1. ADHD for School Nurses
Jackie Tomberlin, MS, RN

2. 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.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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 %
Disruptive Mood Disorder is new DSM 5 dx: severe, chronic irritability, frequent temper outbursts

10. 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

11. MEDICATIONS
STIMULANTS:
methylphenidate (Ritalin)
amphetamine

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

13. 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

14. 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

15. 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

16. 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)

17. 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)

18. 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

19. 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

20. 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

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

22. 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 ( mg/day)
Long acting form Kapvay
Some evidence for combined use with stimulants

23. NON-FDA APPROVED NON-STIMULANTS
Buproprion: helpful with ADHD comorbid with depression. Do not use if seizure history
Tri-cyclic antidepressants: need to monitor baseline and follow-up, blood levels; weight gain
Modafinil: likely mechanism dopamine reo- uptake, not first line med

24. 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

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