ADHD Dr. Ellen Hennessy-Harstad DNP, RN, FNP-BC, CPN Indiana University Northwest Conflict of Interest The presenter indicates that there is no conflict of interest in this presentation, Objectives 1. Recognize signs/symptoms of different types of ADD/ADHD.

2. Differentiate ADHD from other disorders. 3. Identify the medications used for treating ADD/ADHD, and when to initiate therapy, and how to titrate or change medications. 4. Apply diet, behavioral, and medication management to select case study. ADHD by the Numbers 11% of children 4-17 years old 6.4 million (2011) 7.8% in 2003 to 9.5% in 2007 and to 11.0% in 2011.

Boys (13.2%) were more likely than girls (5.6%) Prevalence rates: 5.6% in Nevada to18.7% in Kentucky Indiana 15.7% (2011) 2011 ADD/ADHD What is my ADD is not your ADD Chemical

imbalance of one or more of three neurotransmitters in the brain GABA Dopamine Serotonin The Overlap Primary Symptoms

Inattentiveness Distractibility Hyperactivity Disorganization Impulsivity DMS-5 Criteria Inattention: Six or more symptoms of inattention for

children up to age 16 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: Hyperactivity and Impulsivity:

Six or more symptoms of hyperactivityimpulsivity for children up to age 16 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 persons developmental level. In Addition The following conditions must be met:

Inattentive or hyperactive-impulsive symptoms were present before age 12 years. Several symptoms are present in two or more setting, There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning. The symptoms do not happen only during the

course of schizophrenia or another psychotic disorder. ADD/ADHD Work-UP History Behavior noted in more than 1 environment Behavior before noted before 12 years old

Last Eye/Hearing Exam and by whom Diet Sleep Pattern Physical Exam Attention to the Heart, B/P Behavior during visit Connor

Scale Vanderbilt Scale (AAP toolkit) Tests Lab: CBC, T4, Lead level, Magnesium Screenings: Vision, Hearing Scans (Becoming Standard of Care: AAP) Normal brain activity at rest Decreased activity, especially in the

prefrontal cortex, during a concentration task Differential Diagnoses Autism Elevated Lead Level Hyperthyroidism Anemia Visual/Hearing Disorders Oppositional Defiant Disorder If Behavior Change is New Consider

head injury Substance Abuse Physical, Sexual, or Psychological Abuse Affects of ADD on Brain The Chemicals & the Brain Prefrontal cortex Cerebellum Anterior cingulate Basal ganglia Produces Dopamine

Temporal lobes Limbic System Types of ADHD Classic ADD Inattentive ADD Over-focused ADD Temporal Lobe ADD Limbic ADD

Ring of Fire ADD Anxious ADD Dr. Amens Classic ADD/ADHD Zametkin, et al., 1990 Treating Classic ADD Stimulants and Supplements Medications:

Ritalin, Adderall, Vyvanse, Concerta Supplements: rhodiola, green tea, ginseng, and the amino acid L-tyrosine Fish oil that is higher in EPA than DHA. Inattentive ADHD Treating Inattentive ADD The goal---boost dopamine levels.

Supplements: amino acid Ltyrosine, Stimulant: Adderall, Vyvanse or Concerta. Diet: High-protein, lower-carbohydrate diet Exercise daily.

Over-focused ADHD Treatment Over-Focused ADD The goal-- boost serotonin and dopamine Supplements firstL-tryptophan, 5HTP, saffron, and inositol. If supplements don't help, Effexor, Pristique, or Cymbalta. Diet:

Avoid higher-protein diet with this type, which can make patients mean. Neurofeedback training Temporal Lobe ADD Low activity in the Frontal Lobe Increased activity in the temporal lobe More often seen in patients with head injuries Classic ADD symptoms with a

short fuse Treatment of Temporal Lobe ADHD Supplements: GABA (gamma-aminobutryic acid) Magnesium Gingko Vinpocetine

Anticonvulsant medications Limbic ADD No medication Amphetamine Treatment of Limbic ADD Supplements

DL-phenylalanine (DLPA), L-tryosine SAMe (s-adenosyl-methionine) Fish oil (Omega 3 EPA) Medications Wellbutrin Researchers think it works by increasing dopamine Imipramine is another option for this type.

Exercise: Diet: Regularly Ring of Fire ADD Noticeable overall increased activity across the cortex Low prefrontal

cortex activity (less common) Treatment of R-of-F ADD Stimulants Elimination Diet Supplements: GABA, 5-HTP, and Ltyrosine supplements. Anticonvulsants Blood pressure medicines: guanfacine and clonidine may be helpful, calming overall hyperactivity. Anxious ADD

Classic ADD symptoms Tense, anxious Physical symptoms Predict the worst Freeze in anxiety-provoking situations High Activity in the Basal ganglia and deep structure in brain that produce dopamine. In most types of ADD, there is low activity in these areas Treating Anxious ADD

Goalincrease relaxation and boost GABA and dopamine levels. Stimulants SupplementsL-theanine, relora, magnesium, and holy basil. Tricyclic antidepressants-imipramine or desipramine to lower anxiety. Neurofeedback Treatment Plans Include Parent/Child

education ADHD as a chronic disease Involves a team approach Behavioral intervention strategies School accommodations and interventions Medications Requires regular follow-up and monitoring

Pharmacology Treatment Medications Should be started as soon as diagnosis is made First LineStimulants Second LineAntidepressants, Anticonvulsants, Antihypertensives Supplements

Omega 3 Magnesium Stimulant Medication Immediate Release Mentylphenidate (10-60mg)

Ritalin, Metadate, Methylin, Concerta (18-54mg) Dexmethylphenidate Focalin (5-20mg) Dextroamphetamine Dexedrine (5-40mg) Lisdexamphetamine

Vyvanse (30-70mg) Amphetamines Mixed amphetamine salts (Addrall 5-40mg)) Methamphetamine (Desoxyn-5-25mg) Sustained Release Methylphenidate

(10-60mg) Ritalin SR, Ritalin LA, Metadate ER, Metadate CD, Metylin ER, Concerta, Daytrana (patch 1530mg) Dextroamphetamine Dexadrine spansules (5-40mg) Amphetamine Adderall XR (5-40mg)

How they work o o o o Inhibition of dopamine reuptake Most have a rapid onset of action Symptom reduction in 30 to 60 minutes Duration of action 4 to 12 hours Side Effects & Solutions Side Effects

Solutions Initial Insomnia Earlier dosing or with clonidine or trazodone at bedtime Reduced Appetite Switch to Focalin which may have less affect on appetite Stomach ache

Give medication with Food Mild Dysphoria Switch classes of stimulants, or add an antidepressant such as bupropion Lethargy Reduce dose Headache Reduce dose or Change

stimulants Preston, et al (2010) Special Cases Preschool to School-aged Children 4-5 years of agestart with Behavior therapy; assess for developmental problems When therapy is not achieving

symptom control, may try mediation Currently, only dextroamphetamine is approved by the FDA for this age group. Methylphenidate (Ritalin, Concerta, and Daytrana patch) AAP recommendations Adolescents & Adults Check for Substance Abuse Monitor for refills Medication

coverage for evening. Use motivational interviewing techniques Alpha-2 Adrenergic Agonists Reduce irritability, aggression, impulsivity, and insomnia, tics Generic Brand Typical Dose (for children &

Adolescents) Clonidine Catapres 0.15-0.4mg (3 to 4 times a day) Guanfacine Tenex 0.25-1.0 mg

(2 to 3 times a day) Preston et al (2010) Antidepressants Generic Brand Dose Bupropion

Wellburin DR/LA Child: 100-150 mg Adult: 150-300mg Atomoxetine (Black Box Warning) Strattera 1.2-1.8mg/kg (same for

children and adolescents) Preston et al (2010) AAP recommendation (Monitor Liver function) Benefits of Antidepressants Once

a day dosing No need for special prescription pads No addition potential Most effective 5 to 40 days after starting Typically cover 24hours Can be used to treat comorbid depression Deciding on Medication Does the person have a tic disorder Efficacy of medication Preferred length of time coverage

Can swallow pills or capsules Cost Ease of administration Minimum side-effects Time of day for maximum symptom control (Concerta) Will medication alter sleep pattern Risk status for drug abuse Titrating Stimulants Start with low dose Titrate on a 3 or 7 day bases May evaluate symptom control with phone

meetings with parents or adult Increasing doses can be done by prescriptions that allow for dose adjustments upward Or by 1 prescription of tablets/capsules with instructions to administer progressively higher amounts by doubling or tripling the dose weekly. Week 4: face-to-face meeting with child/parent or adult AAP recommendations When to Change Medications Stomach ache

Mild Dysphoria Headaches If no symptom control after 1 month Target goals are not being meet Supplements Omega 3 (higher in EPA than DHA) Those reduce inflammation When the Medication Does Not Work Consider

the Differential Diagnoses Consider Consider the other types of ADD need for poly-pharm therapy, refer to a specialist. Follow-up Visits and Recommendations Teach

patient/family how to monitor HR and B/P Ask School Nurse to monitor HR and B/P after increase in medications Increase medications at weekly intervals Use long-acting medications Follow-up face-to-face at 4 weeks Every three months if on stimulants and symptoms are controlled Barriers to Treatment The family need to be informed

Myths ADHD does not affect behavior One outgrows ADHD Cost of medication and supplements Need for Lifestyle changes

increasing activity changing diet Being consistent with plan of care Behavioral Interventions Create a routine. Get organized. Avoid distractions. Limit choices. Change your interactions with your child. Use goals and rewards. Discipline effectively. Help your child discover a talent. Case Study Susie, a 7 year old, is referred to your practice, because her teacher says that she daydreams a lot in class and does not get her work done. Mom feels frustrated and asks if the teacher is making too much out of this as Susie does not cause any problems in the class. What is your response? Should this child be worked up for

ADHD? What tests will you run? Who will you have do the Connor or Vanderbilt scale? When will you start Susie on medication or supplements? What about diet? What about exercise? Resources American

Academy of Pediatrics (2013). Impl ementing the Key Action Statements: Algorit hm and Explanation for Process of Care for th e Evaluation, Diagnosis, Treatment, and Moni toring of ADHD in Children and Adolescents, PediatricsSupplemental Information. 1.html d-tests-making-assessment tml

.aspx Thank You Questions? Visit the AAP site for the ADHD toolkit

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