefit and tolerability, they favored methylphenidate for children and amphetamines once patients reach adulthood.

For Derek, a long-acting amphetamine, lisdexamfetamine, is chosen. Its prodrug form releases slowly, which lowers the risk of misuse and gives cover across his workday. It starts at a low dose and is raised weekly based on his report and his wife's. His blood pressure and pulse are checked at baseline and each visit because stimulants can raise both, and his lisinopril dose is reviewed if needed. Before prescribing, the state prescription monitoring program is checked, and a treatment agreement explains safe storage and no sharing.

Adding Skills

Safren et al. (2010) randomly assigned 86 adults with ADHD who still had symptoms despite medicine to twelve sessions of cognitive behavioral therapy or relaxation with education. Those who received therapy had lower symptom scores after treatment, and more responded, 53 percent compared with 23 percent on a global measure, with gains maintained at follow-up. The therapy taught organizing and planning, managing distraction and changing the thoughts that lead to putting things off.

Derek begins twelve sessions after his dose is set. He sets up one task list and one calendar, breaks claims into steps with a timer, closes his browser during claim work and schedules his hardest work for the morning when his medicine is strongest. His wife joins one session to agree on shared household systems.

The sessions also address what happens when the medicine wears off in the evening, when he is most likely to forget household tasks. A short checklist on the refrigerator, set reminders on his phone for daycare pickup and a ten-minute evening review with his wife cover the hours the stimulant does not. These small systems, the therapist explains, will keep working on days he forgets his dose.

Work and Follow-Up

With his consent, a letter supports a request for reasonable accommodations, such as a weekly check-in with his supervisor and written task lists. His adult ADHD rating, blood pressure and claim backlog are reviewed monthly. Cannabis is discussed again at each visit.

Conclusion

Derek has adult ADHD, combined presentation, screened with the ASRS, whose limits are stated, and confirmed through childhood report cards and a structured interview. Lisdexamfetamine, chosen because amphetamines showed the largest effect in adults in a 133-trial comparison and because its slow release lowers misuse risk, is started with blood pressure checks and a monitoring program review. Cognitive behavioral therapy, supported by a trial in medicated adults, builds lasting work skills. His backlog, ratings and blood pressure will show whether the plan works.

References

Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., Carucci, S., Atkinson, L. Z., Tessari, L., Banaschewski, T., Coghill, D., Hollis, C., Simonoff, E., Zuddas, A., Barbui, C., Purgato, M., Steinhausen, H.-C., Shokraneh, F., Xia, J., & Cipriani, A. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 5(9), 727-738. https://doi.org/10.1016/S2215-0366(18)30269-4

Kessler, R. C., Adler, L., Ames, M., Demler, O., Faraone, S., Hiripi, E., Howes, M. J., Jin, R., Secnik, K., Spencer, T., Ustun, T. B., & Walters, E. E. (2005). The World Health Organization Adult ADHD Self-Report Scale (ASRS): A short screening scale for use in the general population. Psychological Medicine, 35(2), 245-256. https://doi.org/10.1017/S0033291704002892

Safren, S. A., Sprich, S., Mimiaga, M. J., Surman, C., Knouse, L., Groves, M., & Otto, M. W. (2010). Cognitive behavioral therapy vs relaxation with educational support for medication-treated adults with ADHD and persistent symptoms: A randomized controlled trial. JAMA, 304(8), 875-880. https://doi.org/10.1001/jama.2010.1192