Pharmacological Approaches to Treating ADHD
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Pharmacological Approaches to Treating ADHD
The diagnosis and treatment of ADHD continue to be surrounded by controversy. The majority of medical research outline that a combination of pharmacological treatments and therapy is best suited to treating the disorder. However, the case might be more complex when it involves children. The subject case study focuses on 8-year-old Katie. The mother brought in the patient for a diagnosis after her educator suggested she could have ADHD. The teacher had observed her student had lost interest in schoolwork and was easily distracted. In addition, she tends to start things but not finish them, not following through with instructions or school assignments. Katie is now performing poorly in arithmetic, spelling and reading. The parents do not believe the patient has ADHD because she has emotional control and is not defiant. The primary objective for the course of treatment would be to restore Katie’s mental functioning for improved academic performance.
The treatment of ADHD tends to follow a multimodal approach for cost-effectiveness and positive health outcomes. According to Martinez-Raga et al. (2017), the treatments are proven to be effective in managing symptoms, emotional and physical functioning and enhanced work and academic performance. Psychosocial and psychotherapeutic interventions are efficient strategies for managing ADHD in adults and children. However, pharmacotherapy alone is identified as the most effective and optimal approach to treating ADHD in children (Martinez-Raga et al. 2017). Pharmacotherapy costs less compared with behavioural therapy. The debate on suitable medications is rooted in insufficient medical evidence outlining the various pathways in ADHD neuropathy. As a PMHNP, the goal is to assess individual factors, such as age and medication tolerance, to determine which course of pharmacological treatment is best for the patient.
Decision One
The primary aim during this stage of medication is to restore the patient’s cognitive functions for improved academic performance. According to the case study, the PMHNP is provided with three decisions, (1) begin Wellbutrin XL 150mg orally daily, (2) begin Intuniv 1mg orally at bedtime or (3) begin Ritalin chewable tablets 10mg orally in the morning. Brown et al. (2018) document that Wellbutrin is an anti-depressant used to treat anxiety and depression. The drug would harm Katie due to its properties, with the potential to cause suicide ideation (Brown et al. 2018). The educator and mother’s explanations of the patient’s behaviour did not point out the possibility of the child suffering from depression. Therefore, Wellbutrin is not an applicable medication in this case. Intuniv is used in treating ADHD in children with comorbid complications, such as defiance, aggression and mood alterations (Osland et al. 2018; Shier et al. 2013). Katie was mentioned not to be defiant by the mother.
The remaining suitable option is to start the child on Ritalin. The recommended dosage is 10mg, taken during breakfast (Martinez-Raga et al. 2017). The medication is offered in the form of chewable tablets because Katie is young. Ritalin will increase the child’s dopamine and norepinephrine levels, improving concentration levels (Martinez-Raga et al. 2017; Shier et al. 2013). The drug will help address Katie’s ability to finish school work or any activity that she begins. Hodgkins et al. (2012) state that Ritalin has no side effects impacting children’s behaviours. There is a chance the patient might experience some insomnia in the first days of treatment. Selecting Ritalin, in this case, leads to a four-week diagnosis where the patient’s symptoms have improved. There are tangible changes in her attention span and class participation.
Decision Two
Katie’s symptoms are much better in the morning. She is performing well in class, but she is building castles in the air by the afternoon. Katie also reports her heart feeling funny, resulting in a heart rate examination. The diagnosis implies Ritalin is working, but its effects are not long-term. Therefore, the objective of the second course of treatment would be to stabilize the effects of Ritalin. According to the case study, the PMHNP has three options to choose from; (1) continue with the same dose of Ritalin and re-assess after four weeks, (2) transition to Ritalin LA 20mg orally daily in the morning or (3) discontinue Ritalin and begin Adderall XR 15mg orally daily. It would be unwise to continue with the same course of treatment because Katie reports feeling her cardiovascular rhythm was uncomfortable and funny. Ritalin could be elevating her cardiovascular risk.
Adderall is a stimulant that might result in the development of negative behaviours. Lakhan and Kirchgessner (2012) state that Adderall can cause a state of euphoria in children that might impede normal cognitive functioning. Adderall can also affect dopamine action, which is critical to Katie’s case (Lakhan & Kirchgessner, 2012). The two lapses make option two unsuitable for the case. The remaining option is three, switch to Ritalin LA 20mg orally once daily. The patient should take the medication early in the morning. Parents, educators and the PMHNP will focus on close monitoring to assess if the effects of the drug are lasting until evening. Katie’s educator reports her symptoms are reduced, and she is able to maintain her concentration levels throughout the day. Her heart rate is equally normal.
Decision Three
Katie is showing tangible improvements in her cognitive and emotional functioning. Eight weeks of treatment have been able to restore her academic participation, and she no longer reports her cardiovascular rhythm feeling out of pace. There is no question that the selected courses of treatment have been effective. The question the PMHNP has to ask is if the changes are permanent. The professional can opt to maintain the current dose of Ritalin LA and re-evaluate within another four weeks, increase the dosage to 30mg or obtain an EKG to determine if there is any further need for treatment. Katie was experiencing changes in her heart rate when the medication was 20mg. Therefore, increasing the dosage to 30mg would be unethical and dangerous to the patient. The patient is not getting worse, so there are no grounds for increasing the Ritalin dosages. The heart rate might have gone down to 90, but it is not a firm indication that the cardiovascular risk associated with the treatment has disappeared.
The objective should be to eliminate all cardiovascular risks and restore the patient’s physical and mental functioning without artificial assistance. The PMHNP should discontinue the provision of Ritalin LA 20mg in the morning. The medication is still associated with a substantial degree of cardiovascular risk (Lakhan & Kirchgessner, 2012). EKGs are recommended before the provision of any stimulant treatment for ADHD. It is important to recall at this point that Ritalin is a stimulant. Discontinuing the drug should be followed by an EKG assessment. According to the case, the EKG shows Katie’s symptoms are not stable and long-term and have minimal to no side effects. There are no indications that the dosages should be changed. The heart is normal for an eight-year-old child. Despite the positive changes, Katie should come in for one more assessment after a four-week window.
Conclusion
Medical research highlights limited awareness among parents and guardians regarding ADHD medications. Stigma and prejudice still impact perceptions of pharmacological interventions. On the other hand, healthcare providers emphasize caution and restraint in treating children with ADHD using pharmacological approaches. As the case highlights, the healthcare practitioner must build a relationship with the guardians to collect patient information comprehensively. Communication is the core aspect of an individualized care plan. Respect for the patient’s autonomy and privacy requires Katie to be actively engaged in developing the care plan. The clinician has the moral and legal obligation to stop a course of treatment at the patient’s request. The clinician is also expected to act in the patient’s best interests. The principle of beneficence requires clinicians to avoid bad outcomes. Such ethical obligations outline why Ritalin was discontinued after it was discovered it was affecting Katie’s heart rate.
ADHD is bound to affect the quality of life of many more children in years to come. Further medical literature is necessary to validate the efficacy of each medication to different neuropathological pathways. PMHNPs should be able to apply a drug to a specific ADHD neuropathy. Research should also cover the behavioural factor as non-compliance to medication is common. There is also the non-compliance with follow-ups, which motivates patients to seek alternative treatments. There are no doubts that available pharmacological treatments have substantial positive impact on patient health. Combined with effective communication, the pharmacological alternatives will improve individual and population health.
References
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
Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245-268. https://doi.org/10.2165/11599630-000000000-00000
Lakhan, S. E., & Kirchgessner, A. (2012). Prescription stimulants in individuals with and without attention deficit hyperactivity disorder: misuse, cognitive impact, and adverse effects. Brain and Behaviour, 2(5), 661–677. https://doi.org/10.1002/brb3.78
Martinez-Raga, J., Ferreros, A., Knecht, C., de Alvaro, R., & Carabal, E. (2017). Attention-deficit hyperactivity disorder medication use: factors involved in prescribing, safety aspects and outcomes. Therapeutic Advances in Drug Safety, 8(3), 87–99. https://doi.org/10.1177/2042098616679636
Osland, S. T., Steeves, T. D., & Pringsheim, T. (2018). Pharmacological treatment for attention deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders. The Cochrane Database of Systematic Reviews, 6(6), CD007990. https://doi.org/10.1002/14651858.CD007990.pub3
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/10.4137/JCNSD.S6691