The American Psychiatric Association highlight in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that Attention-deficit hyperactivity disorder (ADHD) is among the most common diagnosis among children. Approximately higher percentage of boys and girls are affected by this condition at early ages when they begin to have problems with being attentive and persists to adulthood. Children with this condition are often affected at school and at home where they may be incapable of controlling their own impulses, may have hyperactivity and additionally have problems in paying attention. In most cases of ADHD children may record poor performance at school, have social relationship troubles and struggle with low esteem in addition to hyperactivity and impulsive tendencies (Feldman & Reiff, 2014). Furthermore, children may have careless tendencies, forgetfulness and day dreaming that are seen in severe cases of this condition. Several theories have advanced on the likely prevalence of ADHD in children. For instance, chemical and neurotransmitter imbalance in the brain and general brain changes especially in the attention centers in children have been implicated as likely causes. Brain injury and trauma to the frontal lobe and other mental disorders have also been advanced as associated causes of this condition.
Luckily, this condition is treatable but may not be completely cured. The treatment options available range from medications to behavioral therapy and interventions. The treatment interventions serve to alleviate the presenting symptoms. Indeed, the earlier the patient is diagnosed with this condition is treated the more likely they will feel better and have good treatment outcomes. This essay will enumerate further on the treatment decisions to be made concerning the medications when treating Katie who was an 8 year old Caucasian female diagnosed with symptoms of Attention-deficit hyperactivity disorder and how ethical considerations will impact on the treatment and communication with the patient.
Provision of medication based on the presenting symptoms and impact of drugs on age
The patient was an 8 year old Caucasian female, Katie who was brought to my office today by her parents. They report that they were referred to by their primary care provider after seeking her advice because Katie’s teacher suggested that she may have Attention-deficit hyperactivity disorder. Katie’s parents reported that their personal care provider felt that she should be evaluated by psychiatrist to determine whether or not she had this condition. A Conner’s Teacher Rating Scale-Revised was performed on her and filled out by Katie’s teacher and sent home to the parents so that they could share it with their family primary care provider. According to the scoring provided by her teacher, Katie was inattentive, easily distracted, forgot things she already learned, was poor in spelling, reading, and arithmetic. Additionally, her attention span was short, and she was noted to only pay attention to things she was interested in. The teacher noted that she lacked interest in school work. At school she, started things but never finished them, and seldom followed through on instructions and as a result she failed to finish her school work.
I chose this decision because when presented with a case of ADHD in children, one of the most important factors to consider is how the choice of drug to use will impact on the child’s age. The presenting symptoms determine the choice of drug to use in the cases of ADHD conditions. The medication to use must at all times aim at providing relief to the symptoms as well as not having a severe impact on the patient’s age that can subvert the course of treatment. Visser et al., (2014) point out that certain drugs are not recommended as they have negative impacts on age such as severe side effects. Some stimulants such as guanfacine cause headache, diarrhea, and increased heart rate when used in patients below 10 years. The main aim of treatment is to provide the best medication that is safe, efficacious and has least side effects to the 8-year old patient (Thomas et al., 2015).
Therefore, the best medication in an 8-year old patient with ADHD was a stimulant that acts to increase the stimulation, attention, interest and that will have an overall effect inattentiveness and alertness at school. Methylphenidate, given as slow release tablets twice daily is efficacious with few side effects on an 8-year old patient. Pharamcodynamically, this drug is titrated at low start doses to prevent tolerance as the patient may require high doses for effectiveness. However, the parents complained of a slow improvement in the general condition of the child with appetite changes as the only difference in the treatment outcome from the desired outcome. To control this, I recommended a switch of medication to dextroamphetamine which is an immediate release drug that acts quickly in stimulation of children.
Provision of medication based on the previous medical intervention that influence improvement patterns
Katie reported that she didn’t know what the “big deal” was with her condition. She stated that school was fine but found other subjects boring, and sometimes hard because she felt lost. She admitted that her mind did wander during class and was thinking a lot. All these pointed towards inattentive symptoms that could possible alter the course of initial treatment with brain stimulants.
I chose this decision because brain stimulants when used for a long time owing to their slow onset and fast duration of action may introduce an additional risk of insomnia that affects attention and subverts the progress of treatment. One of the most implicated effects of stimulants is insomnia and severe inattention when given at bed time over 4-6 hours periodically. Additionally, intolerance and exacerbation tics in children associated with stimulants use (Casey & Durston, 2014). The patient complained of additional sleep, tics and even slow improvement that required additional dosing hence necessitated a different choice of medication to use in this patients. For this reason, Atomoxetine that works very differently as stimulants was chosen because of its effectiveness and ability to increase noradrenaline in the brain hence improving attention and wakefulness of the child at school. The parents duly reported an improvement in school grades after a period of time indicating that the desired outcome of treatment was met.
Provision of medication based on adherence
I chose this decision because the parents complained that the child had difficulty in taking slow release tablets of Atomoxetine. This led to the child being depressed due to bitter taste hence poor compliance. Additionally, they reported that the dosage led to suicidal tendencies as a result of tolerance by the medication. Therefore, to control this I recommended other drugs such as methylphenidate that works in the same way as Atomoxetine but is not associated with severe side effects of suicidal thoughts and self-injury. Methylphenidate has found extensive use in children with ADHD as the dose required is small and can be given intravenously at bedtime to improve compliance (Gajria et al., 2014). This met the desired outcome because the parents reported an improved condition with compliance and adherence to medication.
How ethical considerations impact on treatment and communication to the patient
Treatment of ADHD in children has often raised controversial ethical issues on their continued use. For instance, Atomoxetine causes suicidal thoughts in children and can expose them to self-harm to their authentic self (Rubia et al., 2014). Additionally, these treatment can compromise a child’s ability for autonomous ethical agency. Medication dependence may prevent children with ADHD from developing a full ability for self-discipline. These will impact on autonomy especially during treatment. Therefore these factors impact on the medication and treatment plan as the mode of treatment must take into consideration the dependence, compromise for autonomy that promotes effective treatment in children with ADHD.
The decision on medication to prescribe to a child who presents with Attention-deficit hyperactivity disorder (ADHD) is based on the presenting symptoms and the impact of drugs on the age of the patient, previous medical interventions that influence treatment and patient adherence to medication.
Casey, B. J., & Durston, S. (2014). The impact of stimulants on cognition and the brain in attention-deficit/hyperactivity disorder: what does age have to do with it?. Biological psychiatry, 76(8), 596-598.
Feldman, H. M., & Reiff, M. I. (2014). Attention deficit–hyperactivity disorder in children and adolescents. New England Journal of Medicine, 370(9), 838-846.
Gajria, K., Lu, M., Sikirica, V., Greven, P., Zhong, Y., Qin, P., & Xie, J. (2014). Adherence, persistence, and medication discontinuation in patients with attention-deficit/hyperactivity disorder–a systematic literature review. Neuropsychiatric disease and treatment, 10, 1543.
Rubia, K., Alegria, A. A., Cubillo, A. I., Smith, A. B., Brammer, M. J., & Radua, J. (2014). Effects of stimulants on brain function in attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Biological Psychiatry, 76(8), 616-628.
Thomas, R., Sanders, S., Doust, J., Beller, E., & Glasziou, P. (2015). Prevalence of attention-deficit/hyperactivity disorder: a systematic review and meta-analysis. Pediatrics, 135(4), e994-e1001.
Visser, S. N., Danielson, M. L., Bitsko, R. H., Holbrook, J. R., Kogan, M. D., Ghandour, R. M., … & Blumberg, S. J. (2014). Trends in the parent-report of health care provider-diagnosed and medicated attention-deficit/hyperactivity disorder: United States, 2003–2011. Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 34-46.