Attention deficit hyperactivity disorder (ADHD) is a disorder which is characterized by impulsivity, hyperactivity and difficulty in maintain attention. According to Parekh (2018), the psychiatric disorder affects boys more than it affects girls. It is less prevalent in adults than in young people. Patients with ADHD experience difficulty in cognitive functions such as problem-solving, planning and sustenance of a working memory (Storebø et al., 2015).
The American Psychological Association classify ADHD as a long-term persistent hyperactivity/inattention and/or inattention (American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders: DSM-5, 2013). The two major symptoms can occur at various developmental stages. The symptoms have to persist for a period of not less than six months to confirm a positive diagnosis. Diagnostic criteria are based on the identification of more than six symptoms for children less than 16 years and identification of more than seven symptoms in 17-year olds and adults. The two core symptoms, hyperactivity and inattention, must be present for at least six months.
Delegate your assignment to our experts and they will do the rest.
According to DSM-V, ADHD can be classified into three types depending on its presentation.
Hyperactive-Impulsive Presentation
Predominantly Inattentive presentation
Combined presentation; both symptoms of hyperactivity-impulsivity and inattention are present.
Case Study
The case study highlights an 8-year-old Caucasian female, Katie. She reports to the PMNHP accompanied by both parents. According to Katie’s school teacher, she was inattentive, and easily distracted by a short memory span. The school teacher has filled the Conner's Teacher Rating Scale-Revised form. The primary care provider insisted that Katie has to be assessed for ADHD. It appears she is losing interest in school activities and was only attentive to her interests. Both parents deny that their daughter has ADHD. They argue that Katie is never defiant and doesn’t get outbursts of emotion. At this interview, the patient denied any form of bullying but admitted to losing interest and having spans of disinterest in school activities. When the PMNHP inquired about Katie’s family, she states that all is fine at home. Also, she declares that she loves her parents.
Upon evaluation, the mental exam revealed that she had a logical speech, which was coherent and clear. Also, she has dressed appropriately for both occasion and weather. Her affect was bright with appropriate judgment and good self-reported mood. A diagnosis of ADHD; predominant presentation is made.
In this paper, my focus will be on assessing and treating Katie who has been diagnosed with ADHD. Three key decisions made in selecting an appropriate medication for this client will be reviewed and evaluated.
Factors Influencing Therapy
Factors that will be affected due to response to pharmacological agents in children include pharmacodynamics of the pharmacological agents and adverse drug reactions. Children have decreased gastric emptying, decreased acid secretion, and lowered levels of bile, decreased metabolism rates and reduced elimination when compared to adults. All these factors play a critical role in influencing response to certain medications. Since metabolism and elimination are age-dependent, children are more predisposed to adverse drug reactions and toxicity. It is thus critical to control the doses administered to children particularly for drugs that target the central nervous system.
Decision Point One
Administer chewable Ritalin tablets-10mg orally in the morning
Reason for Selection
Ritalin (Methylphenidate) is a psychostimulant which is approved by the FDA for management of ADHD in children and adults. According to Stahl, 2014, the pharmacological activity of Ritalin is dependent on elevation of norepinephrine and dopamine levels in the brain via blockade of channels that reuptake these neurotransmitters. The elevated dopamine and norepinephrine levels in the basal ganglia will improve symptoms of hyperactivity and promote sustenance of attention. Through the blockade of norepinephrine and dopamine hypothalamic reuptake inhibitors and the receptors in the medial prefrontal cortex, Ritalin elicits its pharmacological action of alleviating sleepiness, fatigue and inattention.
Intuniv extended release 1 mg is not preferred in this patient. Despite demonstrated efficacy in management of ADHD in children below the age of 12, Guanfacine is only effective for short-term treatment. Also, it is associated with side effects such as constipation, sedation, dry mouth and drowsiness. It is only used when first line agents are ineffective or cannot be tolerated. Wellbutrin (bupropion) XL 150 is not chosen due to its ability to increase suicidal tendencies.
According to Hodgkins, ShawSuzanne, McCarthy, & Sallee (2012), amphetamines and methylphenidate are considered the first-line agents for the management of ADHD I children and adolescents. When used appropriately, under supervision, the efficacy of methylphenidate is demonstrated. Although the benefits of Ritalin may be questioned, current guidelines recommend this agent as the first line. The NICE guidelines (National Institute for Health and Care Excellence) recommend its use in children and adolescents as the first-line agent meta-analyses and review by Banaschewski et al. (2016), demonstrate the short-term efficacy of methylphenidate.
Expected Results
According to Stahl (2014), the use of Ritalin is expected to improve coordination and functioning with a subsequent reduction of inattentive symptoms. The therapy initiated is expected to limit the hyperactivity and impulsivity symptoms. As the PMNHP, I expect an improvement in Katie’s academic performance. Expected side effects are fever joints, skin rashes, insomnia and tachycardia.
Difference between Expected and Actual Results
The patient returned to the clinic after a period of one month. The parents reported that it appears Katie's academic performance is improving. Additionally, she has had better mornings. Despite the improvement, she reports to the PMNHP that she experiences a change in the afternoon with periods of lost concentration and staring into space. The parents are worried about a feeling in her heart which is seen to be a pulse of 130 beats per minutes.
In the examination of the patient, there was no detailed inquiry into the family's history of cardiac disease. According to Stahl (2014), use of this agent is associated with an increase in pulse rate. Form the assessment the drug has not achieved maximum therapeutic effects. Due to the short half-life of Ritalin, the therapeutic benefits of Ritalin wear off in the afternoons.
Decision Point Two
Change to Ritalin LA 20 mg orally daily in the Morning
Reason for Selection
The reason for a changing the formulation of the drug is for purposes of extending the duration of hours to cover for inattentive periods of afternoons. Long-acting formulations of Ritalin have shown efficacy and safety (Hodgkins, ShawSuzanne, McCarthy, & Sallee, 2012) . Additionally, the advantage of this formulation is a decreased probability of abuse. According to Stahl (2014), treatment of ADHD with Ritalin should continue until the maximum therapeutic effect is achieved.
Expected Results
The goal of therapy in the management of ADHD is to relieve the symptoms of inattentiveness. In this patient, a change to the long-acting formulation is expected to improve wakefulness, concentration and executive function. Additionally, I expect Katie to have better afternoons as well as mornings. I hope that the teacher would report an improved concentration from this client throughout the school working hours.
Difference between Expected and Actual Results
After four weeks Katie returned to the PMNHP clinic and reported an improvement in academic performance. Throughout the afternoon, the drug is able to elicit its pharmacological action. Additionally, the cardiovascular side effects have resolved. At this visit her pulse rate was 92bpm. Ritalin produces its maximum effect after several weeks of administration. In some patients, there may be activation of a latent mood disorder with the use of this agent. However, a significant number of patients will experience a decrease in impulsivity/hyperactivity coupled with an enhancement in focusing and learning ability and physical coordination.
Decision Point Three
Maintain current dose of Ritalin LA and reevaluate in four weeks
Reason for Selection
Therapy with Ritalin has yielded the target of therapy. There is a noted improvement in Katie’s attention and concentration. Upon successful attainment of therapy goals, Ritalin should be maintained indefinitely. Upward titration of Ritalin will only increase the side effects and thus it is unjustified. Additionally, treatment will be continued until adulthood.
Expected Results
Long-term management goals include improvement in academic performance through paying attention to academic activities, following instructions and enhanced organizational and social skills. After a 4-week period, I will re-evaluate the client. I have also counselled the patient on compliance to medications. If the disorder worsens or in the event of any medication-related adverse effects, the parents have been advised to report to the PMNHP.
Ethical Considerations
In this client, ADHD has the potential to limit her academic performance. Thus, the administration of medication to this patient is made to suit compliance. For this reason, she has been offered Ritalin chewable tablets. Additionally, in the decision tree, the PMNHP avoided Bupropion which causes suicidal tendencies in patients.
Being a school child, the second decision to change the formulation to a long-acting formulation was influenced by the reduced productivity of the client in the afternoons. The inattentiveness which reverted in the afternoons can be managed appropriately through a change in formulation. Since the client complained of cardiovascular side effect-tachycardia, an increase in dose is not warranted. The choice proves advantageous for this client since there is a noted academic improvement on the next visit.
My ethical considerations have been guided by the age of the patient and the need to establish compliance with this patient. Since the management will last until adulthood, non-adherence can lead to remission. As the PMNHP, I have advised Katie and both parents to ensure adherence to medication with progressive follow-ups. Also, re-evaluations will be carried out periodically.
References
American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders: DSM-5. (2013). Washington, D.C: American Psychiatric Association.
Banaschewski, T., Buitelaar, J., Chui, C. S., Coghill, D., Cortese, S., Simonoff, E., & Wong, I. C. (2016). Perspective Article: Methylphenidate for ADHD in Children and Adolescents: Throwing the Baby Out with the Babywater. Retrieved from European ADHD Guidelines Group: http://discovery.ucl.ac.uk/1515794/5/Wong_Cortese_MAIN_TEXT_V3_REVISION_Editor%20File.pdf
Hodgkins, P., ShawSuzanne, M., McCarthy, & Sallee, F. R. (2012). The Pharmacology and Clinical Outcomes of Amphetamines to Treat ADHD. CNS Drugs, 22 (3), 225-268.
Parekh, R. (2017, July). ADHD . Retrieved from American Psychiatric Association: https://www.psychiatry.org/patients-families/adhd/what-is-adhd
Stahl. (2014). The Prescriber’s Guide. New York: Cambridge University Press.
Storebø, O. J., Ramstad, E., Krogh, H. B., Nilausen, D, T., Skoog, M., . . . Gluud, C. (2015). Methylphenidate for Children and Adolescents with Attention Deficit. Cochrane Database of Systematic Reviews (11), 1-610.
