Jackie Tomberlin, MS, RN. ADHD is the most common childhood-onset psychological disorder, estimated...
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Transcript of 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