jackie tomberlin, ms, rn. adhd is the most common childhood-onset psychological disorder, estimated...

Jackie Tomberlin, MS, RN

ADHD is the most common childhood-onset psychological disorder, estimated to affect 5-7% of children world-wide.

It has been shown to have significant impact on multiple domains of quality of life in children and adolescents.

Self esteem—negative beliefs about self

Leads to maladaptive coping strategies (avoidance, procrastination, acting out)

Social function—poor peer relationships, family conflict, risky early sexual behavior, bullying, substance abuse

Hyperactive, distractible, impulsive Underachieving in school Disruptive and often in trouble Socially unsuccessful Can concentrate on things they find

interesting or fun Cannot concentrate on tedious or complex

Boys 4X more likely to be diagnosed than girls

Found in every culture Lower grades, more delinquency, arrests,

aggression, injuries, hospitalizations, truancy, failed jobs and relationships

Unknown, but strong suggestion of a faulty dopamine transporter

76% risk appears familial (primary relatives have a 5-7X higher risk of having ADHD)

Head injury, lead or other environmental exposure

Maternal smoking, ETOH, prematurity thought to contribute

Pre-frontal cortex inhibits and directs executive function: planning, prioritization, organization, impulse control

Pre-frontal cortex development in children with ADHD is 3 years delayed on average

ADHD is a developmental delay in impulse control, concentration, organization

Pre-frontal cortex is last to develop and most sensitive to perinatal insults

Elimination diets (inflammation, autoimmune, Whole30)

Sugar Food dyes Lack of outdoor time (Nature Deficit

Disorder) and natural sunlight Dysfunctional parenting—no limits, chaos

Seizure disorders Sleep disorders Hearing or vision problems Medical disorders (thyroid, illnesses) PTSD, anxiety, depression, substance abuse Learning or cognitive disability

Results of MTA study guide treatment

Pharmacological and non pharmacological treatments

STIMULANTS: methylphenidate (Ritalin) amphetamine

NON-STIMULANTS: atomoxetinebupropriontri-cyclic anti-depressantsguanfacine, clonidine, intunivmodafinil (Provigil)

Dopamine and norepinepherine re-uptake inhibitors in the pre-frontal cortex

Pre-frontal cortex is the “filter”—helps to attend to important things, ignore unimportant

Stimulants activate the pre-frontal cortex and aid filter skills and executive function skills

Goal is to improve distractibility, hyperactivity, impulsivity

FDA indicated to treat ADHD

Methylphenidate and amphetamine are two separate categories, both efficacious –75% with first trial, 85% with two trials

Decreased appetite, insomnia, irritability Slightly increased BP and HR 1/400 experience psychosis Some small reduction in ht and wt

trajectory while taking them but long term effect unknown

May or may not exacerbate a tic

Short acting: Ritalin (5-60mg/day)

Intermediate: Metadate (20-60mg/day) Ritalin LA

Long acting: Concerta (18-72mg/day) Focalin XR (5-30mg/day) Daytrana patch (10-30mg/day)

Short acting: Dexedrine (5-40mg/day)

Intermediate: Adderall (2.5mg-40mg/day)

Long acting: Adderall XR (10-40mg/day) Lisdexamphetamine (Vyvanse)(30-70mg/day)

Significant abuse potential, especially short acting

“pharming” Children with ADHD have a 2.5 fold increase

in the risk for any substance abuse disorder including nicotine, alcohol, marijuana, and diversions of prescription medications

Research suggests that 16-23% of school-aged children are approached to sell, buy or trade their stimulant medication

Misuse of stimulant medication common (5-9% of grade school and high school aged children and 5-35% college aged)

Methods to reduce the risk for misuse: long-acting formulations, ensure that the DX is correct, educate family regarding the risks for misuse, provide guidance during the transition of medication from parent to child, using non-stimulant medications

ATOMOXETINE (Strattera)—norepinephrine re-uptake inhibitor

FDA approved for ADHD Good second line choice when stimulants

not tolerated or risk of diversion or AODA Not as effective as long-acting stimulants Side Effects: sedation, nausea, poor

appetite

Provides 24 hr coverage, effect starts after 2-4 weeks, 25-100mg/day, can give once a day

Black Box warning regarding suicidal ideation

Centrally acting anti-hypertensive medications FDA approved for ADHD

GUANFACINE (1-4mg/day) Intuniv= long acting form Side effects: sedation, orthostatic

hypotension CLONIDINE (0.1-0.4mg/day) Long acting form Kapvay

Buproprion: helpful with ADHD comorbid with depression. Do not use if seizure history

Tri-cyclic antidepressants: need to monitor EKG @ baseline and follow-up, blood levels; weight gain

Modafinil: likely mechanism dopamine reo-uptake, not first line med

Cognitive Therapy: specific exercises to train attention, working memory, impulsivity via ongoing feedback to reinforce correct responses

Neurofeedback: recent study showed this to be better than CT; in neurofeedback child receives immediate auditory and visual feedback re his level of attention during the exercises; significant improvement sustained over 6 months with reduced med doses; likely due to plasticity in pre-frontal cortex

Groups, practice, reward Implications for school nurses

Questions