This clinical presentation involved a Caucasian female aged eight brought to the clinic by her parents following a referral by their Primary Care Provider (PCP) for an ADHD evaluation after the client’s teacher suspected she might have had the condition. ADHD is a neurodevelopmental childhood disorder characterized by a child being overly active, having controlling impulsive behaviors, or difficulty paying attention (CDC, 2021). According to the teacher’s rating scale, the client is inattentive, forgetful, easily distracted. The report also indicates she is not good in reading, spelling, and arithmetic and that she has a short attention span, only being attentive to what she has an interest in. The teacher also reported that the client did not like schoolwork, never completed whatever she started, including school work, and hardly followed instructions. The parents were in denial that she could have had ADHD because she was ok at home.
The subjective data revealed that the client finds all the subjects boring except art and recess. She also admitted wandering and feeling “lost” during class time. The mental exam did not reveal much of the client’s ADHD status as she appeared to have judgment, insight, and development, which was age-appropriate. The client’s speech was coherent, logical, and clear, and she was well oriented. She did not display any meaningful gestures, mannerisms, or tics and her concentration and attention were intact. She also denied having any hallucinations, delusional thought processes, or suicidal ideations. The aim of this essay is to provide information on the three pharmacological decisions made to treat the 8-year-old ADHD. The evidence-based decisions considered the ethical issues that could have an effect on the treatment process, particularly because she is a minor, as well as the aspects that could impact the client’s pharmacokinetics and pharmacodynamics.
Decision One
The client’s ADHD, pharmacological therapy will commence with Ritalin (Methylphenidate) chewable tablets at a dose of 10 mg orally every morning. Methylphenidate was the preferred pharmacological option for the treatment of the client’s ADHD because it is a stimulant. According to Brown et al. (2018), stimulants such as Methylphenidate are the approved first-line pharmacologic ADHD therapy in children due to their efficacy and high tolerability. Ritalin works by non-competitively inhibiting noradrenaline and dopamine reuptake by blocking their respective transporters resulting in increased levels of the two in the synaptic cleft (Singh, 2017).
Wellbutrin (bupropion) was evaluated but not selected because it is not approved for pediatric ADHD treatment and can only be used for this purpose as an off-label drug (Singh, 2017). Secondly, it is a Non-stimulant drug considered a second-line pharmacological treatment alternative for ADHD and could only be considered if the client had not tolerated the Ritalin therapy (Singh, 2017). Intuniv was also not selected because it is an alpha 2A agonist, only indicated for use in pediatric ADHD when stimulants such as Ritalin are ineffective or cannot be tolerated (Chaplin, 2016).
In selecting Ritalin as the first pharmacological option, it was anticipated that the client would overcome most of the ADHD symptoms. In choosing Methylphenidate as the initial therapy, the ethical considerations included client autonomy, informed consent, non‐maleficence, and beneficence. Despite not being in a position to make her treatment decision because of being a minor, in choosing to start Methylphenidate, the client and her parents were provided with the benefits and risks of the medication options and allowed to make an independent decision (Foreman, 2006). The decision also prioritized the client’s health and quality of life by choosing an option that was thought to have more benefits to them compared to the risks (Varkey, 2021). These ethical considerations were important in ensuring medication adherence.
The results of methylphenidate therapy after four weeks included improved ADHD symptoms, especially in the morning as per the teacher’s report, although some were still present, particularly in the afternoon. However, the medication affected her heartbeat, as reported by the parents and confirmed by a pulse rate of 130 beats per minute.
Decision Two
After evaluating the Methylphenidate therapy results, the pharmacological decision made was to change the medication to Ritalin LA 20 mg oral every morning. This decision was principally informed by the client’s need for an extended-release stimulant such as Ritalin LA to help her manage the ADHD symptoms throughout the day. According to Caballero et al. (2017), extended stimulant formulations such as Ritalin have the capability to provide all-day therapeutic coverage of up to up to 10 hours and better pharmacokinetic profiles, which include lower peak concentrations.
The decision to continue Ritalin at the same dose was disregarded because of the medication’s inability to relieve the client’s ADHD symptoms throughout the day and the accompanying higher heart rate side effects. Adderall 15 mg, although a viable option at this stage, was not favored because at that dose, it could exacerbate the client’s tachycardia. According to Khan et al. (2021), a routine Adderall prescription can cause tachycardia, especially at higher doses.
With the decision to switch from Ritalin to Ritalin LA, the client’s ADHD symptoms were expected to improve throughout the day. It was also expected that she would tolerate Ritalin LA without any side effects. The decision to switch to Ritalin LA was predominantly guided by the ethical doctrines of client autonomy, informed consent, non‐maleficence, and beneficence. Foreman (2006) and Varkey (2021) emphasizes the need for psychiatrists and other health practitioners to act in ways that benefit the patient and ensure the decisions they make do not add more harm to the patient, and that’s why the medication was changed to help the client overcome the ADHD symptoms with less adverse events. However, in making this decision, the client and her parents were provided with sufficient information on the benefits and side effects of all the available pharmacological options at this stage and allowed to make their decision without coercion.
The decision to replace Ritalin with Ritalin LA after four weeks improved the client’s ADHD symptoms throughout the day. Her tachycardia had also cleared, and her pulse rate was at 92 beats per minute.
Decision Three
At this stage of the client’s treatment, the decision was to maintain the same dose of Ritalin LA and reevaluate after four weeks. This decision was primarily informed by the fact that at 20 mg, Ritalin LA was able to assist the client overcome the ADHD symptoms throughout the school day, and at this stage, there is no need to increase the dose. According to Connolly et al. (2015), it is advisable to initiate and sustain lower doses of stimulants medications such as Ritalin LA and only titrate upwards based on efficacy and tolerability. At this stage, it was advisable to maintain the dose and help the client not revert to the Tachycardia side effect she was experiencing with Ritalin.
Increasing the Ritalin LA dose to 30 mg was overlooked because the client had responded well to the medication at 20 mg. According to Docherty & Alsufyani (2021), stimulant drugs such as Ritalin LA tend to cause significant tachycardia even in lower doses. Therefore, titrating the dose upwards could trigger this side effect again, and there it was considered clinically inappropriate at this stage. The other option, which concerned obtaining an EKG based on heart rate at this stage, was also not favored because at 92 beats per minute, the client does not need the test. Had the client’s tachycardia persisted, it would have been appropriate to consider this option, but this was not the case when making this decision as her heartbeat was considered appropriate for her age. In selecting to maintain the same dose of Ritalin LA, it was expected that the client would achieve the full response to therapy and overcome all the ADHD symptoms while also tolerating the medication with few adverse effects. In making this pharmacological decision, the ethical considerations included of client autonomy, informed consent, non‐maleficence, and beneficence.
Conclusion
The first pharmacological decision made to treat the client, a Caucasian female aged eight, was to commence with Ritalin (Methylphenidate) chewable tablets at a dose of 10 mg orally every morning. Methylphenidate was the preferred pharmacological option for the treatment of the client’s ADHD because it is a stimulant which are the approved first-line pharmacologic medication for the treatment of ADHD in children because of their efficacy and high tolerability (Brown et al., 2018). However, with the decision, the client was still experiencing ADHD symptoms, particularly in the afternoon and an elevated pulse rate which led to the discontinuation of Ritalin and the initiation of Ritalin LA 20 mg oral every morning because the client needed an extended-release stimulant to help her manage the ADHD symptoms throughout the day. According to Caballero et al. (2017), extended stimulant formulations such as Ritalin have the capability to provide all-day therapeutic coverage of up to up to 10 hours. The final decision was to maintain the same dose of Ritalin LA and reevaluate after four weeks since, at 20 mg, the drug was able to assist the client in overcoming the ADHD symptoms throughout the school day, and her tachycardia had also cleared with the client’s pulse rate was at 92 beats per minute during the visit. In making these three pharmacological decisions, the ethical considerations included beneficence, non‐maleficence, client autonomy, and informed consent. The client and her parents were provided with sufficient information on the benefits and side effects of all the available pharmacological options at each decision stage and allowed to make their decision without coercion. Further, Foreman (2006) and Varkey (2021) emphasis on the need for psychiatrists and other health practitioners to act in ways that benefit the client and ensure the decisions they make do not add more harm to the patient were considered at every decision point.
References
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