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Jackie Tomberlin, MS, RN
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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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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
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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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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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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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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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Elimination diets (inflammation, autoimmune, Whole30)
Sugar Food dyes Lack of outdoor time (Nature Deficit
Disorder) and natural sunlight Dysfunctional parenting—no limits, chaos
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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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Results of MTA study guide treatment
Pharmacological and non pharmacological treatments
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STIMULANTS: methylphenidate (Ritalin) amphetamine
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NON-STIMULANTS: atomoxetinebupropriontri-cyclic anti-depressantsguanfacine, clonidine, intunivmodafinil (Provigil)
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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
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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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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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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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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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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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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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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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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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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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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
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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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Groups, practice, reward Implications for school nurses
Questions