Attention Deficit Hyperactivity Disorder NURS 6660

Attention Deficit Hyperactivity Disorder NURS 6660

Attention Deficit-Hyperactivity Disorder (ADHD) is a psychiatric disorder that is believed to mostly affect the ability of children to function. Affected individuals show inappropriate levels of inattentiveness, hyperactivity, or impulsivity.

It can also be classified as a neurodevelopmental disorder. Several diagnostic evolutions have taken place in several years especially for neurodevelopmental conditions. The Diagnostic and Statistical Manual of mental disorders (DSM 5) is one of the standard tools for the diagnosis of such disorders.

In the previous versions of the diagnostic manual, attention deficit disorder (ADD) and ADHD were classified as two different diseases. The DSM IV combined both diagnoses into one disorder. ADD is when children are extremely inattentive, but not hyperactive (Higgins & George, 2018).

The symptoms for ADHD begin at a young age. According to the DSM 5 criteria, a diagnosis of ADHD can be made only if the symptoms of ADHD have been present before the age of 12 years. These symptoms should also occur in various settings such as at work, at home, or in school.

These symptoms should also interfere with daily activities and impair social, academic, and occupational functioning so as to meet the diagnostic criteria.  These symptoms should also have been there for a long time, preferably 6 months.

The disorder should also not be accounted for by any other behavior disorder (APA, 2013). An authorized medical practitioner such a psychiatrist or a specialist who is well familiar with the disorder must be present when making the diagnosis. The DSM 5 classifies ADHD into 3 types: predominantly hyperactive/impulsive, predominantly inattentive, and combined.

Why I Chose ADHD.

I chose ADHD because it is a common disorder in childhood that is usually overlooked. This usually results in many patients going undiagnosed. Many people do not understand this illness and believe that it only affects the attention of children. According to the National Institute of Mental Health (NIH), (2019) it is possible that this disorder can be present in adults contrary to common beliefs.

The number of new cases of ADHD has increased in the past few years. Despite this, some doubt that ADHD is common. They believe that these children diagnosed are simply overactive, but otherwise healthy. This is important because a wrong diagnosis can predispose the child to unnecessary treatment.

Diagnosis with certain illnesses also comes with a lot of stigma. Being labeled as mentally ill can affect one’s self-esteem. Some cases of ADHD also go unnoticed and are not diagnosed. This can have a negative impact later in life as they miss out on treatment that could help them.

Severe ADHD is a major burden to the child as it affects the child’s everyday routine and life. The family can also be affected. Patients who have ADHD behave differently from the rest of their peers. Their behavior is usually unexpected and therefore causes trouble to the people who have to deal with them. Children with ADHD usually need a lot of attention.

ADHD has far reaching effects. Teenagers with ADHD are more likely to abuse drugs, smoke and use alcohol. These can make the problem worse. ADHD patients are also more likely to have accidents and hurt themselves. They also tend to have conflicts with their peers or get in trouble because of going against the rules while in school.

This behavior can spill out of the school setting and are more likely to get involved in crimes more than their agemates. Developmental problems can also arise such as difficulties with reading or writing.

Etiology

The etiology of ADHD has not been fully understood. The causes are related to factors that include both environmental and genetic components. Genes play an important role. Among the psychiatric disorders, it is one of the most inheritable. There is a higher concordance in monozygotic twins than dizygotic twins. Siblings are two times more at risk of developing ADHD than the general population (Nigg et al., 2020).

Other factors implicated in the development of this disorder include prenatal factors such as viral infections, nutritional deficiency during pregnancy, and smoking or exposure to alcohol during pregnancy. There is also a link between birth weight and ADHD whereby children who have very low birth weight are most at risk (Sciberras et al., 2017).

Other factors include the number of dopaminergic receptors whereby it is suggested that individuals with ADHD have a decreased number of dopaminergic receptors in the frontal lobes. Research has also shown that dopamine is transported differently between brain nerve cells in patients with ADHD. This especially affects brain regions used for memory and learning (Higgins & George, 2018).

Some theories suggest that ADHD can also be linked to changes in the society. An example is the emphasis of the modern society to success and achievement. Abrupt disruptions in the child’s family situation can also play a role. Also, ADHD can be due to overstimulation or lack of exercise (Nigg et al., 2020).

Nutrition is also an important factor when considering the etiology. Certain foods are linked with ADHD e.g., children who eat artificially colored food are more likely to have abnormal behavioral tendencies. Nutrition, however, plays a minimal role in the development of the condition (Nigg et al., 2020).

Pathophysiology

The pathology of ADHD is not clear. ADHD is thought to be due to both functional and cognitive deficits in the brain. Patients with ADHD have been shown to have a smaller dorsolateral prefrontal cortex and anterior cingulate gyrus. It is possible that these changes explain the deficiencies in goal-directed behavior. Frontostriatal malfunctioning has also been implicated in the etiology.

Deformations in the basal ganglia nuclei have been demonstrated in children with ADHD such that more prominent deformations are associated with more severe symptoms. These deformations can be normalized by using stimulants (Bijlenga et al., 2019)

Slower cortical thinning is associated with higher levels of hyperactivity/impulsivity. This is most notable in the prefrontal cortex. Slower cortical thinning in adolescence is a characteristic of ADHD. Children with ADHD have lesser volumes of grey matter compared to typically developing children.

Adults with ADHD also have depressed dopamine activity. This is associated with inattention. This reinforces the responses to intravenous methylphenidate. The psychostimulants used in the treatment of ADHD have led to speculation that some areas of the brain are deficient in neural transmission. This dopamine dysfunction also contributes to substance abuse.

Signs and Symptoms.

Children with ADHD usually present with inappropriate levels of being inattentive, impulsive, or hyperactive (Higgins & George, 2018). These are however not uncommon in children and teenagers. To classify as ADHD the symptoms have to be extreme and the behavior has to be different to the behavior of other children.

Inattentive simply refers to the fact that the child cannot focus on an activity or has difficulties in focusing. These children are also easily distracted. Children with ADHD have short attention spans and therefore find it difficult to learn. They often do not seem to listen to what is being said.

These children also tend to make careless mistakes in schoolwork or other activities. They find it difficult to focus on their free time. These children are forgetful and lose things. Patients also avoid tasks and find it difficult to organize tasks.

An overly impulsive child will be careless, inconsiderate and act in a way that is extremely rash. These children are usually very impatient for their age. They hardly wait for their turn when performing group activities such as playing games. They also interrupt others.

Being hyperactive means that the child is restless or fidgety. These children usually are unable to sit still and in school this becomes a problem especially during lessons. These children tend to get up and walk a lot around the classroom. They have trouble keeping quiet. They run around a lot and do things like climbing or jumping on furniture.

The severity of the symptoms of ADHD can differ from one child to another. The behaviors which are more pronounced also differ in boys and girls. Some children exhibit inattentiveness more predominantly and they can often appear to be daydreaming. Other children can especially be more impulsive and hyperactive. This leads to children with ADHD being divided into two groups: primarily inattentive or primarily hyperactive-impulsive (Higgins & George, 2018).

In adults, the core symptoms can be missing. These can manifest as problems such as low self-esteem, mood instability and procrastination. Adults with ADHD are more likely to be impulsive in nature. They also tend to be inattentive. Hyperactivity is not usually seen as this is one symptom adults can control. The symptoms of inattention and hyperactivity will be elicited from a proper childhood history. This is however not guaranteed.

ADHD may also interfere with functioning and is noticed from the adult’s inability to complete tasks in time or paying attention when performing important task such as driving. ADHD is usually associated with road accidents. Patients can also have difficulties in expressing their feelings and building relationships (Higgins & George, 2018).

Pharmacotherapy agents

ADHD can be treated both by behavioral therapy and pharmacotherapy. For children, may healthcare providers have hoped for treatment options that do not involve medications. This is however not possible as the specific symptoms of ADHD cannot be treated without medication. Mild cases of ADHD can be treated using behavioral therapy, but this is only moderately successful.

Pharmacotherapy in children faces some drawbacks especially due to compliance issues with medications. Because of this, long-acting medications are preferred to shorter acting drugs. Long-acting drugs are associated with marked increase in adherence and they are also time effective as they cover the full day.

The treatment of ADHD involves the use of stimulants or nonstimulants (Rosenthal & Burchum, 2017). Stimulants are the mainstay for treatment. Stimulants have been shown to be effective in treating ADHD. They enhance arousal in the prefrontal cortex. They block the reuptake of dopamine at the presynaptic and postsynaptic membranes thus boosting dopamine neurotransmission.

These drugs also boost norepinephrine neurotransmission.  Stimulants are then further subclassified into amphetamines and methylphenidates. Amphetamines can directly increase the production of dopamine. Amphetamines also competitively inhibit dopamine by acting directly on the dopamine and norepinephrine transporter as a pseudo-substrate. Methylphenidate acts by inhibiting presynaptic dopamine transporters (Stahl, 2017).

These drugs are further prepared in different formulations. They can either be immediate release, extended release, or long-acting/ sustained release. Immediate release methylphenidate medications include Ritalin and Methylin. Ritalin and Methylin can also be prepared in extended-release forms. Another example of extended-release methylphenidate is Metadate.

Immediate release amphetamines include Adderall. Adderall can also be found in extended-release preparations. Other extended-release amphetamines include Adzenys, Dexedrine and Dyanavel. Methylphenidates are the drugs of choice for the treatment of ADHD. It is approved by the FDA to treat ADHD in children from the age of 6 years and above (Brown et al., 2018).

Non-stimulant medications have also been shown to be effective in the treatment of ADHD. Non-stimulants are classified into two categories, antidepressants and alpha agonists. Atomoxetine is the best-known drug in the antidepressant category.

It works as a selective norepinephrine reuptake inhibitor (SNRI). Many trials have shown it to be an effective treatment option for ADHD. Atomoxetine increases dopamine and norepinephrine concentrations in the prefrontal cortex. It does not affect the concentrations in the nucleus accumbens.

Stimulants are however more effective in comparison. Because of this, the response to atomoxetine is usually much slower and may take several weeks even after titration to the maximum dose. Atomoxetine has minimal antidepressant effects and is used in children who have anxiety or tolerate stimulants poorly (Cortese et al., 2018).

Bupropion is another antidepressant used for ADHD. It is a weak inhibitor of serotonin and norepinephrine. It also inhibits neuronal dopamine reuptake. It is used off-label to treat ADHD.it is not FDA approved for treatment of ADHD in children. Evidence has shown that it is effective in the treatment of ADHD which is comorbid with depression (Ng, 2017).

Alpha-2 agonists include drugs such as clonidine and guanfacine. These drugs act by stimulating alpha-2 adrenoceptors in the brain stem thereby activating inhibitory neurons. This results in the reduction of sympathetic outflow from the CNS. The mechanism of action of alpha-2 agonists in the treatment of ADHD is however not known.

The main theory suggests that postsynaptic alpha-2—agonist stimulation regulates subcortical activity in the prefrontal cortex (Brown et al., 2018). This leads to the regulation of inattention, hyperactivity, and impulsivity. Clonidine has sedating effects. Guanfacine is a more selective alpha 2A adrenergic agonist and therefore has less sedating effect.

The preparation of nonstimulants is mainly in the extended-release forms i.e., Intuniv (guanfacine) and Kapvay (clonidine). These have been FDA approved for adjunctive therapy with stimulants. These drugs can also be used as monotherapy for ADHD but stimulants are relatively more effective.

Immediate release forms are used as second line agents in children who have poor response to stimulants. The use of immediate release forms is not recommended unless it is necessary (Brown et al., 2018).

Clinical Approach to Pharmacotherapy

Extended-release formulations are used as first line. Methylphenidates are chosen. The first choice is Ritalin LA 20 mg orally in the morning. The objective of treatment is to improve the symptoms. The dose is titrated upwards until maximum symptom benefit is achieved to a dose where the benefit outweighs the risk. Ritalin LA is titrated by 20 mg/ week.

The maximum recommended dose is 60mg/day. Switching to another stimulant is recommended if there are no improvements is the symptoms or if there are significant side effects. If both stimulants have been tried without success, switching to the non-stimulants is considered (Brown et al., 2018)

Side Effects of Stimulants

Every drug given has other effects on the body other than the ones intended. These are the side effects. Stimulants have various side effects. These side effects can however be managed and should not hinder treatment. The common side effects of stimulants can be seen in almost all body systems.

The patient may exhibit a decrease in appetite, stomach aches, nausea and weight loss which is usually a less common side effect. These GIT symptoms can be managed by making sure the patient takes frequent meals and snacks. The patient can also take additional meals just before bedtime.

The dosing of medication can also be adjusted such that they are taken with food or after meals. For children, a drug holiday can be recommended if there are significant changes in the growth and development of the child. The last option for managing these symptoms would be to prescribe short acting agents (Brown et al., 2018).

Another side effect noted with stimulants is sleep difficulties. This can be managed by adjusting the dosing times i.e., the dosing regimen can be moved to an earlier time. Afternoon doses can be adjusted or eliminated altogether if the patient is on immediate- release preparations. The patients should also consider adjusting their bedtime routine and reduce bedtime stimuli. Finally, melatonin can also be considered as an additional prescription to help with sleep.

Patients on stimulant also report to have transient headaches. These can be managed by reducing the dose or changing the medication to another stimulant or to a different drug class.  The symptoms should be managed and the patient kept under observation (Brown et al., 2018).

The patient may also exhibit cardiovascular symptoms which present as increased heart rate or increased blood pressure. This can be managed by reducing the dose, using a different stimulant or switching to a different drug class.

Other side effects include irritability, psychosis or severe depression. These can be managed by decreasing the dose or stopping the treatment with stimulants. A mental health specialist should be consulted. The patient can also exhibit behavioral rebound as a side effect.  This is managed by placing the patient on a sustained release stimulant (Brown et al., 2018).

Side Effects of Non-stimulants

The common side effects of atomoxetine include loss of appetite, nausea, diarrhea, mood swings, fatigue and dizziness. These symptoms are managed by watchful waiting as the symptoms usually subside with continued use of the drugs over several weeks (Stahl, 2017).

Behavior changes or suicidal ideation can also occur and should prompt immediate evaluation. Also, an increase in the heart rate and blood pressure can also occur in some children and adolescents. Another side effect of atomoxetine is insomnia which can develop over time.

The most common side effects associated with alpha agonists are dry mouth, sedation, somnolence, dizziness, headache and constipation. Guanfacine also presents with bradycardia and hypotension as side effects (Rosenthal & Burchum, 2017).

Somnolence tends to reduce over time and are less commonly seen in guanfacine than clonidine. Guanfacine also has lesser side effects on the BP compared to clonidine. The symptoms of BP can be managed by using extended-release formulations as these minimize the initial drop in blood pressure. They are also tolerated better than short acting preparations (Brown et al., 2018).

Interactions

Methylphenidates are contraindicated for use together with MAOIs or within 14 days of MAOI discontinuation. Other drugs contraindicated are captopril, haloperidol, terbutaline, warfarin, benzophetamine, diethylpropion, linezolid, phendimetrazine, and phentermine.

MAOIs include isocarboxazid, phenelzine, rasagiline, selegiline, tranylcypromine and safinamide. These drugs increase the effects of methylphenidate by pharmacodynamic synergism. Methylphenidates should also not be taken with alcohol as this results in a more rapid release and enhances their GI absorption. Esomeprazole decreases effects of methylphenidate by enhancing GI absorption (Rosenthal & Burchum, 2017).

Atomoxetine is metabolized by CYP2D6. It should therefore be closely monitored in patients taking strong CYP2D6 inhibitors such as paroxetine, quinidine, fluoxetine. It is also contraindicated for used together with MAOIs or with 14 days of use with MAOIs. MAOIs increase the effects of atomoxetine by pharmacodynamic synergism. Guanfacine should be used with care when take together with CYP3A4 inducers or inhibitors (Stahl, 2017)

Patient Education.

The patient or caregiver should be educated on ADHD. They should be made aware of the condition including what it is and how to best cope with it. Teachers can also be present. This is done to make sure they understand the concept behind the diagnosis (Magnus et al., 2017).

A parent education and training program is important to help parents or caregivers with dealing with ADHD. This should be done especially for children who have a mild form of ADHD.

The caregivers should also be made aware of the treatment options available. These include psychotherapy, behavioral therapy and pharmacotherapy. Both advantages and disadvantages of each option should be made clear and the chosen treatment option made known to the patient or caregiver (Magnus et al., 2017). The drug methylphenidate is the drug of choice.

The caregivers can be educated on strategies to help them cope. These include developing clear rules and routines. The caregivers can also be advised to join a self-help group. Caregivers should know that the child’s behavior is not intentional.

Patients and caregivers should be made aware of the dates for regular checkups. This is important because ADHD patients should be followed up regularly. This is done to check up on their symptoms and comorbidities. This also allows for optimization of medication treatment by interacting with the primary caregiver and the family (Magnus et al., 2017).

The patient or caregiver should be made aware of the side effects and the danger signs to look out for during treatment. The caregiver should observe the child and take note of any changes exhibited by the child during the course of treatment.

Attention Deficit Hyperactivity Disorder NURS 6660 References

• American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Bijlenga, D., Vollebregt, M. A., Kooij, J. S., & Arns, M. (2019). The role of the circadian system in the etiology and pathophysiology of ADHD: time to redefine ADHD?. ADHD Attention Deficit and Hyperactivity Disorders, 11(1), 5-19. https://doi.org/10.1007/s12402-018-0271-z
• Brown, K. A., Samuel, S., & Patel, D. R. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Translational Pediatrics, 7(1), 36–47. https://doi.org/10.21037/tp.2017.08.02
• Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., & Carucci, S. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network metanalysis. Lancet Psychiatry, 5(9), 727-738. https://doi.org/10.1016/S22150366(18)30269-4
• Higgins, E.S. & George, M.S. (2018). The neuroscience of clinical psychiatry (3rd ed.). Baltimore, MD: Wolters Kluwer/Lippincott Williams & Wilkins Co. ISBN 978149637200 [H & G] (Chapter 20)12)
• Magnus, W., Nazir, S., Anilkumar, A. C., & Shaban, K. (2017). Attention Deficit Hyperactivity Disorder (ADHD). [Updated 2021 May 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK441838/
• National Institute of Mental Health. (2019). Attention-Deficit/Hyperactivity Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorderadhd/index.shtml
• Ng, X. Q. (2017). A systematic review of the use of bupropion for attention-deficit hyperactivity disorder in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 27(2), 112-116. https://doi.org/10.1089/cap.2016.0124
• Nigg, J. T., Sibley, M. H., Thapar, A., & Karalunas, S. L. (2020). Development of ADHD: Etiology, Heterogeneity, and Early Life Course. Annual Review of Developmental Psychology, 2, 559-583. https://doi.org/10.1146/annurev-devpsych-060320-093413
• Rosenthal, L., & Burchum, J. (2017). Lehne’s pharmacotherapeutics for advanced practice providers. Atlanta, GA: Elsevier. ISBN 9780323447836 [R & B] (Chapters 8, 29)
• Sciberras, E., Mulraney, M., Silva, D., & Coghill, D. (2017). Prenatal risk factors and the etiology of ADHD—review of existing evidence. Current Psychiatry Reports, 19(1), 1. https://doi.org/10.1007/s11920-017-0753-2
• Stahl, S. M. (2017). Prescriber’s guide (6th ed.). New Delhi, India: Cambridge University Press.

Attention Deficit Hyperactivity Disorder Case Study NURS 6660 Instructions

BACKGROUND

Katie is an 8 year old Caucasian female who is brought to your office today by her mother & father. They report that they were referred to you by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have ADHD. Katie’s parents reported that their PCP felt that she should be evaluated by psychiatry to determine whether or not she has this condition.

The parents give the PMHNP a copy of a form titled Conner’s Teacher Rating Scale-Revised. This scale was filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie is inattentive, easily distracted, forgets things she already learned, is poor in spelling, reading, and arithmetic. Her attention span is short, and she is noted to only pay attention to things she is interested in. The teacher opined that she lacks interest in school work and is easily distracted. Katie is also noted to start things but never finish them, and seldom follows through on instructions and fails to finish her school work.

Katie’s parents actively deny that Katie has ADHD. She would be running around like a wild person if she had ADHD reports her mother. She is never defiant or has temper outburst adds her father.

SUBJECTIVE

Katie reports that she doesn’t know what the big deal is. She states that school is her favorite subjects are art and recess. She states that she finds her other subjects boring, and sometimes hard because she feels lost. She admits that her mind does wander during class to things that she thinks of as more fun. Sometimes Katie reports I will just be thinking about nothing and the teacher will call my name and I don’t know what they were talking about.

Katie reports that her home life is just fine. She reports that she loves her parents and that they are very good and kind to her. Denies any abuse, denies bullying at school. Offers no other concerns at this time.

MENTAL STATUS EXAM

The client is an 8 year old Caucasian female who appears appropriately developed for her age. Her speech is clear, coherent, and logical. She is appropriately oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Self-reported mood is euthymic.

Affect is bright. Katie denies visual or auditory hallucinations, no delusional or paranoid thought processes readily appreciated. Attention and concentration are grossly intact based on Katie’s attending to the clinical interview and her ability to count backwards from 100 by serial 2s and 5s. Insight and judgment appear age appropriate. Katie denies any suicidal or homicidal ideation.

Diagnosis: Attention deficit hyperactivity disorder, predominantly inattentive presentation

Examine Case Study: A Young Caucasian Girl with ADHD. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Attention Deficit Hyperactivity Disorder (ADHD) Example 2

Neurodevelopmental disorders have undertaken several diagnostic evolutions in several past years.  The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is one of the standard diagnostics tools used. A popular belief is that attention deficit hyperactivity disorder (ADHD) is prevalent among children. It is stereotyped that it only affects the attention of children. New information has however shown that ADHD not only affect attention in children, but also involves hyperactivity and impulsivity.

According to the National Institute of Mental Health (NIH) (2019), it is possible that this disorder can be present in adults contrary to common beliefs.  ADHD is usually recognized in early childhood, especially during the preschool years and early school years and can continue into adulthood. It can cause issues such as inattention, hyperactivity, and impulsivity and patients usually present with these as the core symptoms.

Some ADHD patients only present with one of the behaviors while other present with a combination. Specific issues seen with ADHD include poor performance in school, inability to think properly and behavioral problems. According to Krull (2019), patients can also have a difficulty in expressing their feelings and building relationships.

Using the DSM-5 criteria, ADHD symptoms must be present before the age of 12 years and also in more than one setting (APA, 2013). To diagnose ADHD, an authorized medical practitioner such as a psychiatrist or a pediatrician should be present. An expert in ADHD who is licensed to determine the presence of this disorder can also make the diagnosis.

The signs to look out for in order to make a diagnosis are inattention, hyperactivity and impulsivity that has been present over a long period. ADHD management and treatment consists of counseling, behavioral therapy, medication, or a combination of these options.

The goal in managing and treating ADHD is to ensure the patient regains full function and can perform better in school, or work and have better relationships. Another goal is to ensure the patient can function in a society by being able to follow the rules. Successful treatment will increase the patient’s attention span, regulate their level of activity to normal and decrease their impulsiveness.

In this paper, the focus will be on an 8-year-old Caucasian female presenting to the clinic with symptoms that indicate ADHD. The best treatment option for this patient will rely on three decisions informed by ethical and treatment guidelines for the disorder. The overall pharmacodynamics and pharmacokinetics for the drugs will be discussed

Decision 1

After reviewing the patient, a diagnosis of ADHD is made. Decisions have to be made in order to properly manage and treat this patient. My first treatment decision for this 8-year-old school-going female is to start her on Ritalin chewable tablet 10 mg orally in the morning. This choice is mainly influenced by the patient’s clinical manifestations, and the benefit-risk assessment of the available options. The objective of treatment is to improve the patient’s symptoms.

According to Verbeeck et al. (2017), most pharmacological treatments for ADHD facilitate the transmission of catecholamines. ADHD patients are usually treated with stimulant drugs. Ritalin is a stimulant agent which is FDA approved for use as the first-line treatment for ADHD. Approximately 90% of patients on Ritalin show improvement of symptoms (Verbeevk et al., 2017).

Ritalin achieves this by increasing the action dopamine and noradrenaline in the prefrontal cortex thus stimulating the CNS. CNS stimulation helps foster cognition and attention and restores the patient’s ability to focus. The reason for prescribing the drug in the morning is because of the need to achieve concentration during the day. The drug also has a potential of causing insomnia.

The use of Bupropion is not selected because it is an antidepressant which is only used as an alternative when the patients cannot tolerate stimulants because of the side effects or if patients do not respond well to stimulants (Ng, 2017). Bupropion is registered as an antidepressant and is used off-label to treat ADHD. Despite its extensive use, it is not FDA approved for the treatment of ADHD in children. It is also associated with suicidal ideations as a side effect and evidence has shown that it is only effective in the treatment of ADHD that is comorbid with depression.

Intuniv is also not selected as it is a non-stimulant that is not recommended as the first-line treatment of ADHD. It usually takes long to start producing effects as opposed to Ritalin that takes a few minutes to start exhibiting its effects. Intuniv is however suggested as an augmenting agent if stimulants do not offer adequate improvement in symptoms (Stahl, 2017).

With the treatment option selected, I hope to see an improvement in the symptoms as soon as possible, with the patient reporting an improvement in school performance when she returns for a follow-up after 4 weeks. The patient returns four weeks later with improved symptoms but complains of some adverse effects including daydreaming and cardiac symptoms such as tachycardia. With this new information, a re-evaluation is necessary and another decision needs to made to manage this patient.

Decision 2

With new findings in the patient, my decision is to change to Ritalin LA 20 mg orally in the morning. The reason for this is that the symptoms shown could be as a result of Ritalin 10 mg chewable tablets being a short acting agent. The symptoms could also be prevented by reducing the dose to 5 mg. This would reduce the potential side effects but also the efficacy.

A longer acting agent is therefore the best option to use on this patient. This way she gets a pulse dose in the morning and another dose four hours later. I would not want to switch to another drug option because Ritalin seems to be effective in improving the symptoms. Keeping her on the same dose would not change anything in terms of relieving or minimizing the side effects. She would still have symptoms of tachycardia on the same dose.

Changing her medication to Adderall is not an option I would consider because she seems to be responding well to Ritalin, an aspect Cortese et al. (2018) identify as a basis for sticking to the current treatment medication. It is recommended that when patients experience side effects, waiting and making adjustments on the current medications are made before switching to a different drug. If the patient does not show any improvement, then a change in medication can be made (Stahl, 2017).

The goals of treatment remain the same as before but with a new target of reducing the patients heart rate without affecting her concentration throughout the day. The patient returns to the clinic after four weeks and reports a relief of the side effects. Her heart rate is at 92 beats a minute. This shows that the new treatment with Ritalin LA 20 mg is working with significant improvement recorded over the past four weeks.

Decision 3

Because the patient seems to be doing well on the current treatment regimen, my plan would be to maintain her on the current dose of Ritalin LA and do a re-evaluation after four weeks. Ritalin seems to be working as Katie’s heart rate is back to normal and her attention is sustained throughout the day. She also reports no additional side effects. It is recommended that the lowest dose of a stimulant needed should be used to correct a disorder and for this reason, I would not increase the dose to 30 mg. Her heart rate of 92 is within the normal range for her age and an EKG is unnecessary at this point.

Ethical Considerations

When treating patients with ADHD, many ethical considerations have to be taken into account. These include choosing the right medication for the treatment of the condition. This is important as some drug classes such as nonstimulants have harmful side effect which the patient may not be able to tolerate. This is also important because the patients are still developing and some of these drugs may impede their development.

Another consideration is the patient autonomy. Because the patient is a minor, she is not able to make any decisions as regards their health and treatment. Parents therefore have to be incorporated in making decisions that pertain to the treatment of this patient and they have a right to agree to or deny treatment they don’t agree with. It is also important to try and involve the child in the treatment and breakdown everything to a language they can understand (NIH, 2019).

Another ethical consideration is the cardiac effects that are associated with psychostimulants. A family history of cardiac disease should be taken into account before commencing treatment with stimulants. The last consideration is the side effects and the lowest effective dose should be prescribed and the patients monitored regularly for side effects (NIH, 2019). The patient should also be educated on these side effects.

Conclusion

In conclusion, ADHD is a disorder that starts in early childhood and can progress into adulthood if not managed well with psychotherapy and pharmacotherapy. ADHD usually present with three core symptoms i.e., inattention, hyperactivity and impulsiveness but not all patients present with all the symptoms at once. The NP has the ethical obligation to treat ADHD with the most effective options available.

The first-line treatment for ADHD are stimulants such as Ritalin. Other options of treatment include non-stimulants amphetamines and antidepressants such as bupropion. When treating patients with stimulants it is important to consider the potential side effects such as cardiac effects such as tachycardia as seen in the patient. It is also important to use the lowest effective dose to treat the patients. The patient should also be involved in their treatment and patient preference is key to ensure compliance to medication.

References

• American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Cortese, S., Adamo, N., Del Giovane, C., Mohr-Jensen, C., Hayes, A. J., & Carucci, S. (2018). Comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults: A systematic review and network metanalysis. Lancet Psychiatry, 5(9), 727-738. https://doi.org/10.1016/S22150366(18)30269-4
• Krull, K. (2019). Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis. Retrieved from https://www.uptodate.com/contents/attentiondeficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis
• National Institute of Mental Health. (2019). Attention-Deficit/Hyperactivity Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-disorderadhd/index.shtml
• Ng, X. Q. (2017). A systematic review of the use of bupropion for attention-deficit hyperactivity disorder in children and adolescents. Journal of Child and Adolescent Psychopharmacology, 27(2), 112-116. https://doi.org/10.1089/cap.2016.0124
• Stahl, S. M. (2017). Prescriber’s guide (6th ed.). New Delhi, India: Cambridge University Press
• Verbeeck, W., Bekkering, G. E., Van den Noortgate, W., & Kramers, C. (2017). Bupropion for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane Database Of Systematic Reviews, 10(10), CD009504. https://doi.org/10.1002/14651858.CD009504.pub2

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