Attention Deficit Hyperactivity Disorder

In the case study, Katie is an 8-year-old caucasian female who is noted by her teacher to be inattentive, easily distracted, forgetting things she has already learned, and has a short attention span.  In addition to these symptoms, she lacks interest in school work, and only pays attention to the things she is interested in.  Katie performs poorly in spelling, reading, and arithmetic, starts things but never finishes them, fails to finish her schoolwork, and seldom follows through on instructions.  Katie has been diagnosed with attention-deficit disorder, predominantly inattentive presentation.

In the attention deficit hyperactivity disorder decision tree point one, Katie was started on Ritalin (Methylphenidate) chewable tablets 10 mg orally in the morning.  In this decision, she returns in 4 weeks and her symptoms have improved, but in the afternoon she stares off into ‘space’ and is ‘daydreaming’ again. Katie also reports that her heart felt ‘funny’, her heart rate was measured at 130 bpm.  For decision point 2, Katie continues the same dose of Ritalin to be re-evaluated in 4 weeks.  After returning in 4 weeks, her performance in school is still improved, but throughout the school day, her attention span continues to worsen.  Katie also still reports that her heart still feels ‘funny’, and her heart rate is measured at 122 bpm.  At decision point 3, Katie’s prescription is changed to Ritalin LA 20mg PO daily in the morning- a long-acting dose to help with the afternoon problems of daydreaming, and shortened attention span.

Most effective pharmacotherapeutic to treat ADHD

Stimulants such as Methylphenidate are touted as the best medication for children and adults because they respond well to them, with only 33% of adults failing to respond to this type of treatment.  Stimulants are also considered the agents of choice because they are most effective, and combining behavioral therapy with drug therapy may be more effective for the treatment of ADHD(Burchum & Rosenthal, 2021)  Treatments for ADHD in children over six years old includes behavioral treatment for both child and parent, and also medication therapy.  The goals of behavior therapy include strengthening relationships between children and their families.  Behavioral therapy helps reduce disruptive behaviors in children, strengthen positive behaviors, and eliminate problematic behaviors.  In terms of medications, stimulants have been found to reduce symptoms by 70-80%.  Non-stimulants do not work as quickly, but their effects can last up to 24 hours(Treatment of ADHD, 2020)  Medications for ADHD are generally safe but medications alone cannot change behaviors or help develop academic skills or teach the child to regulate their emotions.  Collaboration with schools and caregivers along with behavioral interventions in conjunction with pharmacologic therapy can help develop important skills in children and adolescents(Brown et al., 2018)

Potential impacts of pharmacotherapeutics on physiology

Medications can have a different effect on children as Katie in the case study reported her heart feeling ‘funny’(Treatment of ADHD, 2020)  Although heart rate and blood pressure can increase while using stimulants, the average heart rate increase is usually only 3-4 beats per minute, and children and adolescents should receive a cardiac screening before beginning stimulant therapy.  Additional monitoring should also include neurological examination, sleep, appetite, behavior, and mental health changes, heart rate, blood pressure, and growth parameters.  Side effects of stimulant medications in children include reduced sleep efficiency, shorter sleep duration, sleep latency, along with psychosis, euphoria, severe depression, (Brown et al., 2018)and decreased appetite(Treatment of ADHD, 2020)  The mechanism of action for stimulants specifically methylphenidate and amphetamine involves prefrontal cortex arousal where methylphenidate and amphetamine boost norepinephrine and dopamine transmission.  Methylphenidate inhibits presynaptic dopamine transporters of central adrenergic neurons, and inhibits norepinephrine transporters to a much lesser extent.  The synaptic cleft concentration of dopamine is increased, thereby amplifying dopaminergic neurotransmission(Brown et al., 2018)

References

Brown, K. A., Samuel, S., & Patel, D. R. (2018). Pharmacologic management of attention deficit hyperactivity disorder in children and adolescents: a review for practitioners. Transitional Pediatrics, 7(1), 36–47. https://doi.org/10.21037/tp.2017.08.02

Burchum, J., & Rosenthal, L. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier, Inc.

Treatment of ADHD. (2020, October 21). CDC Centers for Disease Control. https://www.cdc.gov/ncbddd/adhd/treatment.html