ADHD is a behavioral disorder that exhibits a severe long-term effect on victims. The condition poses, even more, grave consequences on the health of females than males. Therefore, given that it can progress unnoticed during childhood, there is the need to conduct a thorough assessment to enable accurate diagnosis. Diagnosis is usually made using the Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM-IV-TR) criteria. An in-depth exploration of all the possible treatment recommendations begins after the diagnosis.
In the treatment of DHD detected in the patient in the case study, various approaches can be considered. Usually, the treatment of ADHD involves both the pharmacological and psychosocial approaches. The psychosocial treatments include school behavioral intervention among other approaches. In decision 1 of the case study, I selected the third option; begin Ritalin (methylphenidate) chewable tablets 10 mg orally in the morning. Stimulants are some of the recommended first-line pharmacological agents in the treatment of ADHD. Given that methylphenidate is a stimulant, it is given in this case. Indeed, the use of stimulants as the first-line pharmacological agents in the treatment of ADHD in children and adolescents is approved by the Food and Drug Administration (FDA) (Pliszka and AACAP Work Group on Quality Issues, 2007).
Even though stimulants are the recommended first-line pharmacological agents in the treatment of ADHD, concerns have been raised that their use may lead to abuse and addiction in adulthood. However, several long-term studies have failed to establish an association between stimulant use in the treatment of ADHD and addiction or abuse. For example, in a study conducted by Barkley and colleagues (2003) to determine whether the treatment of children with ADHD with stimulants contribute to drug use/abuse, it was found that there is no significant association between the treatment with stimulants and substance abuse. As a matter of fact, some studies have found that the use of stimulant in the treatment of ADHD in childhood is correlated with a reduction in drug and substance use and abuse. For example, in the study conducted by Wilens and colleagues (2003) to investigate whether stimulant therapy of ADHD in childhood brings about drug addiction in the subsequent life stages, it was found that the use of stimulant for ADHD treatment in childhood is related to a reduction in the risk for drug and alcohol abuse in subsequent life stages.
The use of methylphenidate as a first-line pharmacological agent in treating the patient in the case study was intended to reduce the symptoms in ADHD. The mechanism of action of methylphenidate has not been adequately established. However, scientists believe that the drug act by increasing the Intra-synaptic concentrations of dopamine and noradrenaline in the frontal cortex. It is also thought to increase the level of dopamine and noradrenaline in the subcortical brain regions: high concentration of dopamine and noradrenaline in the subcortical brain regions is associated with motivation and reward (National Collaborating Centre for Mental Health UK., 2009; Peer and Reid, 2012). Contrary to my expectation, the improvement of the symptoms was only observed in the morning hours. However, in the afternoon, the symptoms reappeared. This observation could be explained by possible low dosage of methylphenidate. In other words, perhaps a different formulation of higher dosage could have lasted the patient the whole day.
In decision 2, a change to Ritalin LA 20 mg orally daily in the morning was implemented. This decision was taken to suppress the targeted symptoms of ADHD for the whole day. It is advisable to start the treatment on a low dose and increase the dosage gradually. The decision 2 was intended to suppress the symptoms of ADHD for the whole day unlike decision 1 which only succeeded in improving the symptoms for a half a day. Starting the children with ADHD on a lower dose and gradually increasing the dose has been found to improve symptoms as noted in The National Institute of Mental Health Collaborative Multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA study) (Ibay, Bascelli, and Graves, 2003). Two hundred and fifty-six children completed the titration in the study. The study showed improvement with the increment of the dose administered to the children who participated in the study. The American Academy of Child and Adolescent Psychiatry recommends that a consistent titration schedule constituting weekly increases in increments of 5-10 mg per dose should be followed to attain symptom control (Ibay, Bascelli, and Graves, 2003; Greenhill, Pliszka, and Dulcan, 2001; Hay, 2014). The decision 2 yielded results that were anticipated. The child responded as had been anticipated. Consequently, I would recommend the same approach in other cases.
The next step that the PMHNP should have taken is to maintain the current dose (to Ritalin LA 20 mg orally daily in the morning) of Ritalin LA and re-evaluate in 4 weeks. This step was necessary because it showed adequate improvement in the symptoms. Besides, this dose resulted in few cases of adverse effects as evidenced by the lowering of pulse rate. The step was intended to ensure that the child responded positively to the dose. No difference between the expected outcome and the results noted in this decision was observed. Therefore, this was the right decision to make at that point.
Treatment of the patient in this case study poses some ethical challenges that should be addressed to ensure that the provided interventions lead to positive outcomes. One of the ethical challenges facing intervention efforts, in this case, is the need to uphold autonomy. In this case, the consent of both the parents and the child should be sought when planning for the intervention. However, the consent of the child is limited. This presents a challenge in balancing the extent to which the child’s consent should be incorporated in the care plan.
Another ethical problem likely to characterize the intervention plan is the difficulty in upholding the principle of maleficence. In this case, there is the need to avoid harm that might result from the treatment as much as possible. However, the side effects associated with the medication cannot be avoided. Nearly all patients exhibit the side effects associated with all drugs. In a bid to uphold the principle of maleficence there is the need to assess the patient comprehensively for the suitability of use of the given medication. This step is important especially considering that some patients respond to certain drugs in a manner that can significantly impact negatively on their health. Indeed, some drugs induce symptoms that are life-threatening. Concerning the case study, the care plan should be based on the assessment of the patient for suitability for the use of methylphenidate for treating ADHD. This assessment is meant to avoid causing harm to the patient.
Lastly, it is crucial to provide the patient will all the information concerning the intervention given. In the case study, the patient is a child who probably understands little about the medication used for treating her condition. Apart from obtaining consent from her parents, the PMHNP should divulge some information about the intervention to the child. However, some information might have to be withheld. Besides, the PMHNP might be forced to give false information deliberately to achieve certain goals. For example, the PMHNP might tell the child that the drug is sweet or makes people look pretty so that the child can cooperate.
References
Barkley, R. A., Fischer, M., Smallish, L., & Fletcher, K. (2003). Does the treatment of attention-deficit/hyperactivity disorder with stimulants contribute to drug use/abuse? A 13-year prospective study. Pediatrics, 111(1), 97-109.
Greenhill, L. L., Pliszka, S., & Dulcan, M. K. (2001). Summary of the practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults. Journal of the American Academy of Child & Adolescent Psychiatry.Top of Form
Hay (2014). Current Diagnosis & Treatment: Pediatrics, 22e. McGraw-Hill.Top of Form
Ibay, A. D., Bascelli, L. M., & Graves, R. S. (2003). Does increasing methylphenidate dose aid symptom control in ADHD?. Clinical Inquiries, 2003 (MU).
National Collaborating Centre for Mental Health (UK. (2009). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. British Psychological Society (UK).
Peer, L., & Reid, G. (2012). Special educational needs: A guide for inclusive practice. London: SAGE.
Pliszka, S., & AACAP Work Group on Quality Issues. (2007). Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 46(7), 894-921.
Wilens, T. E., Faraone, S. V., Biederman, J., & Gunawardene, S. (2003). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 111(1), 179-185.
