Decision tree on Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder: A Decision Tree
Attention deficit hyperactivity disorder (ADHD) is one of the most common brain illnesses that kids have. It’s not just a problem for kids, though. The NIMH (2016) says that it’s common among adults as well. ADHD symptoms, on the other hand, are first seen and diagnosed in children, and in up to 70% of childhood cases, the condition lasts through adolescence and into adults. Classic signs include levels of inattention, hyperactivity, or impulsivity that are too high or too low for the person’s age. Children with inattention, hyperactivity, or impulsivity are also likely to fidget, forget or lose things often, daydream, talk too much, have trouble taking turns, have trouble getting along with others, and take unnecessary risks or make careless mistakes. Most treatment choices include either drug therapy or non-drug therapy (behavioral therapy), or sometimes both.

For this task, we look at the case of a Caucasian girl who is nine years old and has ADHD. Doe, whose real name is not known, came to the outpatient area with her parents. Her parents were upset that their daughter’s teacher said Doe was easily sidetracked and didn’t pay much attention in class. She was easily distracted and only paid attention to things she found interesting. Because of this, she usually starts most of her classwork and homework, but she never really finishes them. She isn’t very good at math, reading, or writing. Because of this, her grades are bad, which worries both her parents and her teachers a lot. Her parents say that she is generally jumpy and playful at home, which is normal for a child her age. A mental status test shows that doe is showing signs of ADHD, which means she needs to start treatment right away. Before choosing what medicine to give her, it may be important to think about her age, her weight, any allergies she may have, and any other health problems she may have. Conduct disorder, oppositional defiance disorder (ODD), and chronic tic disorders are often found together with ADHD (Osland et al., 2018). The fact that she is a child patient means that her age and weight are especially important.

Choice No. 1

Options for choice #1:

Give her 150 mg of Wellbutrin (bupropion) XL by mouth every day.
Give her 1 mg of Intuniv extended release by mouth before bed.
Give her 10 mg chewable tablets of Ritalin (methylphenidate) to take by mouth in the morning.

Decide to give her 10 mg chewable tablets of Ritalin (methylphenidate) in the morning.

Stimulants, like amphetamines and methylphenidate, are suggested as the first-line treatment for ADHD (Cortese, 2020). Since Doe is a recently diagnosed patient, she had to be put on a first-line medication. Methylphenidate was the best choice because of its dosages. Ritalin comes in an edible form that you only have to take once in the morning. This makes it perfect for a child. The other two choices are good, but not the best for a child who has just been given a diagnosis. Like, Intuniv is not a drug to begin with. (Huss et al., 2016) says that the drug works best as a therapy that goes along with stimulants. This means that it should be taken later to help methylphenidate work better.

The doctor thinks that once the patient starts taking Ritalin, her behavior will change in a clear way. Methylphenidate works by increasing the amount of dopamine outside of the cells. This makes the person less hyperactive and lets them stay calm for longer (Cortese, 2020). So, our patient would be able to pay more attention to the tasks and activities she does and keep her mind on them for longer. The drug is also made in a way that kids like, which, along with the parents’ help, makes it easier for the kids to stick to the routine. After four weeks of taking the medicine, the patient will be seen again.

Choice No. 2

Options for choice #1:

Keep giving the same amount of Ritalin and check back in 4 weeks.
Increase the morning amount of Ritalin LA from 10 mg to 20 mg.
Add 1 mg of Intuniv extended release orally to the amount of Ritalin.
Give her 1 mg of Intuniv extended release by mouth before bed.

Decision: Raise the daily oral dose of Ritalin LA to 20 mg every morning.

The first dose of Ritalin worked well for the patient, but when she went back for a checkup, the best thing to do was to up the dose because she still had a lot of trouble paying attention and had times when she was too active or impulsive. By upping the dose, we’d be able to see and understand her reaction to the drug methylphenidate more clearly. Considering the other three choices, it wouldn’t have made sense to keep her on the same dose of Ritalin for another four weeks, since she was still showing some of the symptoms from her first evaluation. It was also too early to add to or change the medicine she was already taking. (Cortese, 2020) Several studies have shown that the average length of treatment with steroids is 4 months.

By upping Doe’s dose, it was thought that the treatment would help her pay more attention and get rid of symptoms like bad writing, forgetfulness, and not being interested in schoolwork in general. The previous dose of medicine had helped her pay attention and stay focused, but not as much as she needed. She has already shown that she can handle methylphenidate, so it is likely that she will be able to handle the higher dose. After four weeks, the subject will be looked at again.

Choice No. 3

Options for choice #1:

Boost the daily oral dose of Ritalin LA to 30 mg.
Add 1 mg of Intuniv extended release orally to the amount of Ritalin.
Give her 1 mg of Intuniv extended release by mouth before bed.

Decision: Add 1 mg of Intuniv delayed release to the Ritalin dose.

At this point, the best way to change the patient’s care would be to add Intuniv, which is not a stimulant, to her therapy. The patient’s attention span, spelling, forgetfulness, and lack of interest in schoolwork were all the same as the last time she was seen. This meant that she had reached her methylphenidate level. (Huss et al., 2016) says that Intuniv is the best choice for both children and adults who don’t respond to first-line treatment. If you look at the other two choices, increasing the dose of Ritalin would have been bad because it wasn’t helping the patient in any way. If she had switched to Intuniv as her only treatment at two months, she would have been more likely to have serious side effects (Cortese, 2020).

After adding to her medicine, the patient should be able to pay more attention than she did on her last visit. She should also have less trouble remembering things and be more interested in schoolwork. Her writing should also get better. We also think she will be able to take Intuniv, since the drug has a big effect when given with methylphenidate (Osland et al., 2018).

Ethical Things to Think About

When a doctor is treating a patient, they should keep in mind the ethical concepts of autonomy, justice, beneficence, and non-maleficence (Horstkotter & De Wert, 2020). For ethical behavior, it’s important to understand the four rules. Before doing any treatment on a child, permission must be asked for from the parents or guardian. In this situation, Doe’s parents had to know everything about how their child was being cared for. It would also be moral to tell them the pros and cons of the drugs and let them make their own choice based on that information.

Conclusion

ADHD is a disease of how the brain develops that is common in children. The three most common signs of ADHD are not paying attention, being too active, and acting on impulses (NIHM, 2016). (Osland et al., 2018) says that these three things can cause other symptoms, such as disorganization, daydreaming, mood swings, trouble multitasking, short temper, fidgeting, forgetting or losing things a lot, having trouble taking turns, talking too much, having trouble getting along with others, and having trouble dealing with stress. ADHD can be treated with either medicine or treatment that doesn’t involve medicine, or both. When caring for a child like Doe, you need to think about their age, weight, if they have any illnesses, and if they have any other health problems. In the first line of treatment, drugs like amphetamines and methylphenidate are used. When the first drug doesn’t work, non-stimulants like atomoxetine, extended-release clonidine, and Intuniv (guanfacine) are usually tried (Cortese, 2020). When caring for kids or people with ADHD, health professionals also need to follow the four traditional ethical principles of autonomy, justice, beneficence, and non-maleficence.

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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