NR 602 Week 2 Grand Rounds – ADHD

NR 602 Week 2 Grand Rounds – ADHD

NR 602 Week 2 Grand Rounds – ADHD

What is ADHD?

Attention Deficit Hyperactivity Disorder, also known as ADHD, is a neurobehavioral or neurodevelopmental disorder that commonly presents in children and teens (Brown et al., 2017). ADHD can be a psychosocial burden that can persist into adulthood (Albrecht, Sandersleben, Gevensleben, & Rothenberger, 2015). ADHD is considered a heterogeneous disease, therefore making treatment a challenge (Albrecht, Sandersleben, Gevensleben, & Rothenberger, 2015). Signs and symptoms of ADHD may include persistent patterns of poor concentration, inattention, overactivity, and/or impulsivity (Ahmann, 2017; Albrecht, Sandersleben, Gevensleben, & Rothenberger, 2015; Silbert-Flagg & Sloand, 2017).

 

Patho –

 

The etiology of ADHD is not well understood, however, studies suggest that there is a dysfunction of the neurotransmitters responsible for dopamine and norepinephrine release and within the prefrontal cortex of the brain (Hollier, 2016). There are some factors that seem to contribute to the diagnosis, these factors include motor and sensory influences, psychosocial, behavioral, genetic, biochemical, physiologic, and environmental influences (Hollier, 2016). Some seem to believe that deficits from ADHD can be seen when the brain is at rest, which can lead to impeding of activity in the neuronal networks involved with processing tasks, which leads to problems with regulation and therefore promotes periodic attention lapses (Albrecht, Sandersleben, Gevensleben, & Rothenberger, 2015).

 

 

Epidemiology –

 

ADHD affects about 5 to 11 percent of children and teenagers and it affects all cultural backgrounds and nationalities (Albrecht, Sandersleben, Gevensleben, & Rothenberger, 2015; Hollier, 2016). Males seem to be more affected than females and females are usually diagnosed later than males (Hollier, 2016). Generally, two out of three people experience ADHD into adulthood (Albrecht, Sandersleben, Gevensleben, & Rothenberger, 2015).

 

Risk factors –

The predominant risk factor is believed to be family history.  Genetic factors explained 76 percent and 92 percent of the covariance between hyperactivity and inattention (Hollier, 2016). The other possible risk factors linked to ADHD include increased lead levels, traumatic brain injuries, and poor prenatal health such as alcohol abuse, smoking, drug abuse, pre-eclampsia, low birth weight, and pre-natal and peri-natal stress (Hollier, 2016).

 

Clinical physical assessment findings –

The Diagnostic and Statistical Manual, fifth edition (DSM-V), says …

 

3 differential diagnoses –

 

– Autism Spectrum Disorder (ASD) is a neurodevelopmental disease that …

 

– Learning Disabilities (LDs) are heterogeneous disorders that inhibit the ability of the patient to acquire, retrieve, and use information appropriately (Hollier, 2016). These children typically have average to above-average intellectual abilities yet these disorders severely interfere with these abilities (Hollier, 2016). The clinical features of LDs manifest as difficulties with reading, writing, math skills, and generalized memory problems (Hollier, 2016).

 

– Dysfunctional Family Situations can cause some children to exhibit behaviors that could be misconstrued as ADHD such as impaired self-esteem, anxiety, depression, an inability to connect with others or socialize properly, and they often avoid or ignore responsibilities (Uphold & Virginia-Graham, 2013).

 

Diagnostic studies to confirm Dx –

Certain diagnostic studies may be done to rule out other diagnoses, however, there is no diagnostic imaging study at this time to confirm …

 

Prevention –

While there is no way to prevent genetic factors, women who become pregnant can try to prevent ADHD by avoiding alcohol, tobacco, illicit drug use, and stress (Brown et al., 2017).

 

Treatment, pharmacologic and nonpharmacologic –

Methylphenidate and amphetamines, which are both schedule II drugs, …

 

Nonpharmacologic management of ADHDis also important and treatment should include both pharmacologic and nonpharmacologic. The provider should address any depression or anxiety that may be associated with the disorder (Uphold & Virginia-Graham, 2013).  Behavioral therapy can also help the child modify the way their social and physical environment effects them, which will effect a positive change in them by allowing them the opportunity to figure out how to best deal with their disability (Uphold & Virginia-Graham, 2013).

 

 

Patient and family education –

Education is focused more on the parent if the patient is a young child but the child must remain part of the education process….

Best practices for optimal outcome –

Parents should be made aware of support groups they can attend in order to further understand how to help their children (Hollier, 2016; Uphold & Virginia-Graham, 2013). There are local support groups and other community resources available to the parents such as the Children and Adults with Attention Deficit/Hyperactivity Disorder (CHADD), which is an international non-profit parent support organization (CHADD, 2018; Silbert-Flagg & Sloand, 2017).

 

References

Ahmann, E. (2017). Interventions for ADHD in children and teens: A focus on ADHD coaching. Pediatric Nursing, 43(3), 121-131. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=123430204&site=eds-live&scope=site   CCN LIBRARY 1

 

Albrecht, B., Sandersleben, H., Gevensleben, H., & Rothenberger, A. (2015). Pathophysiology of ADHD and associated problems – starting points for NF interventions? Frontiers in Human Neuroscience, 9 (359).

http://doi.org/10.3389/fnhum.2015.00359

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Publishing. NATIONAL GUIDELINE 1

 

Brown, N., Briggs, R., Germán, M., Belamarich, P., Oyeku, S., & Brown, S. (2017). Associations between adverse childhood experiences and ADHD diagnosis and severity. Academic Pediatrics, 17(4), 349-355. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=123025413&site=eds-live&scope=site CCN LIBRARY 2

 

CHADD. (2018). AAP clinical practice guidelines. Retrieved from http://www.chadd.org/Understanding-ADHD/For-Professionals/For-Healthcare-Professionals/Clinical-Practice-Guidelines.aspx NATIONAL GUIDELINE 2

 

Hollier, A. (2016). Clinical guidelines in primary care. Scott, LA: Advanced Practice Education Associates, Inc.

 

Silbert-Flagg, J. & Sloand, E. (Eds.). (2017). Pediatric nurse practitioner certification review guide, sixth edition. Burlington, MA: Jones & Bartlett Learning.

 

Uphold, C. & Virginia-Graham, M. (2013). Clinical guidelines in family practice. Gainesville, FL: Barmarrae Books, Inc.

 

Woodburt-Smith, M., Deneault, E., Yuen, R.C., Walker, S., Zarrei, M., Pellechia, G., & Scherer, S.W. (2017). Mutations in RAB39B in individuals with intellectual disability, autism spectrum disorder, and macrocephaly. Molecular Autism 81(10). Doi: 10.1186/s13229-017-0175-3. Retrieved from https://chamberlainuniversity.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=126144157&site=eds-live&scope=site  CCN LIBRARY 3

 

3 Questions to ask Peers:

 

1. What is the predominant risk factor associated with ADHD?
2. Per the DSM-V, what are the diagnostic characteristics of the inattention subtype of ADHD?
3. Which 2 pharmacologic treatments are equally effective and approved by the FDA?

 

PEER RESPONSES:

 

Hi Monique,

Dermatology is my favorite so I loved your presentation. The skin is the largest organ of the body! There are so many disease processes that can manifest as skin problems; I personally feel every advanced level practitioner should have a rotation or two in dermatology so that they can be aware of this. For example, my father had been on Prograf for 13 years and he started itching, no rash, but the itching was so bad he was causing breaks in his skin. He went to his primary doctor, a Dermatologist, an Immunologist and an Oncologist twice, all of them told him he was fine. I knew when he started the medication 13 years ago that Prograf could cause him to develop Lymphoma but the Oncologist told him twice that he was fine so I stupidly assumed they knew what they were doing. When we got to pathophysiology I was reading about Lymphoma and the number one symptom, especially for those with a history of taking immunosuppressants, is idiopathic itching! Come to find out he has Non-Hodgkin’s lymphoma, 6 treatment of IV rituximab later and his itching completely subsided. This is a perfect example of how important disorders of the skin are. All these other providers kept brushing it off as allergies when in fact it was something much more serious. Below I have answered your proposed questions.

What are the four factors in the pathology/development of acne vulgaris?

The 4 factors that are involved in the development of acne vulgaris are an increased production of sebum, or oil, which is usually affected by androgen production, keratin and sebum accumulate in the hair follicle and cause hyperkeratosis, or comedone formation, propionibacterium acnes will reproduce rapidly within the sebaceous follicle and this causes a release of inflammatory cytokines, and from any other inflammatory response (AAD, 2015).

 

What is the average U.S. annual cost of Acne Vulgaris and what factors are calculated into this cost?

The total annual cost of treatment in the U.S. for acne vulgaris is 3 billion dollars. In this cost, 1.74 billion dollars is spent on prescriptions for acne vulgaris. Another fact shared with us is that Americans spend 100 million per year on over the counter acne treatment products. This annual cost rates secondary to skin ulcers and wounds, further proving how common this condition is but also how far people will go to treat it. As Monique mentioned in her video, Acne Vulgaris can cause the patient’s self-esteem to tank or make them the target of bullies. Therefore, the majority of patients will try anything to clear it up.

 

Which are the two preferred tetracyclines used in the treatment of moderate to severe acne vulgaris?

Tetracycline’s are used if topical treatments fail or if the patient has moderate to severe inflammatory acne because they have both anti-inflammatory and anti-bacterial properties (Graber, 2017). As with all medications, the provider should start with the lowest dose possible and titrate up as needed. Of the tetracycline’s, doxycycline and minocycline are newer-generation derivatives of tetracycline that have become the preferred drugs in their class (Graber, 2017). However, tetracycline is still widely used (Graber, 2017). Doxycycline and minocycline can be take with food, which is a plus for the GI tract and for compliance where as tetracycline must be taken an hour prior to eating or 2 hours after eating (Graber, 2017). Tetracycline’s may cause yellowing on the teeth so they should not be prescribed to children who are still going through teethe development (Graber, 2017).

 

American Academy of Dermatology. (2015). Acne vulgaris: Basic dermatology curriculum. Retrieved from https://www.aad.org/File Library/Main navigation/Education/…/Acne.pdf

ORDER NOW FOR A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER WITH ALL INSTRUCTIONS FOLLOWED

Graber, E. (2017). Treatment of acne vulgaris. UpToDate. Retrieved from https://www.uptodate.com/contents/treatment-of-acne-vulgaris?search=acne vulgaris treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 – H27

Hi Afreen,

I am sorry you were not feeling well; I hope you are feeling better by now. Kawasaki disease is a very interesting subject and you did a great job presenting it. Below I have answered your questions.

What complications of aspirin therapy that can occur in kids exposed to chicken pox or influenza while they are taking high doses of aspirin?

High-dose aspirin therapy while a child has an active infection of varicella or influenza should be avoided due to the increased potential for developing Reye syndrome (Scheinfeld, 2017). Reye syndrome presents as an acute but noninflammatory encephalopathy and degenerative, fatty liver failure (Weiner, 2015). Plavix may be prescribed instead of aspirin if the patient develops the influenza or varicella virus and can be restarted on the aspirin once the virus has cleared (Scheinfeld, 2017). Plavix can also be used if the patient is allergic to aspirin (Scheinfeld, 2017).

Should routine immunization for measles, mumps, and rubella (MMR) be delayed following gamma globulin treatment (IVIG)? If so, how long?

If the measles, mumps, and rubella (MMR) vaccine, as well as the varicella vaccine, are given to a patient around the same time or at the same time as an antibody-containing blood product such as IVIG, the vaccine’s desired effect can be diminished (CDC, 2017). Therefore, the MMR and varicella vaccines should be given 2 weeks or more prior to receiving IVIG or the vaccines should be delayed for 3 to 11 months after the patient has received IVIG (CDC, 2017). The time frame depends on the dose of the IVIG (CDC, 2017).

 

CDC. (2017). Spacing of immunobiologics. Retrieved from https://wwwnc.cdc.gov/travel/yellowbook/2018/the-pre-travel-consultation/general-recommendations-for-vaccination-immunoprophylaxis

Scheinfeld, N. (2017). Kawasaki disease treatment and management. Medscape. Retrieved from https://emedicine.medscape.com/article/965367-treatment – d11

 

Weiner, D. (2015). Reye syndeome. Medscape. Retrieved from https://emedicine.medscape.com/article/803683-overview

 

 

INSTRUCTOR:

 

Instructor questions: Regarding a child presenting with attention issues how does a visual or hearing deficit mimic ADHD? I look forward to your response.

Dr. Green

Hi Dr. Green,

I agree with you, so many people are so quick to jump to ADD and ADHD, this includes schools, parents, and providers. Per Hollier (2016), there are quite a few differential diagnoses, and they are developmental delays, learning disabilities, autism spectrum disorder, hearing or vision disorder, seizure disorder or absence seizure, language delays, oppositional defiant disorder or conduct disorder, medication reactions, poor parenting, inappropriate disciple, and dysfunctional family situations.

ADHD is diagnosed via behavior checklists but must also include investigating other disease processes and organic causes to meet guideline standards (DeCarlo et al., 2014). The evaluation should include a thorough head to toe assessment including medical, psychosocial, developmental, and educational evaluation (Krull, 2018). Children with hearing difficulties, vision problems, expressive and receptive language disorders, and learning disorders are at an increased risk of being misdiagnosed with ADHD (DeCarlo et al., 2014; Krull, 2018). These disorders can present themselves as those of ADHD because when children cannot communicate correctly or fully understand what is going on around them, they may become agitated and frustrated (Krull, 2018). One way to differentiate between processing problems and ADHD is with comprehensive neuropsychological testing (Krull, 2018). Children with processing problems will perform poorly in the subject where their problem area lies unlike a child with true ADHD, who will most likely perform poor in more than one area (Krull, 2018).

 

 

DeCarlo, D., Bowman, E., Monroe, C., Kline, R., McGwin Jr, G., and Owsley, C. (2014). Prevalence of attention-deficit/hyperactivity disorder among children with vision impairment. Journal of AAPOS?: The Official Publication of the American Association for Pediatric Ophthalmology and Strabismus / American Association for Pediatric Ophthalmology and Strabismus, 18(1), 10–14. http://doi.org/10.1016/j.jaapos.2013.10.013

 

Hollier, A. (2016). Clinical guidelines in primary care. Scott, LA: Advanced Practice Education Associates, Inc.

 

Krull, K. (2018). Attention defivit hyperactivity disorder in children and adolescents: Clinical features and diagnosis. UpToDate. Retrieved from https://www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-children-and-adolescents-clinical-features-and-diagnosis?search=diagnosing adhd vs hearing or vision loss&source=search_result&selectedTitle=1~150&usage_type=default

 

 

SUMMARY:

 

Dr. Green and class,

 

This week we have discussed many interesting topics such as Acne Vulgaris, Osgood-Schlatter Syndrome, Wilms’ Tumor, Kawasaki Disease, Adolescent Idiopathic Scoliosis, Delayed Puberty, and ADHD. Everyone did a great job on their PowerPoint presentations. For my topic of ADHD, Adefunke did an excellent job elaborating on the screening tools.

 

As stated prior in my presentation, ADHD is a common disorder that presents itself in childhood and can persist into adulthood. Even with its high prevalence, the etiology is still not well understood (Hollier, 2016). Studies have suggested that the problem is associated with the neurotransmitters in the brain that are responsible for dopamine and norepinephrine release (Hollier, 2016). Studies have also found there may be a problem within the prefrontal cortex of the brain (Hollier, 2016).

 

The predominant risk factor for a child developing ADHD is believed to be genetic factors, or a family history of the disorder (Hollier, 2016). There are 3 subtypes of ADHD per the DSM-V, these subtypes are include hyperactive and impulsive, inattentive, or a combination of all 3 (DSM-V, 2013; Silbert-Flagg & Sloand, 2017). These subtypes contain specific symptoms to be aware of. In order to diagnose ADHD, the patient must exhibit 6 or more of the symptoms in one of the categories or a number of symptoms from both categories; these symptoms also must be present before the age of 12 years old and they must be reported by more than one person (DSM-V, 2013; Silbert-Flagg & Sloand, 2017).

 

There are a number of differential diagnoses for ADHD so the provider must be very thorough in their history taking and assessment skills. Some of the differential diagnoses are developmental delays, learning disabilities, autism spectrum disorder, hearing disorder, vision disorder, seizure disorders, language delays, oppositional defiant disorder (ODD), poor parenting, inappropriate disciple, and dysfunctional family situations (Hollier, 2016).

 

Treatment and management of this disorder should always include behavioral therapy to help teach the child how to deal with the symptoms on a day-to-day basis. Parents should participate in behavioral therapy sessions as well; in doing so they will learn how to guide their child better. If medications are needed, the most widely used medications are methylphenidate and amphetamines (Uphold & Virginia-Graham, 2013). Even though stimulants are widely used, children less than 6 years of age cannot take them (Uphold & Virginia-Graham, 2013). This is when a medication, if a medication is needed at that age, such as Strattera could be considered because it is not a stimulant. However, it has its side effects as well, such as the possibility of depression.

 

The important piece of information here is that the parents are educated on the risk verse benefits of medication while understanding that not giving them a medication that is needed can be just as detrimental as giving them a medication they do not need.

 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA: American Psychiatric Publishing

 

Hollier, A. (2016). Clinical guidelines in primary care. Scott, LA: Advanced Practice Education Associates, Inc.

 

Silbert-Flagg, J. & Sloand, E. (Eds.). (2017). Pediatric nurse practitioner certification review guide, sixth edition. Burlington, MA: Jones & Bartlett Learning.

 

Uphold, C. & Virginia-Graham, M. (2013). Clinical guidelines in family practice. Gainesville, FL: Barmarrae Books, Inc.