Response to discussion

Respond to at least two of your colleagues on 2 different days who were assigned your same medication but an opposite stance. For example, if you were assigned the con stance for amphetamine, you should respond to two students who were assigned the pro stance for amphetamine.  Support or expand on your original argument to refute their claims. Work to share additional perspectives on the issue described by your colleague. Additionally, your response needs to be supported by two (2) scholarly peer-reviewed resources located outside of your course Learning Resources.

Discussion 1 The Cons of using Methylphenidate

            Methylphenidate functions as a CNS stimulant by inhibiting the reuptake of norepinephrine and dopamine into presynaptic neurons, leading to increased release of these monoamines into the extraneuronal space. This activity amplifies neurotransmitter function in brain areas governing attention and behavior regulation, enhancing focus, attention, and impulse control. Ultimately, these mechanisms lead to heightened dopaminergic transmission in the brain by prolonging the duration and effectiveness of impulse-released dopamine in the synaptic cleft (Quintero et al., 2022).

Methylphenidate Appropriateness for Malcolm

            ADHD is a condition characterized by symptoms like inattention, hyperactivity, and impulsivity. Methylphenidate functions by increasing the levels of dopamine and norepinephrine in the brain. These neurotransmitters are crucial for attention, focus, and impulse control. Methylphenidate works by blocking the reuptake of these neurotransmitters into the presynaptic neuron and increasing their release. This mechanism helps improve attention and reduce hyperactive and impulsive behaviors (Quintero et al., 2022). Given Malcolm’s diagnosis of ADHD combined presentation, methylphenidate seems appropriate as it directly addresses the core symptoms of ADHD, including inattention, hyperactivity, and impulsivity. This medication could help Malcolm improve his focus and behavior at school and home, which could lead to reduced homework completion time and decreased disruptive behaviors (Quintero et al., 2022). 
 

Advantages and Disadvantages of Methylphenidate

Advantages: 

            Ritalin (methylphenidate enhances norepinephrine and primarily dopamine responses by preventing their reuptake. Ritalin (methylphenidate) augments dopamine and norepinephrine responses in particular brain sections (e.g., dorsolateral prefrontal cortex), which promote attention, concentration, administrative capacity, and consciousness. Ritalin works by increasing the dopamine released in the striatum, a critical region in the brain related to motivation, action, and cognition, and improves distress, weakness, and sleepiness (Quintero et al., 2022).

            This medication is so effective that improvement has been noticed on the first dose; it can help him focus better on tasks like homework and chores; reduced Hyperactivity: It can decrease his fidgetiness and help him stay seated in class, enhance his impulse control such as, reduce his tendency to blurt out answers and improve his interactions with peers. Similarly, Methylphenidate is well-documented to manage ADHD symptoms effectively. Such as available in various forms (immediate-release, extended-release), allowing for tailored dosing schedules; immediate-release forms act quickly, which can be beneficial for controlling symptoms during specific times of the day (Quintero et al., 2022).

Disadvantages:

            The most reported adverse effects in patients using methylphenidate are insomnia and nervousness. Long-term use in children can lead to growth retardation, including decreased height, weight, and bone marrow density. Other frequent side effects affect the central nervous system (such as dizziness, headache, tics, restlessness/akathisia), gastrointestinal system (including nausea/vomiting, dry mouth, decreased appetite, weight loss, and abdominal pain), and cardiovascular system (manifesting as tachycardia and palpitations). Additionally, patients may experience increased agitation, irritability, depression, and mood swings/lability (Storebø et al., 2023). Non-serious adverse events such as headaches, sleep difficulties, abdominal pain, decreased appetite, anxiety, and sadness are also commonly reported in patients being treated with methylphenidate (Storebø et al., 2023).

             Likewise, serious adverse events, such as psychosis, mood disorders, serious cardiovascular events, and sudden unexplained death, have been documented. Regular follow-ups are essential to monitor growth, cardiovascular health, and behavioral changes due to the potential risks associated with methylphenidate use, including the risk of addiction
 (Verghese & Abdijadid, 2023)

Advantages and Disadvantages of Other Medication Options

            While stimulants like methylphenidates and amphetamines have been the primary pharmacologic therapy in ADHD for decades, they are not suitable in many situations, including patients who do not achieve optimal symptom reduction or do not tolerate stimulants; some patients with comorbidities, such as anxiety, depression, and tics; or conditions, such as sleep disorders, eating problems) in which stimulant effects are of concern(Cutler et al, 2022). In children, adverse effects of long-term, continuous stimulant use on growth trajectories that may modestly reduce adulthood height and increase weight and body mass index are also cause for concern (Cutler et al., 2022)

            Nonstimulants can come into play, such as atomoxetine (ATX) and extended-release formulations of guanfacine (guanfacine-XR) and clonidine (clonidine-XR). Nonstimulants can be broadly classified as (1) monoamine reuptake (transporter) inhibitors (eg, ATX); (2) receptor modulators (guanfacine-XR, clonidine-XR) (Cutler et al., 2022)

Advantages and Disadvantages of Other Medication Options

            Non-stimulant medications such as Atomoxetine have a lower risk of abuse compared to stimulant medications. They often only require once-daily dosing, which can improve compliance. However, they have some disadvantages, including a delayed onset of action (it may take several weeks to see full effects) and potential side effects such as gastrointestinal upset, fatigue, and mood swings (Cutler et al., 2022).

            On the other hand, alpha-2 agonists like Guanfacine and Clonidine provide an alternative mechanism for managing ADHD in children who do not respond well to stimulants. However, they may cause drowsiness, low blood pressure, and dizziness. Additionally, they may be less effective than stimulants in managing core ADHD symptoms. There are also potential side effects to consider, such as increased heart rate and blood pressure, reduced growth velocity in children, and the risk of exacerbating anxiety, tics, or mood disturbances (Cutler et al., 2022).

Considerations—Legal, Ethical, and Social Implications

            Legal and ethical considerations include the side effects and potential for drug abuse when using stimulant medications. Conducting thorough evaluations, including assessing blood and platelet counts, cardiac health, weight, and height, is essential for patients. The management of ADHD should involve a partnership with patients and their parents, focusing on psychoeducation and developing a mutually agreed-upon management plan that considers individual treatment priorities and preferences. While standard care is typically provided in clinical settings, schools and other community settings can also play a significant role (Coghill et al., 2023).

            Additionally, ensuring that regulatory guidelines prescribe controlled substances such as methylphenidate is essential to prevent misuse. For instance, this includes appropriately documenting and monitoring prescriptions to prevent abuse, as well as carefully weighing the benefits of the medication against potential side effects and long-term impacts. Involve obtaining informed consent from both the individual receiving the medication and their parents and addressing any potential stigma associated with ADHD and medication use. Educating the individual’s school and peers can also help create a supportive environment that reduces the risk of stigma or differential treatment due to the individual’s condition and medication (Coghill et al., 2023).

Discussion 2 The Cons of using Methylphenidate

Introduction

     Malcolm is a nine-year-old male diagnosed with ADHD-combined presentation, meaning he is both hyperactive and inattentive.  The diagnosis was made based on testing and behaviors exhibited at two locations.  The most common next step may be to offer a pharmacologic agent (such as methylphenidate, also known as Ritalin) to help Malcolm improve his rambunctious behavior and his ability to attend and follow through on tasks.  For the family, having him be able to focus and do all his homework, remember the combination code to the house, and complete household chores would most likely be a huge relief.  The issue at hand is that Malcolm’s parents are very concerned and opposed to medicating their child first.  They want to understand the detrimental side effects that methylphenidate may have on their son and what other options exist.  In general, there are many classes of drugs, including central nervous stimulants (including methylphenidate, amphetamines, lisdexamfetamine) selective noradrenaline reuptake inhibitors, (atomoxetine, viloxazine), alpha 2 adrenergic receptor agonists (guanfacine, clonidine) and several antidepressants and atypical antipsychotics not yet approved by the FDA for ADHD treatment (Nazarova, 2022).  The purpose of this review is to provide the cons against ordering methylphenidate and provide other first-line options. 

Side Effects of Methylphenidate    

     Methylphenidate is a central nervous stimulant and one of the most prescribed, first-line medications offered for ADHD, and it generally has a low side effect profile.  However, there are some side effects that the parents should be made aware of, including loss of appetite so the child may not eat his lunch at school or pick up his dinner.  Weight loss can be a concern due to decreased appetite and caloric intake.  The drug may also cause insomnia, and he may not get a good night’s sleep.  Sometimes kids become more irritable or anxious, this could be a result of both of these side effects.  Some complain about headaches.  Also, growth hormones can be impacted, so his physical growth may be stunted during this time.  Although very rare, kids can develop an addiction, full-blown psychosis, or cardiac issues (Entringer, 2023).  The most common side effects reported include (Entringer, 2023):

· Sweating, increased blood pressure;

· Changes in mood, such as new onset of anxiety, nervousness, irritableness, trouble sleeping,

· Cardiac side effects such as tachycardia, fluttering beats in the chest

· Loss of appetite and unintended weight loss,

· Dry mouth, nausea and vomiting, stomach pain, indigestion or

· Headaches and dizziness.

     Most side effects are considered minor, transient, and resolved with continued treatment. Short-acting doses (4 hours) may be considered to mitigate the decrease in appetite.  Interestingly enough, 695 interventional ADHD trials from clinicaltrial.gov were analyzed; most studies (over 80%) investigated nonpharmacological therapies, and only 20% accounted for pharmacological interventions (Nazarova, 2022). Research trials that only looked at non-medicated participants showed promising results with decreased symptoms. (Lambez, 2020). Nonpharmacological therapies, such as sleep and physical activity (especially aerobic activities), behavioral coaching, meditation, hypnotherapy, neurofeedback, and social skills training, actually worked to minimize ADHD symptoms (Nazarova, 2022).  Most trials examined cognitive behavioral therapies and showed significantly positive results with reduced core ADHD symptoms (Nazarova, 2022).  Researchers also reviewed dietary interventions such as elimination diets, removing artificial food colorings, and adding in free fatty acid supplementation and concluded that removing food coloring and adding in free fatty acids resulted in a decrease in ADHD symptoms (Nazarova 2022).

                A conversation should occur about exploring non-pharmacologic strategies first, especially if this is the parent’s preference, before looking into methylphenidate.  This would include exploring the parent’s time commitment toward parent training and offering support groups for parents with ADHD kids.  They should realize that there could be some environmental triggers that could be creating his behaviors and interventions they, as parents, could take, such as totally minimizing the time on video games and electronics.  The dopamine rush from the games is not helping Malcolm and may, in fact, be depleting the reserves he needs to focus and maintain behavior at school.  Additionally, cognitive behavioral therapy for Malcolm may be considered as it has also shown to be just as effective as medications.  Also, they could speak with the school and request an IEP evaluation.  He may need environmental modifications in the school, such as sitting closer to the teacher, closer to the chalkboard if they use one, working in small groups, being allowed extra exam time, and maybe even a tutor based on his academic scores.  Learning disabilities may also be present and avoidance of work may be because he cannot understand the work presented. 

     Lastly, the importance of diet cannot be overlooked.  A conversation regarding the foods he is eating is critical.  High-sugary soft drinks, sugary cereals in the morning, high carbohydrates, candies, pop tarts, and sugar diets are going to make him hyper versus a diet with high protein, vegetables, and fruits.  As previously discussed, having key vitamins and amino acids in the diet helps tame many behaviors.  Many kids also have hidden food allergies that impact their behavior, so they could be tested to see if he is allergic to milk, eggs, or wheat.  He should also have his eyes examined.  Often, children with vision problems act out from their inability to see well, impacting their ability to learn or concentrate because they simply cannot see well.    

     In summary, if parents are opposed to methylphenidate as a first-line treatment due to the side effects of this stimulant, they may want a referral to a developmental psychologist for cognitive behavioral training.  Also, the consideration of enrolling him into a sport where he can get natural endorphins flowing, such as track, soccer, or basketball, with less time on electronics, could help greatly.  He would be physically tired and would also sleep more soundly.  If these interventions do not work and ADHD symptoms continue, then re-evaluating and adding pharmacologic management with cognitive behavioral therapy may be the next best step.  If the parents are opposed to using a stimulant, non-stimulant drugs such as Strattera (a norepinephrine reuptake inhibitor) or Clonidine or Guanfacine (alpha-adrenergic agonists) could be discussed.