Lindsay Wargelin, APN Pediatric Nurse Practitioner Developmental Pediatrics - PowerPoint Presentation

Lindsay Wargelin, APNPediatric Nurse PractitionerDevelopmental Pediatrics School Nurses’ ConferenceApril 9, 2019 What is ADHD?Updates in ADHD for School Nurses: Diagnostic and Medical Considerations James Weedon, MD Developmental and Behavioral Pediatrician Division Director for Developmental Pediatrics

ObjectivesReview the clinical features and presentation of Attention Deficit Hyperactivity Disorder and evaluation processUnderstand diagnosis and treatment recommendations based on age group Discuss the use and management of medication in treating ADHD

DSM-V criteriaSymptoms of inattention or hyperactivity/impulsivity have persisted for at least six months and there is functional impairment in two or more settings.NEED input from teachers, other adults besides parents.ADHD Subtypes Hyperactive, Inattentive, Mixed What is ADHD?

Prevalence of Subtypes

DSM-5 Criteria Inattentive SymptomsInattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level: Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly.Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework). Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones). Is often easily distracted Is often forgetful in daily activities.

DSM-5 Criteria Hyperactive SymptomsHyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level: Often fidgets with or taps hands or feet, or squirms in seat.Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).Often unable to play or take part in leisure activities quietly. Is often "on the go" acting as if "driven by a motor". Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or games)

Why is ADHD a Problem?Prevalence of 8-10% of all school-age children5.2 Million Children, 2 ½ :1 -- Male : FemaleHigh incidence of co-morbid disorders Learning Disability, ODD, CD, Anxiety, Depression Left untreatedSchool failureDifficulty with peer relationships Risk taking behaviors Difficult to achieve success

AAP Clinical GuidelinesPublished November 2011 in PediatricsResult of a 2 year task force including members of:American Academy of Pediatrics American Academy of Child and Adolescent Psychiatry Child Neurology Society Society for Pediatric PsychologyNational Association of School Psychologists Society for Developmental and Behavioral Pediatrics American Academy of Family Physicians Children and Adults With Attention-Deficit/Hyperactivity Disorder (CHADD) Epidemiologist from the Centers for Disease Control and Prevention (CDC).

Key Action StatementsPrimary care clinician should initiate an evaluation for ADHD for any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.Previously 6 through 12 years of age.ADHD is difficult to diagnose accurately in the earlier years of life.

Key Action StatementsInclude assessment for other co-morbidities Emotional or behavioral Anxiety, depressive, oppositional defiant, and conduct disordersDevelopmental Learning and language disorders or other Neurodevelopmental disordersOther tics, sleep apnea

Diagnostic ConsiderationsAnxiety or depression can present as hyperactivity or inattention in childrenChildren with developmental delay should be assessed according to their developmental expectationsChildren with ADHD-combined or primarily hyperactive are identified earlier than with inattentive subtype and boys tend to be more hyperactive than girls. Most common presenting symptom in preschool is hyperactivity and impulsive control

Treatment of ADHDThree-pronged approachBehavioral modification Educational supportUse of medication to supplement

Evidence for Treatment by AgeAge 4-5 (Preschool-aged)First line: Evidence-based parent and/or teacher-administered behavior therapy Quality of evidence A / Strong recommendationIf behavioral interventions do not provide significant improvement and symptoms are moderate-severe, trial of stimulant medication with weighing harm of early medication with delay of diagnosis and treatment Quality of evidence B / Strong recommendation

Evidence for Treatment by AgeAge 6-11 (Elementary school-aged)Evidence stronger for ADHD medication Quality of evidence A / Strong recommendation And/or Parent/teacher behavior therapy Quality of evidence B / Strong recommendationPreferably both with educational supports

Evidence for Treatment by AgeAges 12-18 (Adolescents)ADHD medicationQuality of evidence A / Strong recommendation Behavior therapy Quality of evidence C / RecommendationPreferably both with educational supports

Educational Accommodations and Supports

Educational SupportsClassroom environmentSpecial education vs. mainstream classroomAccommodations Educational strategies Individualized Education Program – IEP504 plan

Examples of School AccommodationsPhysicalSeatingOrganization of materials Removal of distractions including during testing Instructional accommodationsRepeat and simplify directionsCheck in for understanding Provide examples and written instructions Behavioral accommodations Positive reinforcement Special jobs or leadership duties Open communication with parents

ADHD Medication

Medication ConsiderationsFinding the right medication (stimulants vs non-stimulants)Starting at a low dose and increase slowlyMonitor for side effects versus benefit Use Vanderbilt questionnaire as a baseline to monitor response to treatment

ADHD MedicationsStimulants1. Methylphenidates2. Amphetamines Nonstimulants – Atomoxetine (Strattera) Alpha-2-adrenergic agonists Antidepressants Tricyclics and dopamine reuptake inhibitors

Stimulant PharmacokineticsWeight dependent dosing in children is not well established. In general, start at a low dose and increase slowly.Onset of action 45 min to 1 hour DurationImmediate release 3-5 hours Extended release 8-12 hoursBe wary of peaks and valleys

Stimulant Medications

Methylphenidates

Amphetamines

Side Effects of StimulantsAppetite suppressionSleep disturbanceWeight loss Transient symptoms: Headache, stomachacheStop taking immediately if: Acute marked changes in behavior or mood Symptoms of hallucination, psychosis, or mania

Other ConcernsStimulants as gateway to drug abuse?NO! Untreated ADHD has increased risk of substance abuse. Treated ADHD risk of substance abuse is near population levels.

Atomoxetine (Strattera)Selective norepinephrine reuptake inhibitorNot a controlled substanceOral capsule – do not open and sprinkle Starting dose of 0.5 mg/kg/day, titrate to 1.2 mg/kg/day. Max of 1.4 mg/kg/day Daily dosing or BIDMust be given every day

Side Effects of StratteraLess commonAbdominal pain, nausea, vomitingDecreased appetite HeadacheSomnolence

Alpha-2-Adrenergic AgonistsClonidine (Catapres) Initial dose 0.1mg at bedtime, titrate by 0.1mg weekly, maximum 0.4mg/day, up to QIDExtended-release: KapvayGuanfacine ( Tenex ) Initial dose 0.5-1mg/day at bedtime, titrate by 0.5-1mg weekly, maximum 4mg/day, up to QID dosing Extended-release: Intuniv

Alpha-2-Adrenergic AgonistsCan be used as monotherapy or adjunct to stimulant medication Requires 1-2 weeks for initial response Must taper off slowly to prevent rebound hypertension

Side EffectsSedationBradycardiaHeadache Hypotension May be useful in children who are over-aroused, highly active, and aggressiveImprovement in tics

MTA Study – 14 month f/u

How to Track EfficacyVanderbilt Rating Scales Parent and teacher School reports Academic progress Behavior reports

Additional treatment strategies Social skills groups Occupational therapyADHD coach Parent support groups

ResourcesTaking Charge of ADHD by Russell Barkley, PhDSOS Help for Parents by Lynn Clark, PhD Smart But Scattered by Dawson and Guare Siblings Without Rivalry by Faber and Mazlish CHADD – chadd.org Family Resource Center on Disability www.parentsmedguide.org