PEDIATRICS:ADHD Part I
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serves as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.
ABSTRACT
Attention Deficit/Hyperactivity Disorder (ADHD) is a diagnosis that tends to cause a lot of fear and confusion in parents and caregivers, but receiving the proper information in a timely manner from medical professionals can help alleviate many of those feelings. ADHD is a chronic disorder that includes a combination of symptoms, including hyperactivity, impulsivity, and difficulty sustaining attention. Millions of children struggle with ADHD, but there is plenty of cause for hope. Symptoms of ADHD frequently ease as the patient reaches adulthood, and there are good medical and behavioral treatment strategies available. However, it is important to carefully screen patients according to current standards before making an ADHD diagnosis. In order to avoid overdiagnosing, a child shouldn't receive a diagnosis of ADHD unless the core symptoms of ADHD start early in life and create significant problems at home and at school on an ongoing basis.
Continuing Nursing Education Course Director & Planners
William A. Cook, PhD, NurseCe4Less.com Director
Doug Lawrence, MS, Nurse Ce4Less.com Webmaster Course Planner
Susan DePasquale, CGRN, MSN, Nurse Ce4Less.com Lead Nurse Planner
Accreditation Statement
This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 8 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements
It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all CNE educational activities. All authors and course planners participating in the planning or implementation of a CNE activity are expected to disclose to course participants any relevant conflict of interest that may arise.
Statement of Need
Nurses, depending on their role and training, may or may not have primary responsibility to diagnose ADHD; however, they contribute to the formulation of a diagnosis and plan of care through observation and interaction with children, parents and teachers and rely upon expert knowledge to use the right screening tool and methods identify behaviors and social challenges associated with ADHD.
Course Purpose
Toprepare nurses to have knowledge of pediatric ADHD,methods of diagnosing associated disorders and behavioral outcomes, and to participate in interprofessional collaborative treatment that involves the patient and their family.
Learning Objectives
- Understand the three types of ADHD diagnoses.
- Recognize the typical clinical presentation of ADHD.
- Explain common symptoms of inattentiveness.
- Describe common symptoms of hyperactivity-impulsivity.
- Identify age-appropriate medication strategies.
- Identify age-appropriate behavior modifications.
- Explain the diagnostic process.
Target Audience
Advanced Practice Registered Nurses, Registered Nurses and Licensed Practical Nurses, and Medical Assistants
Course Author & Director Disclosures
Jassin M. Jouria, MD has no disclosures
William S. Cook, PhD has no disclosures
Doug Lawrence, MS has no disclosures
Susan DePasquale, CGRN, MSN has no disclosures
Acknowledgement of Commercial Support:
There is no commercial support for this course.
Activity Review Information:
This course has been peer reviewed by Susan DePasquale, CGRN, MSN. Review Date: December 21, 2013.
Release Date: January 7, 2014 Termination Date: January 7, 2017
Please take time to complete the Self Assessment Knowledge Questions for Pre-Course (p. 4) and Post-Course (p. 101)
Pre-Course Self-Assessment Knowledge Questions:
1) _____ are the primary neurotransmitters that mediate frontal-lobe function.
Amino acids
Catecholamines
Gaba peptides
Acetlycholine derivites
2) The predominantly hyperactive/impulsive type of ADHD is usually characterized by high energy and constant movement. The classic manifestation(s) of this type of ADHD is/are ______.
Inattentiveness or lack of attention
Disorganization
Forgetfulness
All of the above
3) Children with predominantly ______type of ADHD face barriers when trying to form social relationships with other children due to their tendency to be easily angered and provoked.
Inattentive
Impulsivity
Autistic
Hyperactivity
4) A comprehensive neurologic examination needs to be performed in children with ADHD to rule out the possibility of neurodegenerative disorders such as ______.
Alzheimer’s Disease
Parksinson’s Disease
Adrenal leukodystrophy
Mad Cow disease
5) A comorbidity of ADHD, oppositional defiant disorder, is seen when children engage themselves in ongoing destructive patterns that is defined by persistence of disobedience and triggered by anger and hostility.
Autism
Antisocial Disorder
Oppositional defiant disorder
Asperger’s Syndrome
6) The formal diagnosis of ADHD in children, adolescents, and adults usually occur in ______.
School
Primary care settings
Secondary care settings
Home
7) Children with attention deficit hyperactivity disorder are ______likely to have ______levels of comorbidities related to mood, anxiety, and disruptive behavior disorders and impairments in the cognitive, interpersonal and academic functions.
More; higher
Less; lower
More; lower
Less, higher
8) In obtaining the ______history of the child suspected of ADHD, the general health and well-being of both the child and the parents need to be carefully assessed.
Social
Family
Psychiatric
Medical
9) Information about the presence of other conditions that might have triggered ADHD, and the use of medications and other substances that can cause side effects or interact with ADHD medications are obtained in the ______.
Medications list
Social history
Family history
Past medical history
10) The interview with teachers constitutes the ______line of the stepwise diagnostic process in identifying students with ADHD.
First
Second
Third
Last
INTRODUCTION
According to the National Institute of Mental Health, attention deficit hyperkinetic disorder or ADHD is a relatively common brain disorder that is often diagnosed at childhood and continues to adolescence and adulthood (1). Children with ADHD sometimes exhibit uncontrollable behavioral symptoms that are frequent and severe which interferes with their ability to cope at school and live normal lives outside of it.
Pediatric ADHD causes hyperactivity and impulsivity and/or inattention in affected children. Many children experience these behavioral issues at some time during their childhood. However, in children with ADHD, these behavioral problems persist over a long period of time. To be diagnosed with ADHD, these behaviors must continue for at least 6 months and be present in two environments such as home and school.
Clinicians should be able to diagnose this disorder early on to evaluate the patient and provide for all the necessary pharmacotherapeutic and behavioral interventions that will minimize symptoms and restore social and academic functions. This course specifically discusses ADHD in children or pediatric ADHD.
An effective management of ADHD requires a multidisciplinary team approach that includes the patient, the family, the school, and the clinician. This course discusses in detail the management and diagnostic approaches that every healthcare professional in contact with an ADHD patient should be familiar with and understand.
DEFINITION OF TERMS
Hyperactivity: Refers to constant activity, being easily distracted, impulsiveness, inability to concentrate, aggressiveness, and similar behaviors.
Impulsivity: Refers to actions that are poorly conceived, prematurely expressed, and unduly risky, or inappropriate to the situation.
Inattention: Refers to inability to focus
History
The modern concept of attention deficit hyperactivity disorder (ADHD) as defined by the Diagnostic and Statistical Manual IV (DSM-IV) is fairly new. However, its hallmark symptoms of over activity, inattentiveness, and impulsiveness in children have been observed and recorded by physicians as early as the 19th century. A notable example is Sir Alexander Crichton who, in 1798, wrote a book entitled “On Attention and its Diseases”. In this book, he defines ADHD as; “when any object of external sense, or of thought, occupies the mind in such a degree that a person does not receive a clear perception from any other one, he is said to attend to it”. Crichton further records his observations of the progression of the disorder, writing, ”when born with a person it becomes evident at a very early period of life, and has a very bad effect, inasmuch as it renders him incapable of attending with constancy to any one object of education. But it seldom is in so great a degree as totally to impede all instruction; and what is very fortunate, it is generally diminished with age” (2).
The idea brought forth another idea i.e. that ADHD is a pediatric disorder which patients outgrow as they grow older. This idea of growing out of ADHD was prevalent up until the late 1990s. It was only fairly recently that scientific studies have shown otherwise; that in fact, approximately half of affected children diagnosed with ADHD continue to exhibit the symptoms well into their adulthood (3, 4).
Another physician, Heinrich Hoffman, published a series of illustrated children’s books depicting characters with symptoms of ADHD. One of the most notable ones was Johnny Look-in-the-air, who was depicted as a boy who exhibited telltale symptoms of inattention. In the book, Johnny was always “looking at the sky and the clouds that floated by”, a symptom that the American Psychiatric Association attributes to frequent distraction by an extraneous stimuli (5).
The scientific concept of ADHD started with the publication of Goulstonian Lectures by the British pediatrician, Sir Frederic Still. In these lectures, he describes symptoms of abnormal defect of moral control in children with mental retardation, which are commonly seen today in patients diagnosed with ADHD. Some of these symptoms are passionateness, spitefulness, jealousy, lawlessness, dishonesty, and destructiveness. The common thread that ties these symptoms together is immediate self-gratification with disregard for the good of others or one’s self (6). Self-gratification is a major problem in patients with ADHD. It is closely tied to impulsivity, one of the identifying symptoms of ADHD.
It wasn’t until 1932 that Franz Kramer and Hans Pollow reported hyperkinetic disorder as a single disorder, instead of part of residual effects of encephalitis. The two German physicians described motor symptoms that coincide with modern day’s diagnostic criteria for ADHD. Essentially, their report established a concept of hyperkinetic disorder that closely resembles the modern concept of ADHD.
The earliest stimulant used to treat hyperactivity symptoms in children was benzedrine. The drug resulted in significant behavior improvement and school performance in some of the children it was tested on (7, 8).
Epidemiology
The 2007 National Survey of Children's Health (NSCH) published a report on the epidemiology of ADHD. The report showed an almost 22% increase in the number of children between 4-17 years of age who were reported by their parents to exhibit symptoms of attention-deficit/hyperactivity disorder (ADHD). This result reinforces to the medical community what it knows already, that parents and guardians play a vital role in early detection and subsequent treatment (9).
As of 2007, there are approximately 5.4 million American children with ADHD. Children with ADHD exhibit symptoms of either inattention and hyperactivity or impulsivity, or both. These symptoms interfere with not just the children’s social and academic functions at home, at school, or with friends but also strain the family ties with those who have to bear this burden.
Pediatric ADHD is a public health concern. It affects all aspects of family life; from the expectations of what a typical day is going to be like, through to the expectations for school achievements, and to relationships with family and friends. Indeed, there are very difficult challenges for families to face day after day, year after year (9).
The results of the NSCH survey were not surprising; in fact it reflected their own clinical experiences with such patients. More and more pediatric healthcare professionals have to deal with ADHD patients, with 2.7 million children taking medication in 2007 (9).
The results also highlighted some significant demographic prevalence previously reported by population-based studies. Specifically, the study revealed a 2:1 or even a 3:1 ratio of boys to girls in terms of diagnostic prevalence. These rates were also found to increase with age, which is an expected finding since many parents were told of their children’s ADHD diagnosis (9).
The report also found a significantly greater increase of prevalence among 15-17 year olds when compared with younger children. This suggests that clinicians may be encountering later diagnosis, and subsequently delayed treatment interventions and management of ADHD than in the past (9).This finding may be attributed to a decrease in stigma around ADHD in the recent years and greater acceptance of available treatment strategies, or increasing demands on students with greater college expectations.
The report also brought to light the prevalence of pediatric ADHD among ethnic groups. In the past, the rates of ADHD in the United States have been lower among the Latino groups compared with non-Latino groups (9).Another significant finding in the report point to greater rates of diagnosis brought on by parent reporting among multiracial children. There are, however, no clear indications of the driving factors behind this (9).Also, it is worth noting that genes play a role in the development of ADHD. In any population there will be a core group of children who, by virtue of their genetic make up, are more prone to develop ADHD regardless of the environmental factors surrounding them (9).
There is also dramatic difference among US states in the prevalence of pediatric ADHD reported by parents. The state with the largest prevalence of parent-reported ADHD was North Carolina at 15.6%, representing nearly a 63% increase in ADHD prevalence from 2003 to 2007 (9).These differences are not clearly understood but some researchers attribute them to demographic factors. The risk for ADHD increases as income decreases, this is usually brought on by lesser-resourced educational services, fewer support systems for parents and guardians, and greater behavioral problems combined with lesser accessibility of adequate resources and services (9).
The wide disparity noted above may be due to other states having greater and more aggressive quality screening and diagnostic practices and protocols in place. These states were reported to have higher reports of prevalence rates. This is because the more rigorous the screening process is, the greater is the likelihood to find more symptoms of ADHD (9).
Greater awareness and better screening efforts may be the two greatest determining factors at play. There has been quite a lot of education. The American Academy of Pediatrics, for example, has really focused on quality improvement for pediatric practices, and the efforts around autism and ADHD have been focused on trying to standardize the approach to screening and diagnosis for behavioral issues (9).
Pathophysiology
Various neuropsychological studies propose a causal link between the frontal cortex and the networks connecting them to the basal ganglia in the pathophysiology of pediatric ADHD. These links are very important for many decision-making functions and, therefore, also for attention and exercising inhibition (10).
The frontal lobe is responsible for the majority of decision-making functions. Magnetic Resonance Imaging (MRI) results of the right mesial prefrontal cortex in ADHD patients show clearly its diminished activation during activities needing both inhibition of a planned motor response and timing it to a sensory stimulation. The same images also exhibit weak right inferior prefrontal cortical and left caudal stimulation during activities involving timing of a motor response to a sensory stimulus (10).
A study by Spinelli et al explored the neural correlates that regulate response inhibition deficits in pediatric ADHD. It studied closely the many functional MRI brain activation activities of children between the ages of 8 and 13 years who were both diagnosed and not diagnosed with ADHD on a go/no-go task. It found lapses in attention that preceded the response inhibition errors in the children with no ADHD. It also found involvement of brain circuitry in the response selection and control activation occurring before these errors in children diagnosed with ADHD (11).
Catecholamines are the primary neurotransmitters that mediate frontal-lobe function. Neurotransmission mediated by the dopaminergic and noradrenergic receptors seem to be the primary medication targets when treating ADHD.
A decade-long study by the National Institute of Mental Health (NIMH) found that the brains of children and teens with ADHD are 3-4% smaller in size compared to children without the disorder. The finding also pointed out that pharmacologic treatment played no role in this case. The greater the symptom severity of pediatric ADHD were, as rated by parents and clinicians, the smaller their frontal lobes, temporal gray matter, caudate nucleus, and cerebellum were.
The results from 357 healthy subjects, acquired from the NIH MRI Study of Normal Brain Development, also found that a thinner cortex due to slow cortical thinning process was linked to greater attention problem scores. These results suggest an association between attention and cortical maturation (12).