ADHD for School Nurses

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ADHD for School Nurses

• Jackie Tomberlin, MS, RN

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Why does ADHD matter?

• 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.

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Why does ADHD matter?

• Self esteemnegative beliefs about self
• Leads to maladaptive coping strategies
  (avoidance, procrastination, acting out)
• Social functionpoor peer relationships, family
  conflict, risky early sexual behavior, bullying,
  substance abuse

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Do you know this child?

• 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

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TRENDS

• 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

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CAUSES

• 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

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BRAIN STUDY

• 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

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CONTROVERSIAL IDEAS

• Elimination diets (inflammation, autoimmune,
  Whole30)
• Sugar
• Food dyes
• Lack of outdoor time (Nature Deficit Disorder)
  and natural sunlight
• Dysfunctional parentingno limits, chaos

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OTHER DIAGNOSES THAT LOOK LIKE ADHD

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

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TREATMENT

• Results of MTA study guide treatment
• Pharmacological and non pharmacological
  treatments

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MEDICATIONS

• STIMULANTS
• methylphenidate (Ritalin)
• amphetamine

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MEDICATIONS

• NON-STIMULANTS
• atomoxetine
• buproprion
• tri-cyclic anti-depressants
• guanfacine, clonidine, intuniv
• modafinil (Provigil)

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STIMULANTS

• Dopamine and norepinepherine re-uptake inhibitors
  in the pre-frontal cortex
• Pre-frontal cortex is the filterhelps to
  attend to important things, ignore unimportant
• Stimulants activate the pre-frontal cortex and
  aid filter skills and executive function skills

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STIMULANTS

• 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

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STIMULANT SIDE EFFECTS

• 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

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METHYLPHENIDATE PREPARATIONS

• 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)

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AMPHETAMINE PREPARATIONS

• Short acting Dexedrine (5-40mg/day)
• Intermediate Adderall (2.5mg-40mg/day)
• Long acting Adderall XR (10-40mg/day)
  Lisdexamphetamine (Vyvanse)(30-70mg/day)

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STIMULANTS

• 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

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STIMULANTS

• 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

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NON-STIMULANTS

• 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

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ATOMOXETINE

• Provides 24 hr coverage, effect starts after 2-4
  weeks, 25-100mg/day, can give once a day
• Black Box warning regarding suicidal ideation

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Alpha-2-agonists

• 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

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NON-FDA APPROVED NON-STIMULANTS

• Buproprion helpful with ADHD comorbid with
  depression. Do not use if seizure history
• Tri-cyclic antidepressants need to monitor EKG
  _at_ baseline and follow-up, blood levels weight
  gain
• Modafinil likely mechanism dopamine reo-uptake,
  not first line med

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NON- PHARMACOLOGICAL TREATMENT

• 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

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BEHAVIOR THERAPY

• Groups, practice, reward
• Implications for school nurses
• Questions