Decision tree on Attention Deficit Hyperactivity Disorder

Decision tree on Attention Deficit Hyperactivity Disorder
Attention deficit hyperactivity disorder (ADHD) is among the most common neurodevelopmental disorders witnessed in children. It is, however, not just a childhood disorder and has significant prevalence in the adult populations (NIMH, 2016). ADHD symptoms are however first seen and diagnosed in children, with the condition lasting through adolescence and adulthood in up to 70% of childhood cases. Classical symptoms include age inappropriate and impairing levels of inattention, hyperactivity or impulsivity. Children may often also be seen fidgeting, forgetting or losing things a lot, day-dreaming, talking too much, trouble taking turns, difficulty interacting with others and taking unnecessary risks or making careless mistakes; all of which occur as a result of inattention, hyperactivity, or impulsivity. Treatment options usually include either pharmacologic or non-pharmacologic (behavioral) therapy, or in some instances both.

For this assignment, we look at the case of a nine-year old Caucasian girl with ADHD. Doe (not her real name), reported to the outpatient department accompanied by her parents. Her parents complained that their daughter’s teacher complained that Doe was very forgetful, easily distracted and highly inattentive in class. She had a short attention span and only paid attention to activities she felt were interesting to her. As a result of this, she usually starts most class work and assignments but never really sees them through. She is poor in arithmetic, reading and spelling. Her grades are consequently poor, which is a huge concern for both her parents and teachers. At home she is usually jumpy and playful, which her parents report to have considered normal for a child her age. A mental status exam reveals that doe is displaying signs of ADHD; and should be put on treatment protocols immediately. Before deciding what medication to put her on, specific patient factors that may be important to consider include her age, her weight, any allergies she may have and lastly, any comorbidities. Common comorbidities for ADHD include conduct disorder, oppositional defiant disorder (ODD) and chronic tic disorders (Osland et al., 2018). Her age and weight are especially very significant, going by the fact that she is a pediatric patient.

Decision #1

Choices for decision #1:

Put her on Wellbutrin (bupropion) XL 150 mg orally daily
Put her on Intuniv extended release 1 mg orally at bedtime.
Put her on Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.

Decision: Put her on Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning.

The recommended first-line treatment for ADHD comprises stimulants, usually amphetamines and methylphenidate (Cortese, 2020). Therefore, seeing that Doe is a newly diagnosed patient, it was necessary to place her on a first-line medication; and preferably methylphenidate due to its dosages. Ritalin comes in a chewable formulation taken once in the morning, hence is ideal for a pediatric patient. The other two options are good choices, but not ideal for a pediatric patient who has just been diagnosed. Intuniv, for example, is a non-stimulant to begin with. The drug is best used as an adjunctive therapy to stimulants and therefore would be best given later to complement the action of methylphenidate (Huss et al., 2016).

The expectation is that once the patient begins taking Ritalin, there will be some marked improvements in her behavior. Methylphenidate acts by increasing extracellular dopamine levels, thus reducing hyperactivity and allowing the individual to remain calm for extended periods (Cortese, 2020). Our patient would as such be able to increase her attention span and focus more on tasks and activities she undertakes. The drug also has a formulation that appeals to the pediatric population which, coupled with the parents’ follow-up, allows for compliance to the regimen. The patient will report for review after four weeks of taking the medication.

Decision #2

Choices for decision #1:

Continue with same dose of Ritalin and re-evaluate in 4 weeks
Increase the dose of Ritalin LA to 20 mg orally daily in the morning
Augment the Ritalin dose with Intuniv extended release 1 mg orally
Put her on Intuniv extended release 1 mg orally at bedtime.

Decision: Increase the dose of Ritalin LA to 20 mg orally daily in the morning.

The patient responded well to the first dose of Ritalin but upon examination on her return, the best decision was to increase the dose since she still displayed marked symptoms of inattention and episodes of hyperactivity and impulsivity. Increasing the dosage would allow us to accurately observe and conclude her response to the stimulant methylphenidate. Looking at the other three options, it would not have been prudent to continue with the same dose of Ritalin for another four weeks as she was still displaying some symptoms from her first assessment. It was also too early to supplement or change her current medication. Various studies have shown that the average duration for treatment with stimulants is 4 months (Cortese, 2020).

In increasing Doe’s dosage, expected results were that the treatment would further increase her attention span; while eliminating symptoms that persisted such as poor spelling, forgetfulness and a general lack of interest in school work. The previous treatment dosage had increased her attentiveness and concentration span to some extent but not the desired levels. It is expected that she will tolerate the increased dosage, since she already demonstrated tolerance for methylphenidate. The patient is to return for re-evaluation after four weeks.

Decision #3

Choices for decision #1:

Increase the dosage of Ritalin LA to 30 mg orally daily
Augment the Ritalin dose with Intuniv extended release 1 mg orally
Put her on Intuniv extended release 1 mg orally at bedtime.

Decision: Augment the Ritalin dose with Intuniv extended release 1 mg orally

Introducing Intuniv, a non-stimulant into the patient’s therapy would be the best way to modify her treatment at this stage. On assessment, the patient still had the same attention span, poor spelling, forgetfulness and lack of interest in school work as during the previous visit; which meant that she had achieved her threshold for methylphenidate. Intuniv is the best option for patients, both pediatric and adults, who fail to respond to first-line medication (Huss et al., 2016). Looking at the other two options, increasing the dosage of Ritalin would have been detrimental as an increase in dosage was not having any effect on the patient’s symptoms. Changing her treatment completely to Intuniv at two months would have also predisposed her to major side effects (Cortese, 2020).

After augmenting her medication, the expectation is that the patient will have in increased attention span from her previous visit. She should also experience diminished forgetfulness and lack of interest in school work, as well as displaying an improvement in spelling. We also expect that she will also tolerate Intuniv, as the drug has significant synergistic effect when administered with methylphenidate (Osland et al., 2018).

Ethical Considerations

Ethical principles that every health practitioner needs to have at the back of their mind when treating a patient include autonomy, justice, beneficence and non-maleficence (Horstkotter & De Wert, 2020). Understanding the four principles is key for ethical practice. In management of a pediatric, consent has to be sought from the parents or guardian before performing any procedure. In this scenario, Doe’s parents had to be informed of everything concerning their child’s care. It would also be ethical to explain to them the merits and demerits of the drugs and giving them the autonomy to make an informed decision.

Conclusion

ADHD is a neurodevelopmental disorder commonly seen in children. The condition is characterized by three classical symptoms: inattention, hyperactivity and impulsivity (NIHM, 2016). These three give rise to other symptoms which include but are not limited to disorganization, day-dreaming, frequent mood swings, trouble multitasking, hot temper, fidgeting, forgetting or losing things a lot, trouble taking turns, talking too much, difficulty interacting with others and trouble coping with stress (Osland et al., 2018). Management of ADHD comprises either pharmacologic or non-pharmacologic therapy, or both. In managing a pediatric patient such as Doe in our scenario, patient factors to consider include their age, weight, any allergies they may have and lastly, any comorbidities. First-line treatment options involve the use of stimulants: amphetamines and methylphenidate. Non-stimulants such as atomoxetine, extended-release clonidine and Intuniv (guanfacine) are usually considered in patients who fail to respond to the first-line medication (Cortese, 2020). Health practitioners also need to observe the four traditional ethical principles of autonomy, justice, beneficence and non-maleficence when caring for ADHD patients; whether pediatrics or adults.

References

Huss, M., Chen, W. & Ludolph, A. G. (2016). Guanfacine Extended Release: A New Pharmacological Treatment Option in Europe. Clinical Drug Investigation; 36: 1-25. Retrieved from https://doi:10.1007/s40261-015-0336-0

Cortese, S. (2020). Pharmacologic Treatment of Attention Deficit-Hyperactivity Disorder. The New England Journal of Medicine; 383: 1050-1056. Retrieved from https://doi:10.1056/NEJMra1917069

National Institute of Mental Health (2016). Attention Deficit/Hyperactivity Disorder (ADHD): The Basics. Retrieved from https://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-adhd-the-basics/index/shtml

Osland, S. T., Steeves, T. D. L. & Pringsheim, T. (2018). Pharmacological treatment for attention deficit hyperactivity disorder (ADHD) in children with comorbid tic disorders. Cochrane Database of Systematic Reviews. Retrieved from https://doi:org/10.1002/14651858.CD007990.pub3

Horstkotter, D. & De Wert, G. (2020). Ethical Considerations. Fundamentals and Clinics of Deep Brain Stimulation: pp. 145-159

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