Updates in ADHD: Diagnostic and Medical Considerations for School Nurses

 
Lindsay Wargelin, APN
Pediatric Nurse Practitioner
Developmental Pediatrics
 
 
School Nurses’ Conference
April 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
 
Objectives
 
Review the clinical features and presentation
of Attention Deficit Hyperactivity Disorder and
evaluation process
Understand diagnosis and treatment
recommendations based on age group
Discuss the use and management of
medication in treating ADHD
 
DSM-V criteria
Symptoms 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
Symptoms
 
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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
Symptoms
 
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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 children
5.2 Million Children,  2 ½ :1 -- Male : Female
High incidence of co-morbid disorders
Learning Disability, ODD, CD, Anxiety, Depression
Left untreated
School failure
Difficulty with peer relationships
Risk taking behaviors
Difficult to achieve success
 
AAP Clinical Guidelines
 
Published November 2011 in Pediatrics
Result 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 Psychology
National 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 Statements
 
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Previously 6 through 12 years of age.
ADHD is difficult to diagnose accurately in the
earlier years of life.
 
Key Action Statements
 
Include assessment for other co-morbidities
Emotional or behavioral
Anxiety, depressive, oppositional defiant, and conduct
disorders
Developmental
Learning and language disorders or other
Neurodevelopmental disorders
Other
tics, sleep apnea
 
Diagnostic Considerations
 
Anxiety or depression can present as hyperactivity
or inattention in children
Children with developmental delay should be
assessed according to their developmental
expectations
Children 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 ADHD
 
Three-pronged approach
1.
Behavioral modification
2.
Educational support
3.
Use of medication to supplement
 
Evidence for Treatment by Age
 
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First line:  Evidence-based parent and/or teacher-
administered behavior therapy
Quality of evidence A / Strong recommendation
If 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 Age
 
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Evidence stronger for ADHD medication
Quality of evidence A / Strong recommendation
And/or Parent/teacher behavior therapy
Quality of evidence B / Strong recommendation
Preferably both with educational supports
 
Evidence for Treatment by Age
 
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ADHD medication
Quality of evidence A / Strong recommendation
Behavior therapy
Quality of evidence C / Recommendation
Preferably both with educational supports
 
Educational
Accommodations and
Supports
 
Educational Supports
 
Classroom environment
Special education vs. mainstream classroom
Accommodations
Educational strategies
Individualized Education Program – IEP
504 plan
 
Examples of School
Accommodations
 
Physical
Seating
Organization of materials
Removal of distractions including during testing
Instructional accommodations
Repeat and simplify directions
Check in for understanding
Provide examples and written instructions
Behavioral accommodations
Positive reinforcement
Special jobs or leadership duties
Open communication with parents
 
ADHD Medication
 
Medication Considerations
 
Finding the right medication (stimulants vs
non-stimulants)
Starting at a low dose and increase slowly
Monitor for side effects versus benefit
Use Vanderbilt questionnaire as a baseline to
monitor response to treatment
 
ADHD Medications
 
Stimulants
1. Methylphenidates
2. Amphetamines
Nonstimulants – Atomoxetine (Strattera)
Alpha-2-adrenergic agonists
Antidepressants
Tricyclics and dopamine reuptake inhibitors
 
Stimulant Pharmacokinetics
 
Weight 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
Duration
Immediate release 3-5 hours
Extended release 8-12 hours
Be wary of peaks and valleys
 
 
Stimulant Medications
 
Methylphenidates
 
Amphetamines
 
Side Effects of Stimulants
 
Appetite suppression
Sleep disturbance
Weight loss
 
Transient symptoms:
Headache, stomachache
Stop taking immediately if:
Acute marked changes in behavior or mood
Symptoms of hallucination, psychosis, or mania
 
Other Concerns
 
Stimulants 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 inhibitor
Not a controlled substance
Oral 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 BID
Must be given every day
 
Side Effects of Strattera
 
Less common
Abdominal pain, nausea, vomiting
Decreased appetite
Headache
Somnolence
 
Alpha-2-Adrenergic Agonists
 
Clonidine (Catapres)
Initial dose 0.1mg at bedtime, titrate by 0.1mg
weekly, maximum 0.4mg/day, up to QID
Extended-release: Kapvay
Guanfacine (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 Agonists
 
Can 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 Effects
 
Sedation
Bradycardia
Headache
Hypotension
 
May be useful in children who are over-
aroused, highly active, and aggressive
Improvement in tics
 
MTA Study – 14 month f/u
 
How to Track Efficacy
 
Vanderbilt Rating Scales
Parent and teacher
School reports
Academic progress
Behavior reports
 
Additional treatment strategies
 
Social skills groups
Occupational therapy
ADHD coach
Parent support groups
 
Resources
 
Taking Charge of ADHD
 by Russell Barkley, PhD
SOS 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
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Review clinical features, diagnostic criteria, and treatment options for Attention Deficit Hyperactivity Disorder (ADHD) presented by experts during a School Nurses Conference. Covering DSM-V criteria, prevalence of subtypes, assessment of inattentive and hyperactive symptoms, and medication management for ADHD across different age groups.


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  1. 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 Lindsay Wargelin, APN Pediatric Nurse Practitioner Developmental Pediatrics School Nurses Conference April 9, 2019

  2. Objectives Review the clinical features and presentation of Attention Deficit Hyperactivity Disorder and evaluation process Understand diagnosis and treatment recommendations based on age group Discuss the use and management of medication in treating ADHD

  3. What is ADHD? DSM-V criteria Symptoms 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

  4. Prevalence of Subtypes

  5. DSM-5 Criteria Inattentive Symptoms Inattention: 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.

  6. DSM-5 Criteria Hyperactive Symptoms Hyperactivity 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)

  7. Why is ADHD a Problem? Prevalence of 8-10% of all school-age children 5.2 Million Children, 2 :1 -- Male : Female High incidence of co-morbid disorders Learning Disability, ODD, CD, Anxiety, Depression Left untreated School failure Difficulty with peer relationships Risk taking behaviors Difficult to achieve success

  8. AAP Clinical Guidelines Published November 2011 in Pediatrics Result 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 Psychology National 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).

  9. Key Action Statements Primary 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.

  10. Key Action Statements Include assessment for other co-morbidities Emotional or behavioral Anxiety, depressive, oppositional defiant, and conduct disorders Developmental Learning and language disorders or other Neurodevelopmental disorders Other tics, sleep apnea

  11. Diagnostic Considerations Anxiety or depression can present as hyperactivity or inattention in children Children with developmental delay should be assessed according to their developmental expectations Children 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

  12. Treatment of ADHD Three-pronged approach 1. Behavioral modification 2. Educational support 3. Use of medication to supplement

  13. Evidence for Treatment by Age Age 4-5 (Preschool-aged) First line: Evidence-based parent and/or teacher- administered behavior therapy Quality of evidence A / Strong recommendation If 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

  14. Evidence for Treatment by Age Age 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 recommendation Preferably both with educational supports

  15. Evidence for Treatment by Age Ages 12-18 (Adolescents) ADHD medication Quality of evidence A / Strong recommendation Behavior therapy Quality of evidence C / Recommendation Preferably both with educational supports

  16. Educational Accommodations and Supports

  17. Educational Supports Classroom environment Special education vs. mainstream classroom Accommodations Educational strategies Individualized Education Program IEP 504 plan

  18. Examples of School Accommodations Physical Seating Organization of materials Removal of distractions including during testing Instructional accommodations Repeat and simplify directions Check in for understanding Provide examples and written instructions Behavioral accommodations Positive reinforcement Special jobs or leadership duties Open communication with parents

  19. ADHD Medication

  20. Medication Considerations Finding the right medication (stimulants vs non-stimulants) Starting at a low dose and increase slowly Monitor for side effects versus benefit Use Vanderbilt questionnaire as a baseline to monitor response to treatment

  21. ADHD Medications Stimulants 1. Methylphenidates 2. Amphetamines Nonstimulants Atomoxetine (Strattera) Alpha-2-adrenergic agonists Antidepressants Tricyclics and dopamine reuptake inhibitors

  22. Stimulant Pharmacokinetics Weight 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 Duration Immediate release 3-5 hours Extended release 8-12 hours Be wary of peaks and valleys

  23. Stimulant Medications

  24. Methylphenidates

  25. Amphetamines

  26. Side Effects of Stimulants Appetite suppression Sleep disturbance Weight loss Transient symptoms: Headache, stomachache Stop taking immediately if: Acute marked changes in behavior or mood Symptoms of hallucination, psychosis, or mania

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

  28. Atomoxetine (Strattera) Selective norepinephrine reuptake inhibitor Not a controlled substance Oral 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 BID Must be given every day

  29. Side Effects of Strattera Less common Abdominal pain, nausea, vomiting Decreased appetite Headache Somnolence

  30. Alpha-2-Adrenergic Agonists Clonidine (Catapres) Initial dose 0.1mg at bedtime, titrate by 0.1mg weekly, maximum 0.4mg/day, up to QID Extended-release: Kapvay Guanfacine (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

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

  32. Side Effects Sedation Bradycardia Headache Hypotension May be useful in children who are over- aroused, highly active, and aggressive Improvement in tics

  33. MTA Study 14 month f/u

  34. How to Track Efficacy Vanderbilt Rating Scales Parent and teacher School reports Academic progress Behavior reports

  35. Additional treatment strategies Social skills groups Occupational therapy ADHD coach Parent support groups

  36. Resources Taking Charge of ADHD by Russell Barkley, PhD SOS 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

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