ADHD for School Nurses Jackie Tomberlin, MS, RN

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.

Why does ADHD matter? 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

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

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

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

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

CONTROVERSIAL IDEAS Elimination diets (inflammation, autoimmune, Whole30) Sugar Food dyes Lack of outdoor time (Nature Deficit Disorder) and natural sunlight Dysfunctional parenting—no limits, chaos

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 ODD present up to 75% in children w/ ADHD/ LD present in 20-30% of children w/ ADHD Tics present 35-90% Disruptive Mood Disorder is new DSM 5 dx: severe, chronic irritability, frequent temper outbursts

TREATMENT Results of MTA study guide treatment Pharmacological and non pharmacological treatments 579 children 7-10 yrs were enrolled in one of 4 study options for 14 months 1)meds alone (ritalin 3X day) 2) Behavioral tx only 3) combo 4) no tx Combo tx and meds alone best Anxiety, academic performance, oppositionality, parent-child relations social skills were better w/ combo therapy Combo tx resulted in successful tx on lower doses of ritalin Early treatment response predicted outcome, higher SES better outcome, maternal depression poorer outcome, low IQ poorer Children w/ ADHD did worse than normal controls on 91% of variables tested

MEDICATIONS STIMULANTS: methylphenidate (Ritalin) amphetamine

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

STIMULANTS 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

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

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 Risk of sudden death, stoke or heart attack no higher than in general population

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)

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)

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

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

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

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

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 Some evidence for combined use with stimulants

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 @ baseline and follow-up, blood levels; weight gain Modafinil: likely mechanism dopamine reo- uptake, not first line med

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

BEHAVIOR THERAPY Groups, practice, reward Implications for school nurses Questions