The medical case centers on eight-year-old Katie

Posted: November 7th, 2023

The medical case centers on eight-year-old Katie. The patient is an energetic child displaying symptoms of delayed thought and short attention spans. According to the mother, the girl has been showing the symptoms and were adviced by their PCP to seek an ADHDF diagnosis. The initial diagnosis by Katie’s educator identifies the patient is suffering from ADHD. The disorder refers to a neurobehavioral complication is common in children, impacting several elements of individual life (Hodgkins et al. 2012). The primary objective of the care plan is to restore the patient’s potential in social and academic functioning. Due to the availability of different ADHD treatment methods, it is critical that medical practice adhere to a minimal common standard for evaluating the efficacy of pharmacological interventions.

Attention Deficit Hyperactivity Disorder (ADHD) is no longer a subtle or understudied clinical problem due to its increasing prevalence and significance to individual and population health. Medical research is yet to validate the neuropathological pathways that cause ADHD (Hodgkins et al. 2012). It is more likely the causes are multifactorial, including environmental and genetic. However, there are substantial achievements in the treatment and management of ADHD. Interventions may include non-pharmacological methods, pharmacological therapy or a combination of the two. The suitability of the treatment approach used is dependent on the patient’s individual factors, including age, access to social support and tolerance to medications (Hodgkins et al. 2012). The purpose of this report is to assess the various ADHD treatment methods applicable to the case of a young nine-year-old girl. While diagnosis of ADHD should be done in a safe environment, medical literature supports the use of pharmacologic therapy combined with behavioural interventions in individualized care plans.

Decision One

The patient’s mother complaints the patient’s main problem is the short attention span in school work. Katie is easily distracted and performs poorly. Such symptoms underpin the diagnosis of ADHD. Treatment of ADHD in children accords the PMHNP with three medication alternatives, namely Wellbutrin (bupropion). Intuniv ER and Ritalin (methylphenidate) (Osland et al. 2018; Brown et al. 2018). The objective is to determine which will have the least adverse effect on the patient. Wellbutrin is an antidepressant used in treating depression. The drug is not recommended for children because there is an increased risk of suicide ideation (Feldman et al. 2018). Moreover, there is no indication that the patient is suffering from depression. Intuniv is an anti-hypersensitive agent used in the treatment of children with comorbid disorders, like mood swings and defiance (Brown et al. 2018). Since the mother does not state the patient has any behavioural problems, the use of intuniv is unsuitable.

I will start the patient on Ritalin 10mg in the morning. According Prince et al. (2016), Ritalin is perceived as the first line of medications in ADHD treatments. Since Katie is a young girl, Ritalin will be given in the form of chewable tablets. The medication operates by elevating dopamine and norepinephrine in the prefrontal cortex to enhance concentration (Prince et al. 2016; (Hodgkins et al. 2012). Therefore, the drug is bound to improve Katie’s attention span in class, and his subsequent academic performance. The drug does not pose a significant threat to the patient’s behaviour. However, medical literature informs on the possibility of insomnia and nervousness as potential side effects (Prince et al. 2016). The patient will continue receiving 10mg until tangible improvements are seen, where the dosage is lowered to 5mg every breakfast. The daily dosages should never exceed 60mg to avert the adverse side effects. The patient and the mother should report back after four weeks for follow-up.

Decision Two

            The second session shows behavioural improvements in the patient. With the need to stabilize the changes, the goal remains the reduce the ADHD symptoms, enhance focus and social engagement. The PMHNP has three choices at this point; (1) to continue with Ritalin and reassess, (2) reduce the dosage of Ritalin or (3) discontinue the use of Ritalin in favour of Adderall. Option one is unsuitable because of the emotions underlying the improved behaviour. Katie’s self-reported euthymic sense could be due to an increased heart rate. Continuing with the same dosages would be putting the patient at a heightened risk of cardiovascular disorders. While the FDA does approve the use of Adderall XR in children above the age of six, the drug may cause the same sense of false euphoria (Brown et al. 2018; Prince et al. 2016). Adderall is a very strong stimulant that might impede dopamine action. The possibility of the adverse side effect makes option two equally unsuitable.

            The most suitable alternative would be to continue with Ritalin, but in a different formulation. There are no significant behavioural changes to warrant the use of anti-depressants. Instead, the PMHNP should switch to a long-acting form of the drug and prescribe it once a day during breakfast. Therefore, the patient will receive Ritalin LA 20mg orally once every day during breakfast. Close monitoring should be done to ensure the treatment does not increase the patient’s heart rate any further. In the next clinical visit, the patient should report improved classroom concentration, performance and behaviour. The heart rate should also be steady.

Decision Three

            Eight weeks of treatment should have significant and tangible changes in the patient’s behaviour, cognitive and emotional functioning. Based on possible developments, the PMHNP can either discontinue the use of Ritalin or increase its dosage to 30mg daily. The current diagnosis shows that Katie is responding well to the treatment. Side effects are less visible and are manageable. Since the patient is progressing well, there is still no need to change the medication. There are no indications that the dosage should be increased or decreased. Therefore, it is recommended that the patient stick to the lowest amount necessary. Ritalin is working, but there is still the issue of the increased heart rate from the initial four-week diagnosis.

 Due to the efficacy of the drug, the goal is to now eliminate the cardiovascular risk associated with ADHD treatments. Katie is too young for an EKG to be done, which means there is no clear information on the patient’s cardiovascular health and how it is being impacted by the ADHD intervention. EKGs are normally done in children above the age of ten (Uygur & Aydogdu, 2019). The promotion of patient wellbeing implies the patient should stop taking Ritalin because it is not clear to which extent the drug could be impacting his cardiovascular system. For the third choice, the PMHNP decides to discontinue the provision of Ritalin. The patient’s condition has improved, which negates the need for further treatment. However, the PMHNP should schedule another four-week follow-up to ensure the symptoms did not return after stopping the use of pharmacologic medications.

Conclusion

            Caution and care are emphasized in the treatment of children and adolescents with ADHD. Foremost, the PMHNP is required by law to acquire informed consent from the patient’s parents or guardians before the commencement of any treatment plan (American Psychiatric Association, 2013). The communication shared between the guardian and the healthcare provider in the acquisition of consent provides a basis for the individualized care plan. The PMHNP is also expected to show respect for the patient’s autonomy. Treatment should be changed if the patient confesses it is impacting their functioning and overall independence. Respect for autonomy also means accepting the patient’s decision not to receive medication (American Psychiatric Association, 2013). Autonomy is guaranteed through active participation by the patient in the development of the care plan. The PMHNP is also expected to abide the rule of beneficence. Since the child has limited cognitive functioning, the healthcare provider has to protect them from harm and ensure medical practice does not result in adverse complications.

            ADHD will affect millions of children spread across the globe in years to come. Medical literature supports the use of pharmacological alternatives in the management of ADHD symptoms. Drugs categorized under the stimulant class are perceived as the most reliable and less harmful. Pharmacologic treatment should be based on long-acting stimulants, but supported by suitable non-pharmacologic treatments for behavioural modification. For most patients, such an approach will entail psychoeducation, including family members. Further research is required to confirm the agents used in managing ADHD, especially in patients with comorbid disorders. Each drug has its distinct mechanism and pathways, which underpins the need to generate more insight on the pathophysiology of ADHD.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.). https://doi.org/10.1176/appi.books.9780890425596 

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

Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current concepts and treatments in children and adolescents. Neuropediatrics, 51(5), 315–335. https://doi.org/10.1055/s-0040-1701658

Feldman, M. E., Charach, A., & Bélanger, S. A. (2018). ADHD in children and youth: Part 2-Treatment. Paediatrics & Child Health, 23(7), 462–472. https://doi.org/10.1093/pch/pxy113

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

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

Prince, J. B., Wilens, T. E., Spencer, T. J., & Biederman, J. (2016). Stimulants and other medications for ADHD. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (pp. 99–112). Elsevier.

Uygur, Ö., & Aydoğdu, A. (2019). Normal electrocardiogram values of healthy children. Turk Pediatri Arsivi, 54(2), 93–104. https://doi.org/10.14744/TurkPediatriArs.2019.04568