NR 602 Week 2 Grand Rounds Graded A

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, preeclampsia, 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 there are 3 subtypes of ADHD, which include hyperactive and impulsive, inattentive, or a combination of all 3 (DSM-V, 2013; Silbert-Flagg & Sloand, 2017). In order to be diagnosed with ADHD, one must have 6 or more symptoms in one of the categories or multiple symptoms from both categories and these symptoms should be present before the age of 12 years old (DSM-V, 2013; Silbert-Flagg & Sloand, 2017). The DSM-V criteria for inattention includes poor attention to detail/careless mistakes, hard time keeping focused or paying attention during activities, failure to pay attention even when spoken to directly, difficulties following directions and completing assignments on time, disorganization with tasks and activities, forgetful, easily distracted, may avoid activities that require focused mental attention, and frequent loss of items needed to complete certain tasks or assignments (DSM-V, 2013; Silbert-Flagg & Sloand, 2017). The DSM-V criteria for hyperactivity/impulsivity includes difficulty staying seated when it’s expected, fidgeting and squirming, boundless energy for activities such as running and climbing, difficult time with quiet activities, excessive talking, answers questions before question is done being asked, difficult time waiting for their turn, and often interrupts others and acts meddlesome (DSM-V, 2013; Silbert-Flagg & Sloand, 2017). 3 differential diagnoses – - Autism Spectrum Disorder (ASD) is a neurodevelopmental disease that presents in childhood and lasts a lifetime (Woodburt-Smith et al., 2017). ASD is associated with a rare inherited genetic mutation and other complex structural gene variations (Woodburt-Smith et al., 2017). However, most of the genes found with ASD are autosomal (Woodburt-Smith et al., 2017). ASD seems to affect males more than females therefore leading researchers to believe there is a sex chromosome role involved as well (Woodburt-Smith et al., 2017). Characteristics of ASD include difficulty interacting and communicating with others, limited interest in most activities, repetitive behaviors, and these symptoms are noticeable within their first 2 years of life (Hollier, 2016). - 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 selfesteem, anxiety, depression, an inability to connect with others or socialize properly, and they often avoid or ignore responsibilities (Uphold & VirginiaGraham, 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 the diagnosis of ADHD (Hollier, 2016). A diagnosis of ADHD must follow the guidelines from DSM-V, which include specific documentation of a number of symptoms over at least 6 months of time and they must be present in at least 2 major settings, such as in school and at home (Chadd, 2018). There are some screening tools or rating scales that can be used to identify those with ADHD; these tools cannot be used to diagnose but they can be used as a part of the comprehensive evaluation (Uphold & Virginia-Graham, 2013). These tools are designed with the primary care practice in mind and can be found online at no cost to the provider (Uphold & Virginia-Graham, 2013). For children ages 6 to 12 years old, there is the Vanderbilt Assessment Scales that contain a version for the teacher and for the parent; this tool is helpful in documenting the presence of symptoms and the severity of symptoms (Uphold & Virginia-Graham, 2013). For children ages 6 to 18, there is the SNAP-IV scale, which is completed by both the parent and the teacher as well (Uphold & Virginia-Graham, 2013). 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, have been found to be equally effective forms of pharmacologic treatment for ADHD and they are both approved by the FDA (Uphold & Virginia-Graham, 2013). In fact, 80 percent of children do well when one of these medications is prescribed to them (Uphold & Virginia-Graham, 2013). Children must be 6 years of age or older before they can begin one of these medication; these medications also work long term for adolescents and adults but medication vacations are recommended periodically (Uphold & Virginia-Graham, 2013). Stimulants are the mainstay of treatment in clinical practice (Hollier, 2016; Uphold & Virginia-Graham, 2013). 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. Education includes making sure the parent knows the normal stages of development for children so that they can help guide the child in the right direction, the parent and teachers should give specific directions in small, simple steps rather than overload them with information, and immediate and consistent consequences should be upheld for any broken rules (Uphold & VirginiaGraham, 2013). Close monitoring of school activities and redirection with