ADHD

Introduction

Attention deficit hyperactivity disorder (ADHD) is a typical childhood neurodevelopmental disorder. Although its initial diagnosis is during childhood, it often lasts into adolescence and adulthood. Children with ADHD have controlling impulsive behaviors, challenges paying attention, and can be overly active. It is usual for children to have challenges behaving and paying attention at certain times. Nonetheless, children with ADHD do not outgrow these behaviors; hence the symptoms persist, can be severe, and cause difficulty in their interpersonal relationships at school, with friends, and at home. The common symptoms of ADHD fall under inattention and hyperactivity (Feldman et al., 2018). The main signs of inattentiveness include; difficulty organizing tasks, short attention span, being forgetful and easily losing items, inability to stick to time-consuming activities, failure to execute instructions, and the constant change of a task. In contrast, hyperactivity manifests through constantly fidgeting, acting impulsively, interrupting conversations, minimal sense of danger, inability to sit still in quiet and calm environments, excessive talking, and failure to take turns (CDC, 2021). Boys have a higher likelihood (12.9%) than girls (5.6%) of being diagnosed with ADHD (CDC, 2021). Five percent of adolescents and children are also affected by the disorder globally (Song et al., 2021). ADHD is affecting a significant portion of the global population hence the need to comprehend it in client care to understand better the applicability of evidence-based practice in improving patient care.

Case Study Summary

An interview was conducted to collect the patient's data and medical and family history to improve the quality of patient care. The patient is a six-year-old male seen in the clinical setting during my private practice in El Paso, Texas. He resides with his mother and three older siblings in a single-family home after the parents divorced. However, his father later died due to alcohol addiction, a condition he had before the patient was born. His teacher had requested his parents to bring him in due to his behavioral problems at school. He struggled with organization, management, and finishing tasks at school and often lost his work. His teacher noted that his interpersonal relationships were short-lived. He lacked self-control, underperformed academically, was messy, and often seemed lost. When going through a set of instructions with him, he often peered at a peer's work or worked through what was going on in a confused state. The boy's family was also concerned about his behavior because he often engaged in fights with his three older siblings, a behavior that has dented the relationship between them. Other concerns from the parents include; severe sleeping difficulties, messy backpack, room, and notebooks, resisting bedtime, avoiding homework, and losing items. In addition to the strenuous task of waking him up in the morning, he is slow in his morning routine and performs hygienic duties impulsively. For instance, he would take three seconds to brush his teeth, evidence of his quickness and impulsiveness, which is standard behavior for boys with ADHD Combined Type. Despite these challenges, the patient wanted to have good friends, improve his baseball skills, make new friends, and be able to find his lost homework. 

The patient had manifested these symptoms a year before his hospital visit. Although teachers had expressed concern, the parents thought the behaviors would wade off after a few months. The child also has motor challenges, including agility and bilateral coordination, as diagnosed using the Bruininks-Oseretsky Test. The mother reported using tobacco and alcohol when pregnant with the patient to deal with the stress her marriage imposed on her. However, she stopped engaging when she and her husband got divorced. Nonetheless, neonatal exposure to alcohol and cigarettes is the predominant risk factor that could have led to the patient's ADHD. Diagnosing him with ADHD was sequential using the lists of symptoms provided by the Diagnostic and Statistical Manual of Mental Disorders, a medical examination involving vision and hearing tests, and the child's history as reported by the child's teacher and parent. The child's vaccinations are up to date, and their Review of systems (ROS) is remarkable. Although the parent has heard of the term ADHD before, she has no information on what it is or how to help her child manage it. The parent must therefore be well informed on ADHD to position her better to take care of her child. According to the CDC (2021), the first line of treatment for the child would be behavioral management and behavioral classroom interventions. If they fail, methylphenidate can be used to mitigate the child's severe issues. 

Multiple Viewpoints on ADHD

Various controversies regarding ADHD exist, including its overdiagnosis in adolescents and children. In this regard, Beheshti et al. (2021) address gender and age bias, the two main directions of the issue. The authors claim that ADHD is among the most frequently diagnosed childhood and adolescent disorders, leading to a global prevalence of 5%. Simultaneously, there has been an implied increase in the prescription rate of psychostimulants accompanying the rise in ADHD diagnoses. There is a possibility of better recognition of the condition in underdiagnosed groups, enhanced knowledge on diagnosis and psychopathology, and increased healthcare access for particular groups (Fabiano & Haslam, 2020). However, there are justifiable concerns that there is an ADHD overdiagnosis which the authors summarize under gender and age bias. The authors' findings indicate that psychiatrists are overdiagnosing ADHD, and gender was a significant factor as boys received a false ADHD diagnosis twice as much as females (Beheshti et al., 2021). These false-positive diagnoses increase the psychostimulant prescription rates hence the need to develop strategies to mitigate diagnostic errors and overcome heuristic biases. 

Soundness of Research

Both journal articles addressing the overdiagnosis controversy are credible. Fabiano & Haslam (2020) systematically examined the inflation rates of the diagnosis of ADHD due to the updating of diagnostic measures by quantitatively reviewing 123 studies. In these studies, two consecutive DSMs diagnosed a single sample, generating room for comparing diagnostic rates. In the study, there was notable inflation of ADHD, which is supported by other research articles, including Beheshti et al. (2021). In contrast, Beheshti et al. (2021) are more credible as the study focuses on data collection from 344 licensed psychiatrists who were asked to diagnose eight children of both genders. They then filled the questionnaire with their diagnosis, treatment recommendations, and sociodemographic details. In this way, their study was more practical as it analyzed the handling of an actual case and assessed the overdiagnosis. Additionally, their findings aligned with that of other researchers, including Kazda et al. (2021), who also found that children and adolescents were over-diagnosed with ADHD. Overall, there is a clear indication of the increase in false positives in the diagnosis of ADHD. 

Evaluation of Current EBM (evidence-based medical guidelines) Guidelines

Feldman et al. (2018) suggest a multimodal treatment approach for children and adolescents with ADHD involving the combination of pharmacological treatments and behavior management. Because ADHD is chronic, the authors claim that the first step in its treatment is formulating a shared-care approach with the child and their parents based on a shared comprehension of treatment preferences and goals and accurate data on underlying etiology (Feldman et al., 2018). Non-pharmacological interventions should be individualized according to the specific objectives, be age-appropriate, follow a comprehensive evaluation of comorbid conditions, and be acceptable to the parents, school teachers, and family. For children aged below six, the authors recommend parent behavior training due to the weak evidence on the psychostimulants' effectiveness. Medication is primarily effective on severe ADHD symptoms and should be considered for children aged six and older. However, most children with ADHD exhibit developmental and psychiatric comorbidities; hence non-pharmacological interventions should be a routine part of their comprehensive care.

Similarly, Leahy (2018) recommends that children with ADHD undergo multimodal treatment that integrates caregiver education to improve the illness' symptoms, eliminate behavioral hurdles, and improve functional performance. She also recommends that school-aged children undergo behavioral interventions to complement pharmacotherapy. Additionally, timely treatment would positively affect the child's outcomes as an adult. Methylphenidate and amphetamine derivatives are the first options in treating children with ADHD as they reduce the core symptoms of hyperactivity-impulsivity and inattention. Non-responsiveness to stimulants would result in using non-stimulants such as the noradrenergic reuptake inhibitor and two α-adrenergic agonists (extended-release [ER] guanfacine and clonidine) (Leahy, 2018). From the preceding, one must educate caregivers and customize the child's treatment according to medical evidence and preferences.

EBM's Impacts on Practice

The data indicates that the patient should receive a multi-modal treatment that combines pharmacotherapy and behavioral interventions as they are aged six and above and are exhibiting core ADHD symptoms. First, the parents will be provided with accurate information and education to ensure effective planning and management and to eliminate misconceptions they may get online (Leahy, 2018). The child's parent would then be involved in the shared decision-making as they have the autonomy to consent to either pharmacotherapy and behavioral interventions or opt for non-pharmacological treatment only. The treatment planning will involve identifying improvement objectives, including behavioral compliance, academic performance, and social relations (Leahy, 2018). Non-pharmacological interventions would include; parental behavior therapy, social skills training, and classroom management. Suppose the parents agree to the recommended intervention. In that case, the non-pharmacological treatments will be complemented with a dose of 5mg of methylphenidate twice a day if in solution or chewable tablets form. However, these interventions can be adjusted as needed. 

Cultural, Spiritual, and Socioeconomic Issues

Research posits that patients' religious and spiritual beliefs are vital, hence the need for their integration into their care. Integrating patients' spiritual beliefs into their treatment increases the likelihood of their recovery due to increased patient comfort, adherence to treatment, and the improvement of their general life quality. Cultural competence also improves the healthcare professional's communication allowing for correct and more accurate diagnoses (Bringedal & Isaksson RØ, 2021). In addition, culture determines a patient's response to treatments and diseases, affecting adherence and patient-healthcare provider therapeutic relationship. By understanding the patient's socioeconomic status, one is also better positioned to provide practical intervention methods, communicate better with the patients, and mitigate the negative factors that adversely affect the patient's healthcare (Bringedal & Isaksson RØ, 2021). Thus, it is vital that healthcare professionals consider the patient’s cultural, spiritual, and socioeconomic status.

ADHD is a serious global concern due to its significant prevalence hence the need to comprehend how to improve the care for ADHD patients through the case study and applying evidence-based practice. The patient under study was a six-year-old male recently diagnosed with ADHD, which has affected his academic and home life. As a result, there was a need to research factors regarding his condition, including; common controversies, evidence-based medical guidelines, and clinical information. The collected data was then analyzed and applied to his case, after which recommendations were made on how his illness could be treated. Finally, there was a consideration of the cultural, spiritual, and socioeconomic issues that healthcare professionals should integrate into the patient's care. Collectively, these approaches will improve the care for ADHD patients. 

References

Beheshti, A., Chavanon, M., Schneider, S., & Christiansen, H. (2021). ADHD overdiagnosis and the role of patient gender among Iranian psychiatrists. BMC Psychiatry, 21(1). https://doi.org/10.1186/s12888-021-03525-3

Bringedal, B., & Isaksson RØ, K. (2021). Should a patient’s socioeconomic status count in decisions about treatment in medical care? A longitudinal study of Norwegian doctors. Scandinavian Journal of Public Health, 140349482110336. https://doi.org/10.1177/14034948211033685

CDC. (2021). ADHD treatment recommendations. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/guidelines.html.

CDC. (2021). Data and statistics about ADHD. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/data.html#:~:text=Facts%20about%20ADHD&text=The