TREATMENT ISSUES AND PHARMACOLOGY IN PEDIATRIC ADHD

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 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 health clinicians can help alleviate many of those feelings. It includes a combination of symptoms, including hyperactivity, impulsivity, and difficulty sustaining attention. Millions of children struggle with these symptoms, which frequently ease as the patient reaches adulthood. It is important for clinicians to carefully screen patients according to current medical standards before making a diagnosis of attention deficit hyperactivity disorder.

1 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Policy 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. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 1 hour.

Statement of Learning Need

Depending on their role and training, clinicians may or may not have primary responsibility to diagnose ADHD; however, often nurses and therapists 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 to identify behaviors and social challenges associated with ADHD.

Course Purpose

To prepare clinicians 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.

2 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA,

Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.

3 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 1. Attention deficit hyperactivity disorder or ADHD is

a. disease of the central nervous system. b. a neurological disorder. c. a rare brain disorder. d. a relatively common brain disorder.

2. As high as ____ of all children with ADHD have an associated learning disorder.

a. 15% b. 25% c. 30% d. 45%

3. Studies have shown that adverse side-effects of medications for ADHD may include:

a. suppression of growth b. sleep problems c. stomach upset d. All of the above

4. True or False: The role if nortriptyline in pediatric ADHD is that at higher doses it improves symptoms within several days of starting therapy.

a. True b. False

5. Atomoxetine (Strattera) is a non-stimulant medication approved for the treatment of pediatric ADHD in children between ______years old.

a. 2 to 17 b. 3 to 17 c. 6 to 17 d. None of the above

4 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Introduction

Attention deficit hyperactivity 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. Hyperactivity and impulsivity and/or inattention occur in children affected with ADHD. While these are behaviors that many children exhibit at some time during their childhood, in children with ADHD, these behavioral problems persist over a long period of time. To be diagnosed with ADHD, such 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 help to minimize symptoms and restore social and academic functions. This course on pediatric ADHD expands on prior courses with a sharper focus on the effective management of ADHD, including psychopharmacology. The two arms of behavioral and pharmocological treatment are highlighted in this course.

Screening For Related Disorders

Health clinicians need to be aware of current recommendations for patient monitoring and complications of treatment that may arise. A strong professional liaison between a child’s pediatrician and mental health team will ensure implementation and follow up of current best practice guidelines for children with ADHD at home and school. Disorders that appear either as a part of the symptoms of ADHD or develop because of its existence are considered comorbid conditions. Comorbidities in the context of ADHD are

5 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com those disorders that may worsen the presence of ADHD or cause it to have different presenting symptoms. These may already be present when the main problem was first diagnosed or occur later on during the course of the disorder, leading to complex problems and difficulties in symptom management in the future.

Children diagnosed with ADHD may experience a variety of related disorders or comorbidities. These comorbidities vary according to the prevailing type of ADHD, their severity, as well as the developmental stage of the child when they were first seen (i.e., preschool, school-age or adolescence). Comorbidities are divided into two broad categories of learning disorders and psychiatric disorders.12,102

Learning Disorders

Due to the complex nature of behavior problems in ADHD, children often face learning difficulties at school. These are not limited or entirely rooted in their academic performance alone but include disruptive behaviors which are often triggered by and exhibited in response to challenges posed to them in a variety of school environments. Their behaviors result in apparent difficulties to learn new concepts, and subsequent poor or lack of academic achievements.

It cannot be overemphasized that children with both ADHD and coexisting learning disorders often suffer from overall poor school performance and corresponding low self-esteem. They especially face difficulty in keeping up with subjects wherein control is needed by the child. The worst outcome for these children is frustration from having to face and accept failing grades from teachers, and the need to repeat the course or take special classes in order to catch up with the rest of the children. These problems in academics

6 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com and learning are not limited to the preschool and grade school years. Most of these learning problems continue to persist during the late adolescent years, leading to a host of new problems related to academic underachievement and failure in school.

It may be true that while most of the difficulties experienced by children with ADHD, in terms of academic and non-academic performance at school, are clearly evident in many children, it is quite another story when the problems are not always consistent with the known criteria for ADHD. This is because the symptoms exhibited by these children often overlap with a coexisting learning disorder which makes differential diagnosis all the more difficult for the clinician. Moreover, some of the symptoms presented by children with ADHD can also mimic specific learning difficulties. One of the ways to avert this problem is to simply take note of specific difficulties and delays faced by children such as failing grades in school subjects of spelling, math or reading, and then comparing these with the child’s IQ scores.

Other difficulties stem from developmental delays, which can also impair the overall performance of the child in the school environment. Some of the most common examples of these difficulties include: • Language problems • Speech and communication disorders • Self-expression, which affects approximately a majority of children who have been found to have ADHD

The following section discusses in detail some of the most common learning difficulties experienced by children with ADHD.12,102,103

7 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Intellectual Development Problems

Perhaps one of the most common learning problems encountered by children with ADHD are problems associated with intellectual development. It also happens to be the most serious of conditions. This is because there is a very high possibility that children who are diagnosed with ADHD may either be or not be at par with their peers who do not have ADHD.

Most of these children attain IQ scores that may be lower by 15 points or so when compared with their peers, and may experience problems in verbally expressing themselves. However, since most tests are standardized and not necessarily developed to assess children with ADHD per se, it is still unclear whether the results really denote the presence of a problem or just a result of a child’s behavior while taking the test. Moreover, as IQ tests are basically used to assess problems related to intellectual development, factors such as the child’s age while taking the test and the number of times the same test has been taken by the same child may also play a large role. It may be that some children who have taken the same tests have developed a form of mastery of the subjects instead of actually gaining the intellectual function expected from the specified age group.

Difficulties in Speech

Children with ADHD have been found to manifest delays in speech development. This is primarily based on the observation that they have the tendency to experience delays in speech development as compared to children who do not have the condition. Additionally, difficulties in speech in children with ADHD has also been backed by results of studies showing that they demonstrate a greater tendency to start speech later on in their childhood, despite the lack of problems in language reception. Although children with ADHD are able to process and understand the spoken language,

8 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com it may be a little while before they are able to fully express their response to them. They also show problems achieving language fluency, particularly in verbal context.

Dyslexia

A common comorbidity in children with ADHD is dyslexia. It is manifested by a child’s difficulty to read fluently and to comprehend reading materials. This may be present with or without any neuropsychological deficits on the part of children with ADHD and may manifest as an inability of the child to comprehend written language, problems with self- expression using verbal or written language, inability to hold information in memory, and problems with phonetics.104

Problems with Task Performance Variability

Children with ADHD are known mostly for their impulsivity and hyperactivity. This is also seen in terms of how they accomplish and perform tasks given to them. Observation over time has yielded results that strongly suggest ADHD children to be lacking consistency in terms of school performance, quality of homework, and general academic performance. This is because they tend to start a lot of tasks without actually finishing them.

Difficulties in Motivation

One of the challenges faced by teachers of children with ADHD is their apparent lack of motivation. Children diagnosed with ADHD usually present with a very low motivation level accompanied by lack of interest in tasks

9 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com appointed to them. This is especially true when these children are required to respond repetitively to certain tasks and requirements without outside reinforcement from their teachers.

Psychiatric Disorders

Psychiatric and other psychological disorders are other comorbidities that are of great concern among children with ADHD. Since most of these conditions exist as a result of the negative emotions, social pressure, and stigma that occur, it is imperative for the clinician to take notice of these comorbidities before they get worse. This section addresses the most commonly seen psychiatric disorders among patients with ADHD.12,17,27-29,36,37,102-108

Depression

A significant number of children and adolescents who are diagnosed with ADHD suffer from episodes of depression throughout their lives. Symptoms of depression seen among them include:

• Irritability and mood irritation

• Apparent lack of interest in engaging in pleasurable activities

• Sleep problems (either too much or too little)

• Appetite suppression

In 2007 the risk of depression in children was studied and revealed the prevalence of depression was as follows: 3 to 5 years – 0.5 percent, 6 to 11 years – 1.4 percent, and 12 to 17 years – 3.5 percent. The rates of depression grew higher during a survey of adolescents aged 12 to 17 years in the U.S. between 2010 and 2011; it was found that the one-year prevalence of major depression was 8 percent.

10 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com The existence of depression in children with ADHD usually occurs a few years after ADHD is diagnosed. It is usually a result of the constant battle with stressors in the immediate environment, which may include peers, bullying, and academic pressures to perform well. When these external stressors become too overwhelming to bear, depression sets in.

Symptoms of depression in children with ADHD may not be apparent right away because the resulting symptoms and social isolation often hide the disorder. The clinician must therefore be vigilant when observing children for depression and address symptoms as soon as possible before conditions worsen to lead to suicidal ideation and self-harming behaviors develop.

Suicidal Ideation

Suicidal ideation is one of the most common problems and comorbid conditions in children who are diagnosed with ADHD and also suffering from depression. This is more common in boys who are also more likely to develop phobias from peer rejection and associated environmental stressors. The clinician must observe the behavior and listen carefully to overt and covert communication patterns that might be suggestive of the desire to end life. Interventions such as early treatment with stimulant medications may help reduce the risk of suicide.

11 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Bipolar Disorder

Aside from being a comorbid condition in children with ADHD, bipolar disorder can also mimic most ADHD symptoms, making definitive diagnosis rather difficult to do. The occurrence of bipolar disorder as a comorbid condition in ADHD patients occurs is approximately 50% among male patients and 25% among female patients. Most children who exhibit bipolar behavior, on top of ADHD symptoms, present with hyperactivity, extremely strong emotional feelings, overbearing manners, and difficulty with waking up in the mornings. They may also show temper tantrums that are longer than other children with ADHD, and exhibit destructive behaviors and angry demeanors. Additionally, these children have a greater tendency to talk excessively, act inappropriately with apparent disregard to time and place, make verbal responses that are demeaning to others, lack self-control in social situations, are easily distracted and irritated.

Oppositional Defiant Disorder

One of the most common psychiatric comorbidities associated with ADHD is oppositional defiant disorder (ODD), usually affecting around 60% of children with the condition. The presence of this comorbidity is highlighted when children do things to intentionally defy rules and regulations, and act out against them, often through violent means. The symptoms of oppositional defiant disorder are usually more prevalent when a caregiver or parent of a child with ODD is in

12 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com close proximity to them, stimulating their behavior from an added sense of safety brought on by their familiar presence.

Conduct Disorders

The comorbidity of a conduct disorder occurs in approximately 45% of children with ADHD, and quite uncommon in children who do not have ADHD. The main symptom associated with conduct disorder is the apparent aggression towards animals or even people, the habit to destroy things willfully, engage in violation of rules both in school and in society, and stealing other peoples’ belongings. This is also considered to be a precursor to antisocial personality disorder when the condition is left untreated.

Anxiety

Anxiety may be defined as a state of psychological and physical discomfort, which is focused on emotions, perceptions, feelings, and behavior necessary to deal with certain life issues. It manifests in children with ADHD through symptoms such as:

• Difficulty in keeping with normal routine of things

• Separation anxiety

• Generalized anxiety disorders

Most ADHD children who also suffer from this comorbidity often display an extreme preoccupation with a specific fear, making them unable to focus on accomplishing tasks at present. This is mostly attributed to a perceived inability to function satisfactorily in everyday life and the difficulty in adjusting to the limitations set by ADHD symptoms in both social and academic settings. 13 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Tic and Tourette Syndrome

Two of the most common disorders that can be classified as neurodevelopmental and coexisting among ADHD patients are tic and Tourette Syndrome. These two disorders affect approximately 47% of children with ADHD, although they are not usually diagnosed individually. Most of the diagnoses made of these two disorders are commonly present in one patient. The most common manifestations of tic disorders in children with ADHD include intermittent vocal and motor tics, which tend to become less severe over time. Tourette Syndrome, however, manifests itself as motor tics that are concomitant with vocal tics (i.e., sudden increase in tone of voice with associated facial muscle twitches which are uncontrollable). Such comorbidities usually occur in children with ADHD approximately 2-3 years after the diagnosis of ADHD is made. Tics are frequently seen as a comorbidity of ADHD in children with a family history of it.

Obsessive Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a psychiatric problem that is defined by the presence of intrusive thoughts. These thoughts are usually self- injecting and serve to heighten feelings of guilt and anxiety in the ADHD patient, leading to the compulsion or need to avert or relieve them.

14 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com There are approximately 30% of children with ADHD who are also diagnosed with obsessive-compulsive disorder. The symptoms of OCD in these patients are usually seen early on during its course. The severity of OCD in children with ADHD is likely to increase over time, which makes early treatment and care very imperative in these patients.

Substance Use Disorders

Substance use is a common problem among individuals who experience difficulties in coping with life challenges, and patients with ADHD are especially vulnerable to their effects. In fact, more ADHD patients are vulnerable to commit themselves to alcohol, drug, and other substance use because of the myriad of social, personal and other problems they are facing due to their disorder. Apart from this, there is also a greater tendency for patients with ADHD to engage in self-medication, and associate themselves (almost impulsively all the time) with individuals who also encounter the same coping challenges and difficulties while in school and socially.

Children and adolescents who are diagnosed with ADHD tend to identify with individuals who also cannot seem to fit into society the same as they do. One of the most common substances used by children with ADHD is tobacco. Cigarette smoking in children with ADHD usually starts at a younger age and continues to be a habit throughout their life. In fact, patients with ADHD are more prone to start smoking cigarettes as compared to the rest of the population by at least 20%. Another substance commonly used by individuals with ADHD is alcohol, with approximately 35% of patients using it. Illicit drugs and prescription and over-the-counter drugs are substances that also tend to be frequently used by ADHD patients.

15 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Personality and Other Psychiatric Disorders

The presence of psychiatric and personality disorders is usually acknowledged in adult ADHD patients. However, when these conditions or their associated symptoms occur in children and adolescents, they are simply put in the category of conduct or oppositional defiant disorders. Personality disorders usually manifest themselves in the late adolescent years and may occur as more than one syndrome in an individual. The majority of personality disorders appear as schizoid or schizotypal, obsessive-compulsive tendencies, borderline personality, and avoidant personality profiles. The most important thing for the clinician to take note of is that these disorders may also mimic typical symptoms of ADHD and must therefore be properly assessed before a complete diagnosis is made. Personality profiles, behavior, and even thought content should be well assessed to determine and differentiate the presence of simple hyperactivity/impulsiveness or inattentiveness associated with ADHD from the major presenting symptoms of these disorders. Moreover, because these disorders usually affect the individual’s personality, treatment must be started as early as possible for better prognosis.

Pervasive Developmental Disorders

Autism and other pervasive developmental disorders usually manifest as a severe impairment or difficulty in social interactions and communications in a social context, accompanied by behaviors, which can be considered as restrictive and repetitive in nature. Along with these symptoms, there is also intelligence impairment as well as a grave restriction in the ability to take in new information and learn from it.

16 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Due to the similarity between many of the symptoms of pediatric ADHD and autism, there is greater risk for a mixed diagnosis early on, which can be corrected later on in life, once the symptoms become more distinguishable from each other. Symptoms of autism in children with ADHD include:

• Short attention span • Greater tendency to show temper tantrums • Hyperactivity • Impulsivity • Aggressiveness • Impaired executive functioning

The table below shows diagnostic tips for differentiating between ADHD and other psychiatric and learning disorders.

Oppositional Defiant • Lacks disinhibited behavior or restraint Disorder (ODD) and • Defiance primarily directed toward mother initially Conduct Disorder • Unble to cooperate and complete tasks requested by others (CD) • Lacks poor sustained attention and marked restlessness • Resists initiating demands, whereas ADHD children may initiate but cannot stay on task • Often associated with parental child management deficits or family dysfunction • Neuromaturational delays in motor abilities not present

17 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Learning Disorders • Has a significant IQ or achievement discrepancy (+1 standard deviation) • Places below the 7th percentile in an academic achievement skill • Lacks an early childhood history of hyperactivity • Attention problems arise in middle childhood and appear to be task or subject specific • Not socially aggressive or disruptive • Not impulsive or disinhibited

Anxiety Disorders • Likely to have a focused not sustained attention deficit • Not impulsive or aggressive; often over-inhibited • Has a strong family history of anxiety disorders • Restlessness is more like fretful, worrisome behavior not the “driven,” inquisitive, or over-stimulated type • Lacks preschool history of hyperactive, impulsive behavior • Not socially disruptive; typically socially reticent Asperger’s • Show oddities or atypical patterns of thinking not Syndrome seen in ADHD and Schizotypal • Peculiar sensory reactions Personality Disorder • Odd fascinations and strange aversions • Socially aloof, schizoid, disinterested • Lacks concern for personal hygiene or dress in adolescence • Atypical motor mannerisms, stereotypes, and postures • Labile, capricious, unpredictable moods not tied to reality • Poor empathy, cause-effect perception, • Poor perception of meaningfulness of events Juvenile • Characterized by severe and persistent irritability Onset • Depressed mood exists more days than not Mania or Bipolar I • Irritable/depressed mood typically punctuated Disorder by rage outbursts • Mood swings often unpredictable/related to minimal events • Severe temper outbursts and aggression with minimal provocation (thus, ODD is often present and severe) • Later onset of symptoms than ADHD (but comorbid early ADHD is commonplace)

18 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com • Pressure of speech and flight of ideas often present • Psychotic-like symptoms often present during manic episodes • Family history of Bipolar I Disorder more common • Expansive mood, grandiosity of ideas, inflated self-esteem, hypersexuality often seen in adults with Bipolar Disorder are sometimes present though not as well formed; children may, however, have the dysphoric type of disorder • Requires that sufficient symptoms of Bipolar Disorder be present after excluding distractibility and hyperactivity (motor agitation) from Bipolar symptom list in DSM-IV before granting Bipolar I diagnosis to a child with symptoms of ADHD • Suicidal ideation is more common in child (and suicide attempts more common in family history)

Legal And Ethical Issues

The evaluation of children suspected of ADHD can raise several legal and ethical issues often secondary to family stressors related to correlating behaviors of the disorder. Some of the legal and ethical issues are listed and further discussed in the sections below.111,116,117

• Custody and guardianship of the child • Disclosure to state agencies of any suspected physical or sexual abuse or neglect of the child • Legal accountability of actions

Custody and Guardianship of the Child

The custody or guardianship of the child is related to who can request the assessment of the child who is suspected to have ADHD. Children with ADHD

19 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com and associated comorbidities such as ODD or CD will often have parents who are divorced or separated or experiencing marital issues. Because of this, the clinician must first determine who has legal custody of the child, and especially determine who has the right to ask for mental health services on behalf of the child. In cases of joint custody, the clinician must also determine whether the parent who is not living with the child has the legal right to refuse the referral for the evaluation, consent to the evaluation, to attend on the day of appointment, and have access to the final report.

The right to assess or refuse mental health services may also include the provision of treatment. If these issues are not determined prior to the evaluation, it may fuel contention and even legal action among the parties to the evaluation.

Disclosure and Reporting of Abuse

A second issue related to the evaluation of ADHD children is the duty of the clinician to report to state agencies any suspected abuse or neglect of the child. It is also the duty of clinicians to inform parents of this duty to report prior to the start of the formal evaluation process. Because of the relatively greater stress that ADHD or ODD children pose to their parents, clinicians will do well to remember that the risk for abuse of defiant children may be higher than average.

It is widely believed that there exists a genetic component to the origins of ADHD, therefore, it stands to reason that children with ADHD may also be under the guardianship of parents with ADHD or other psychiatric disorders themselves. This in turn, leads to a greater likelihood that evaluations of children with disruptive behavior disorders will also include suspicions of abuse. Each state has their own legal requirements regarding such cases,

20 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com which clinicians must be familiar with in order to ensure close adherence while, at the same time, remain sensitive to the bigger clinical issues.

The widespread awareness of ADHD and the special needs of children with ADHD and co-occurring disorders have been growing steadily over the last 20 years. As a result, these children have also been gaining access to government grants and aid, all of which clinicians must be well informed about, especially if they are to give appropriate advice and support to the parents and school staff. For example, children with ADHD that is remarkably severe enough to interfere with regular schooling have the right to formal special educational services under the Other Health Impaired Category of the Individuals with Disabilities in Education Act. Additionally, these children also have legal protections and entitlements under Section 504 of the Disability Rights Act or the more recent Americans with Disabilities Act as it applies to the provision of an appropriate education for children with disabilities.

Children belonging to low-income families may be eligible for financial assistance under the Social Security Act. Generally speaking, clinicians working with ADHD children need to be familiar with the federal and state laws concerning the rights and entitlements of children with these specific needs.

Legal Accountability of Actions

Last but not least, the third legal issue concerning ADHD children is accountability for their own actions, usually as it pertains to their developmental disorder, which undermines self-control. Some of the important questions that arise from this issue are:

21 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com • Should children with ADHD be held legally responsible for the damage they may cause to property? • Should children with ADHD be held legally responsible for the injury they may inflict on others? • Should children with ADHD be legally responsible for the crimes they may commit?

The answers to the questions above are unclear and merit further attention from medical and legal experts. ADHD can explain why the actions were committed and despite the incomplete understanding of the origins and nature of the disorder, the disorder is not an excuse to forego legal accountability. It is worth noting that there has been no solid scientific evidence to help predict criminal conduct within samples of ADHD children followed into adulthood.

Treatment And Management

The treatment and management of ADHD in children has two essential components, which are psychotherapy interventions and pharmacotherapy. Research data in recent years have found that medication alone is insufficient to address the core issues of ADHD. Medication can help manage the symptoms, allowing children to live relatively normal lives while psychotherapy and behavior interventions help them learn the necessary skills to be successful while living with the disorder.

Behavior management (psychotherapy), and medication management (pharmacotherapy) are discussed in detail later on; however, certain criteria are first raised here that are helpful to clinicians deciding the course of treatment to follow based on three key factors of age, severity of symptoms

22 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com and comorbid conditions. An overview of the preliminary criteria that the parents, teachers and clinicians review and act upon all together when deciding the best course of care for the child with ADHD will be highlighted below.77-84,86-89,91,92

Pre-school Children

According to the NICE Clinical Guidelines, parent-training and education programs are the initial treatment for parents or caregivers of pre-school children. These programs are very similar to the ones recommended for the parents or caregivers of children with a conduct disorder.

Medication therapy is not recommended for pre-school children with ADHD. After a diagnosis of ADHD in a child of pre-school age has been made or confirmed, clinicians need to contact the parents or caregivers and obtain their consent to initiate contact with the child's pre-school teacher to explain the diagnosis and severity of symptoms and deficits, interventional plan, and special educational needs. Also, following the diagnosis, clinicians should advise parents or caregivers of pre-school children with ADHD to enter a parent-training and education program.

Group-based parent-training and education programs, intended for the management of children with conduct disorders should be available to such parents or caregivers, and parent training should be started regardless of whether or not the child has been diagnosed formally with a comorbid conduct disorder.

Individual-based parent-training and education programs are recommended in the management of children with ADHD in the following situations:

23 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com • a group program is unavailable due to low participation • there are specific challenges for families in attending group sessions such as physical disability, language differences, parental ill-health, transport problems • the family needs are multifaceted and cannot be met by group-based parent-training and education programs

It is important to note that the skills training stages of the individual-based parent-training and education programs require the involvement of both parents or caregivers and the child.

Once the parent-training and education program and other treatment interventions have been found to be effective to manage ADHD symptoms and associated deficits in pre-school children, and when considering termination of training and discharge from the parent-training program, clinicians should follow the child as recommended below:

• Re-assess the child, with their parents or caregivers and siblings, for any outstanding comorbidities and develop a subsequent treatment plan

• Monitor the child, through routine follow up and best practice screening tools for the recurrence of ADHD symptoms and associated deficits once the child enters school

On the other hand, if the parent-training and education programs and other treatment interventions have not been found to be effective to manage ADHD symptoms and associated deficits in pre-school children, clinicians must consider giving them a referral to tertiary services for further care.

24 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com School-age Children with ADHD and Moderate Impairment

Similar to pre-school age children with ADHD, the group-based parent- training and education programs are considered the first-line treatment for parents and caregivers of school-age children with ADHD and moderate deficit. In addition to this, young school age children may also benefit greatly from group psychological treatment such as cognitive behavioral therapy (CBT) and/or social skills training, all of which are discussed later in this section. Those who are older can benefit the most from individual psychological treatment if they have not responded well to group behavioral or psychological approaches or simply refused them.

Medication therapy is the second line of treatment and may be initiated for those school-age children with ADHD who present with moderate levels of deficit. It is important to note that medications should only be reserved for those with severe symptoms and deficit or for those with moderate levels of impairment who have either refused or not responded to psychological or behavioral interventions.

After a diagnosis of ADHD in a school-age child or young person has been made or confirmed, clinicians need to obtain the consent of parents or caregivers to contact the child or young person's teacher to discuss the following the diagnosis and severity of symptoms and deficit, interventional plan and special educational needs. It would be very beneficial to the family and the school systems if school-age children with ADHD are placed under the supervision of teachers who have received training about ADHD and its management so they can receive adequate behavioral interventions in the classroom.

25 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com If the school-age child with ADHD only has moderate levels of impairment, the parents or caregiver should be given a referral to a group parent-training and education program, mentioned earlier, either individually or together with a group treatment program that includes interventions such as CBT and/or social skills training. It is important to note that when enrolling school-age children in group treatment interventions such as CBT and/or social skills training in conjunction with a parent-training and education program, special importance must be given to targeting a range of areas, including social skills with peers, problem solving, self-control, listening skills and dealing with and expressing feelings. In addition, active learning strategies need to be employed, and rewards given when important aspects of learning are achieved.

Older adolescents with ADHD and moderate impairment stand to benefit the most from individual psychological interventions such as CBT or social skills training instead of the group parent-training and education programs or group CBT and/or social skills training that younger counterparts require. Whereas, older school-age children and adolescents with ADHD along with a coexisting learning disability will stand to benefit the most from parent- training and education program on either a group or individual basis, whichever is the preference.

When a parent training and education program is initiated, the professional in charge of the program may want to obtain parental consent to contact the school and provide the child's teacher with written information on the aspects of behavioral management tackled in these programs. Once the outcomes of the parent-training and education program have been achieved, the child, parents or caregiver may be discharged from the program. Prior to discharge from the program, the clinician must first perform the

26 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com interventions of 1) re-assessing the child with their parents or caregivers and siblings, 2) looking for outstanding problems such as anxiety, aggression or learning difficulties, and 3) developing treatment plans if coexisting conditions are found. On the other hand, if the parent-training and education program has proven to be unsuccessful, school-age children with ADHD and persisting deficits must be offered medication treatment.

School-age Children with Severe ADHD and Impairment

When symptoms of ADHD and other associated deficits are severe, the first- line treatment for school-age children and young people is medication therapy. If it is still refused, either by the child or the parents or caregivers, a psychological intervention can be initiated. In this group of patients, medications are clearly the better choice but often can be foregone because of a lack of consent between parties involved in the care and education of the child.

Like parents of children with ADHD from other age groups, parents of school-age children with ADHD should also be offered a group-based parent- training and education program. Medication therapy should only be started by a qualified healthcare professional with expertise in ADHD and when based on a comprehensive evaluation and sound diagnosis.113 The medications may be prescribed continually and monitored regularly by general practice clinicians under shared care planning.

Medication therapy requires the consent and full cooperation of the child, parents or caregiver. If either one refuses it the clinician should advise them of the benefits and superiority of medication therapy. If it is still not accepted, a group parent-training and education program should be offered.

27 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com If a group parent-training/education program is indeed effective in children with severe ADHD who have refused drug treatment, clinicians need to evaluate for the presence of comorbidities and develop a longer-term care plan. On the other hand, if a group parent-training and education program is ineffective for children with severe ADHD who have not consented to medication therapy, clinicians need to again raise the issue of starting drug treatment or other psychological treatment, making sure to underline its benefits and superiority.

After school-age children are diagnosed with severe ADHD, clinicians need to obtain the consent of parents or caregivers to contact their teacher to discuss the following aspects of care.

• The diagnosis and severity of symptoms and deficit • The interventional plan • Any special educational needs

As raised earlier, ideally, children with ADHD should be placed under the supervision of teachers who have received training on ADHD and its management.

Role of School Nurses in School-age Children with ADHD

School teachers, nurses and support staff are a vital part of the multidisciplinary team required to successfully manage ADHD in school-age children. School nurses can bridge the gap between specialist ADHD services, schools and families. It is their duty to lend support and training to children and families, schools and professionals in the primary care setting. The school nurse plays an important role in the management and treatment of school-age children during school hours. They are part of the team that

28 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com monitors the status of the child during school hours. Additionally, they are also among the first person to notice the existence of comorbid conditions such as learning and conduct disorders or simple visual and hearing impairments. School nurses are also the most qualified healthcare professional in the school environment to administer prescribed ADHD medications and monitor their effectiveness and adverse effects.

In many cases, the school nurses become the primary person managing the case of the child with ADHD. In this role, they help parents or guardians identify and access resources where the child can receive appropriate care and they support and make appointments with the appropriate resources, provide counseling, and assist in the follow-up assessments. The school nurses may also serve as an advocate for the child and the family. In this role, they coordinate with teachers and school staff to develop suitable classroom management techniques, assist parents/guardians with their insurance needs, ensuring that the child continues to receive coverage of the effective treatments. As mentioned previously, school nurses do not work alone with children with ADHD. They play a very crucial role in the treatment and management. They interact with many professionals and support resources to achieve the best possible outcome for the child diagnosed with ADHD.

Together with various primary health clinicians, school psychologists, pediatricians, neurologist, community counselor, psychiatrists, teachers, school support staff, parents/guardians, and social workers, school nurses are able to provide well-coordinated and effective care. The teamwork ensures that the team addresses the child’s psychological, physical, emotional and academic needs appropriately. The combined monitoring 29 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com efforts of the team members ensure that the child is given the best chances of succeeding at school and at home.

The school nurse is also among the most qualified health professionals (along with child psychologists) who can educate teachers and other school staff about ADHD and how to identify those in the class who need assistance. Teachers need to be able to understand ADHD in order to be able to help those children diagnosed with it. In addition to this, they can help teachers select the most effective interventions that can be applied in their specific classes to help children with ADHD cope better.

The role of team members, including school nurses, teachers, and school counselors in the school is to provide a reasonable and effective accommodation that meet the needs of children with ADHD, and to help them adapt and live with their condition.

Nursing Interventions

Some of the nursing interventions that school nurses can provide for children with ADHD are highlighted below.

• Gather academic information including the child’s progress and behavior at school. The nurse should gather initial information and track the changes so the team will have a chart or history of the child’s symptoms while on treatment. • Assess vision and hearing status yearly. The presence of visual and hearing problems may help explain the lack of progress of a child already

30 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com on ADHD medication or behavioral therapy. Additionally, these problems should be brought to the attention of a medical professional. • Identify barriers to pharmacotherapy and behavioral therapy. • Help parents/guardians identify and access various resources for the further evaluation and treatment of the child. • Refer to support groups such as a child study group and pupil assistance team. • Offer educational resources to the child to help understand their condition and expectations. • Provide clinicians and other members of the multidisciplinary team feedback regarding academic performance and behavior at school. • Communicate openly with parents/guardians regarding the implementation of the prescribed treatment plan. • Educate parents/guardians on ADHD diagnosis, treatment options, and follow-up assessments. • Identify behavioral problems. • Formulate behavior plan that teach and encourage appropriate behavior. • Identify factors that motivate the child to exhibit and maintain appropriate behaviors. • Advice teachers and parents/guardians on how to provide consistent structure and expectations to the child. • Identify appropriate behaviors and motivate the student to maintain it through reinforcement and token rewards. • Work with school psychologist or counselor in educating the child about self-monitoring techniques, including finding social cues from peers and adults, strategies that help refocus attention, differentiating between significant and insignificant stimuli, and relaxation exercises. • Educate teachers and school support staff about academic expectations and classroom interventions that help manage symptoms. These may

31 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com include preferential seating arrangements, alternative methods of completing schoolwork and other related activities, personalized behavior modification plans, and reward system. • Obtain parent/guardian and clinician consent to administer medication during school hours according to school policy and procedure. • Evaluate the child regularly for the incidence of adverse effects to the prescribed medications. • Provide support to the child whenever needed during school hours. • Allow the child time to express feelings about the ADHD diagnosis and treatment plan. • Help the child find support sources within the school environment. • Record injuries of the child, if any.

Child Abuse And ADHD In Children

A study by Briscoe-Smith, et al., explored the link between child abuse in girls and ADHD. The behavioral impairments following child abuse and the symptoms of children with ADHD have several similar features, such as aggression, externalizing behavior, depression and cognitive problems. The overlap has brought to mind the possible link between ADHD and child abuse, which brings up the possibilities of the 1) precipitating and exacerbating role of child abuse in the development of ADHD, and 2) misdiagnosis of abuse- related post-traumatic stress symptoms as ADHD. Children who were abused and have ADHD may also be more likely to re-experience the trauma of the abuse and be hypervigilant both of which manifest as poor concentration and hyperactivity, as described more specifically below.77-87,110-112

32 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Outcomes of Child Abuse

Child abuse results in “acting out” in the later years of the child’s life; female children who were abused exhibit marked aggression and externalizing problems, such as:

• Hostility • Difficulty with anger management • Impulsivity • Physical attacks

Physical abuse is particularly linked to externalizing problems while sexual abuse is linked to childhood post-traumatic stress disorder symptoms and, later on, internalizing problems. In addition, girls who experienced sexual abuse also have been reported to exhibit patterns of “sexual acting out”, including:

• Sexualized talk • Preoccupation with sexual themes • Sexual aggression toward other peers • Provocative behaviors at early ages

On the other hand, girls with ADHD who were not abused usually present with externalizing problems later on in life. This partly explains why there is a greater rate of diagnosis of ADHD among young boys. Child abuse has also been found to precipitate distorted self-perceptions and perceptions of the world, which in turn lead to helplessness, anxiety and depression, self- destructive and suicidal tendencies.

33 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Girls who were abused also tend to suffer from poor social interaction skills and difficulties in cultivating peer relationships. Their peers often see them as more rejected, less popular, and more disruptive than those who were not abused. Parents and teachers have also observed them to be excluded socially by their peers. Additionally, girls who were abused or neglected are associated with both poor academic functioning and late development of cognitive functions. They score lower than non-abused children in verbal ability and comprehension tests.

As mentioned, ADHD is reported as a predominantly male disorder. However, ADHD affects many girls as well. The behavioral patterns of symptoms exhibited by abused and neglected girls often overlap with those who have ADHD.

Parenting, and Risk of Abuse

Several studies in recent years suggest the etiologic roots of ADHD have genetic and neurodevelopmental origins. It does not mean, however, that school and social environments are not significant in the development or maintenance of ADHD. Abuse and violence are in fact environmental factors that can exacerbate ADHD. The primary neurodevelopmental origin of ADHD eliminates the prior belief that parenting is a major cause of ADHD. Additionally, given the role of genetics in the development of ADHD, biological parents of children with ADHD have greater likelihood of experiencing and exhibiting poor impulse control and attentional problems themselves, possibly contributing to the likelihood of abusive tendencies. Study data collected over the past few years show that parents of children with ADHD report experiencing more stress and dysfunctional parent/child interaction styles in contrast to their counterparts who do not have children

34 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com with ADHD. In addition to these, parents of children with ADHD also experience greater feelings of self-blame, incompetence, isolation, and depression. In fact, many mothers with hyperactive children are either separated or divorced compared to those whose children without ADHD.

Observed Link Between ADHD and Abuse

Research studies demonstrate a link exists between ADHD and child abuse. Wozniak, et al. studied whether children with ADHD are at greater risk of experiencing trauma and PTSD symptoms. The results showed that 7% of their ADHD population reportedly experienced child abuse. Ford, et al. also examined the association between a history of trauma and both ADHD and oppositional defiant disorder (ODD). The study found that children with comorbid ADHD and ODD had a history of trauma.

At infancy, the human brain is comparatively immature compared to other mammals. As a result, during the first two years of life, a child will experience remarkable growth and development. It is during this growth spurt that the brain will either establish or lose many of its cellular interconnections. A mix of genetic and environmental factors influences brain development during this early development. The rapidly growing science of epigenetics have mapped out and offered some explanation to how these processes are interrelated and affect each other.

There is a growing body of literature focused on study data and descriptive analysis and explanation of the impact of environmental violence on the developing brain. In particular, a most informative finding in the literature for clinicians to keep in mind is that children exposed to violence early in their lives tend to exhibit permanently altered responses to confrontation

35 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com and conflict. This gives rise to the idea that these children have been “hard- wired” to respond with anxiety, poor concentration, and impulsive aggression in situations of conflict. Because they exhibit the three key symptoms of ADHD, of hyperactivity, distractibility and impulsive aggression, they can easily be misdiagnosed with the disorder.

Similar to their younger counterparts, adolescents who are currently exposed to violence and abuse are also anxious, highly aroused, and have greater levels of cortisone. However, adolescents who only experienced violence and abuse later on in their lives do not experience the same long- term impact on the brain structure. The difficulties with attention and concentration are attributed to the constant re-living of previous experiences of trauma, a notable symptom of post-traumatic stress disorder. On the other hand, the physical agitation they exhibit is a function of hypervigilance. For these children, these symptoms can be treated and the rate of recovery among them is especially high after they have been removed from the abusive environment and placed into safe homes.

When it comes to the treatment and diagnosis of ADHD in abused children, The American Academy of Pediatrics (AAP) states that its guidelines are inappropriate for use on such patient groups. This serves as a reminder to clinicians to avoid the mistake of misdiagnosing abused children with ADHD because they fulfill the criteria stated in the guidelines. However, according to the American Academy of Child and Adolescent Psychiatry (AACAP) practice guidelines, screening for psychological trauma and an interview is recommended for children at risk for abuse.

There are very limited studies, if any, on the appropriate treatment and management of children, especially girls, who have both ADHD and a history

36 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com of abuse. This is an area that requires urgent study since there are a greater number of children with ADHD who have been referred to child protective services. What is certain is that it is crucial to find safe and permanent homes for such children in order to successfully manage their symptoms. This is not to say that abused children with ADHD will necessarily have greater chances of positive outcomes as a result of placing them in a different home environment. Therapy for such children will need to be long- term and thoughtfully planned (involving modalities specifically aimed at treating abuse/trauma).

On the other hand, there are also those children diagnosed with ADHD whose abuse history was not uncovered diagnostically, either as a precipitating factor or an exacerbating factor. If the trauma is not addressed early on, the symptoms associated with it may go unchecked for years to come and even worsen, as the child grows older. As mentioned previously, the standard interventions recommended for the treatment and management of ADHD such as behavioral modification strategies and stimulant medications may not be the appropriate treatments for traumatized children.

Many of these children actually develop a personality disorder when they reach adulthood. A study by Philipsen, et al., showed that adults, especially women, who were diagnosed with a severe form of borderline personality disorder actually have a history of symptoms of pediatric ADHD. Since ADHD is a lifetime disorder, it often overlaps with other psychiatric disorders that develop later on in life. Moreover, severe borderline personality disorder diagnosed in adulthood has been frequently found among adults who were abused emotionally as children.

37 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Behavioral Management

Attention deficit hyperactivity disorder is a clinical syndrome with core symptoms of hyperactivity, inattention, and impulsivity. The core symptoms have been discussed previously and we will now focus more specifically on the various methods of behavioral management of these symptoms. ADHD is one of the most common childhood-onset psychiatric disorders; and, ADHD may be accompanied by learning disabilities, depression, anxiety, conduct disorder, and oppositional defiant disorder. ADHD is a chronic disorder affecting individuals of all ages and requires developmentally-sensitive interventions.

It has been raised that children and adolescents with ADHD often have poor social skills, learning difficulties, and disruptive behaviour, which can all result in low self-esteem, disrupted relationships, and academic failure. It is important to remember that as high as 30% of all children with ADHD have an associated learning disorder of reading, writing, and/or mathematics; and, out of this cohort of children with ADHD, up to 80-85% continues to be impaired by ADHD symptoms as adolescents and up to 60% into adulthood.

Keeping in mind that comorbid disorders in children with ADHD include behavioral disorders, depression, anxiety, tics, bipolar disorder, motor skill development difficulties, learning difficulties, and verbal and cognitive difficulties there are various preventive/complimentary and often combined therapeutic approaches to treatment that must be considered. Although pharmacological treatment is the first line measure for ADHD, evidence- based psychological interventions like behavioral therapy are still widely preferred. This is due to the following considerations.

38 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Pharmacologic Side Effects and Limits to Efficacy

Although pharmacological treatment is relatively safe, some patients experience significant functional impairment with psychiatric drugs. Studies have shown that adverse side-effects, such as, suppression of growth, sleep problems, tiredness, loss of appetite, stomach upset, headaches, nausea, and increases in heart rate and blood pressure can occur with long-term treatment.

There are also short-term effects of medications that require consideration. Although the psychostimulant drugs used in the treatment of ADHD are effective in controlling the core symptoms, they may not be effective over a longer term and improvements may not be maintained into adolescence. Additionally, there are narrow clinical benefits of some medication and the secondary problems and comorbid conditions associated with ADHD may not be relieved with drugs alone.

A significant number of children and adults either fail to respond or exhibit a weak response to drugs used in ADHD treatment. These patients do not experience symptom alleviation, as expected from the administration of these medications.

Treatment in young children requires close observation when administering ADHD medication. The psychostimulant drugs used in the treatment of ADHD (except dexamphetamine) are not approved for clinical use in children less than 6 years of age. Therefore, treatment of younger children with ADHD requires nonpharmacological measures.

39 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Ethical concerns regarding the use of psychotropic medications are often involved. Psychological and behavioral treatments alone are not advisable in moderate to severe ADHD, but they are recommended as first-line treatment in the management of preschool-aged children, patients with mild symptoms, and as an adjunct to medication in patients with comorbid disorders or suboptimal responses to pharmacotherapy.

Because of the wide array of symptoms and comorbid conditions associated with ADHD, a long-term multimodal treatment plan is the most ideal. It helps to reduce the symptoms as well as addresses other areas of difficulty. Long-term multimodal treatment plan for ADHD may involve any of the following methods and considerations.

• Psychoeducation, which is information, explanation and counselling for children with ADHD, parents and others • Psychological and behavioral approaches • Social assistance such as parent support groups, financial assistance, and respite care • Appropriate education strategies in school including assistance for children with coordination difficulties • Discussion and consideration of pharmacotherapy

Clinicians responsible for the management of ADHD have to liaise with multidisciplinary professionals, including behavioral therapists from a variety of theoretical and training backgrounds. Behavioral therapy for ADHD generally includes cognitive behavioral approaches and interventions as well as parent training.

40 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com In children less than 6 years of age, treatment is primarily focused on the behavioral approach including parent-training interventions. For older children, the treatment modalities are cognitive behavioral treatment (CBT), social skills training and self-instructional training coupled with parent training.

Objectives of Behavioral Management in ADHD

The clinical syndrome of ADHD in children and adults comprises behavioral problems coexisting with mental disorders like depression, poor self-esteem, anxiety, defiant and oppositional behaviour, relationship problems, and learning difficulties. The mainstay of treatment is to improve the behavior as well as the peer, social and family relationships. There is moderate-to-high- level evidence suggesting that non-pharmacological interventions, like behavioral measures, can be effective in managing the core ADHD symptoms, conduct disorders, social skills, self-efficacy, and emotional outcomes at 6 months follow-up.

Behavioral treatment approaches have also been shown to be effective in improving on-task behavior, reducing aggression, and improving short-term academic and behavioral performance. Moreover, behavioral management measures can be used as an adjunct to pharmacological measures to reduce the dose of psychostimulant drugs. The parent training measures are designed to help parents cope with the difficult behaviors of the child.

Cognitive behavioral therapy is used for controlling the impulsivity, inattention and hyperactivity aspects of ADHD. Cognitive behavioral therapy aims at helping parents and patients understand the link between thoughts, feelings, and actions and how this can lead to destructive consequences.

41 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Cognitive behavioral therapy also trains the patient how to reframe and challenge their thoughts to alter feelings and behaviour into those that produce desirable outcomes.

Methods and Strategies

Behavioral strategies like positive and negative reinforcement methods, ‘time out’ methods are highlighted below.

Positive reinforcement strategies:

Positive reinforcement strategies are interventions designed to produce a targeted change in motor, impulse or attention control. The rewards can include more time allowed for recreational activities or giving of valuable things. Younger children use tokens like stars, chips, or marbles as rewards and may be effective, but for older children the reward has to be something that is of value. Social approval like praise or achievement certificates can also be used as rewards for this age group.

Negative Reinforcement Method:

The negative reinforcement method includes measures like a verbal reprimand or reproof by a parent, caregiver, or teacher when the child behaves undesirably. This approach is effective in changing actions such as impulsive behaviour that have disruptive effects and require immediate cessation. There is a reward cost strategy to this method, which involves loss of a potential reinforcement such as an earned token or deduction of a promised reward, at the time of an inappropriate behavior.

42 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Time Out Method:

The Time Out Method is short for “time out from social reinforcement.” In this method, the child is required to spend a specific duration of time away from the attention of others and is expected to be quiet and cooperative. This approach is effective when the hyperactive, impulsive behavior is provoked by the attention of others like parents, peers, or siblings.

Behavioral strategies like positive and negative reinforcement methods, time out methods may be used, which include or overlap with strategies such as token economy (explained in more detail later on) and task simplifying. Other helpful strategies to augment the above methods include maintaining home and/or school diaries. The methods here have to be continued over time to be effective. Appropriate support for associated learning difficulty should also be included in the behavioral management interventions.

Parent Management Training

Parent management training as already mentioned, is a type of behavioral therapy intervention that teaches parents coping skills to deal with their children with ADHD. It is raised here in more detail as part of a family systems approach to therapy considered integral to successful outcomes for the child and parent(s)/caregiver(s).

The term parent training, is applicable not only to parents but also to others who are instrumental in providing care for the child, including caregivers and guardians of the child. The parents, or caregiver, or guardian, and therapist form a collaborative team. They are taught to target and keep track of problematic behaviors, put in place clear and developmentally-appropriate behavioral expectations, and provide positive reinforcement for appropriate

43 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com behavior and negative consequences for inappropriate behavior. When done correctly, parent management training decreases child behavior problems, increases homework completion, and results in better parent–child interactions. This type of intervention primarily focuses on issues that hinder the parent’s coping mechanisms and responses to internal and external stressors, such as poor self-esteem, social isolation, depression and marital difficulties.

The main aims of parent training are listed below:

• Teach parents the basics of child behavioural management • Increase confidence in parental capabilities • Develop competence in raising children with ADHD • Improve parent-child relationship by using good communication and positive attention to aid the child’s development

Parent training programs follow a set curriculum, which usually runs for several weeks. It is usually conducted in groups, but can also be modified for individual training. Triple P and Webster-Stratton are some of the well- recognized parent training programs. The American Academy of Child and Adolescent Psychiatry recommend that parent management training of preschool children with ADHD be the initial intervention before using stimulants. Children with ADHD are much more difficult to parent. It is not uncommon for parents to eventually become less effective, and feel overwhelmed and unable to manage the behavioral symptoms of ADHD. Parent management training programs are designed to aid in stabilizing the home situation.

44 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Parent management training may include video clips and role-playing, which can aid in the analysis and demonstration of parenting skills that are especially important for ADHD children. They may include the following measures.

• Improve structure and daily routine • Keep consistent supervision • Obtain the child's attention prior to giving instructions • Give step-by-step instructions • Provide positive experiences such as praises and rewarding experiences

One very important element present in interactions between parents and child with ADHD is power struggle. The children react to parents, and parents react to them, in a vicious cycle that employs less effective but more coercive behaviors. The continuous struggle often leads to parents lowering their expectations and refusing to give the children attention. This can be corrected with parent management training; if done correctly, the parents will learn how to interact with their children without power struggles. They will learn about giving rewards for appropriate behaviors, and creating prospects that will change the pattern.

While parent management training for disruptive behavior is backed by very strong evidence-based studies in mental health, it is not available to many families who could benefit from it. The strong prospects of parent management training and its vital role in evidence-based mental health practices should make it accessible to parents and families who need it the most. Wider availability will not only benefit families and parents, it will also help bring down mental health costs.

45 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com In a report published by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality (AHRQ), parent management training involving parenting strategies is both a low-risk and effective method for improving behavior in children with ADHD at the preschool age (< 6 years old). It is an ideal first line treatment in these cases. This is especially important since there is very limited available data supporting the safety and efficacy of ADHD medications in this age group. However, there is one huge barrier to the success of parent management training, which is the large number of parents who drop out of therapy programs. This is especially true among parents whose children were initially diagnosed with disruptive behavior. In fact, a large number of preschool-age children with aggressive or noncompliant behavior who eventually develop ADHD usually first receive an initial diagnosis of disruptive behavior disorder.

Cognitive Therapy

Cognitive therapy is another psychological treatment approach used among children with ADHD. It involves the following approaches: • Cognitive modelling • Self-evaluation • Self-reinforcement • Response cost

Self-instructional training is the most commonly used cognitive modeling approach. Children are taught to adopt a systematic, reflective, and goal- directed approach to tasks and problem solving, thus helping them develop a planned and reflective way of thinking and behaving. The learning strategies include abstract learning schemas, concrete step-by-step approaches and physical cues or reminders.

46 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Think Aloud is a program with an abstract reasoning strategy devised by Camp and Bash in 1981 based on the ideas of Meichenbauem. Children are taught to adopt a 4-point schema when faced with a problem, which are:

1. What is the problem? 2. What is my plan? 3. Do I use my plan? 4. How did I do?

This strategy is taught initially with cognitive modelling that involves an adult verbalising a response to a problem-solving task. Children are encouraged to emulate this by first talking out loud, and then whispering and finally using self-talk to solve problems. Self-evaluation is then encouraged. In this type of program, children are instructed in task-specific strategies related to activities like schoolwork, social activities, and leisure pursuits. Other methods taught are self-reinforcement and response-cost techniques wherein the children have to pay a penalty for mistakes or earn rewards for following the strategies taught.

Family Therapy

Family therapy is focused on improving interpersonal relationships within the family and subsequently, family function. The different models used are briefly listed below, and involve extensive research, theory as well as extensive therapist training for these therapy approaches:

• Structural family therapy • Strategic family therapy • Brief solution-focused therapy

47 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Behavioral Interventions in Educational Settings

Schools are ideal settings for intervention since school-based services are easy to access and the stigma associated with accessing behavioral services in a clinic is minimized. Schools are also ideal settings for the implementation of evidence-based interventions (EBI) aimed at preventing or minimising academic, peer-social or behavioral problems in ADHD.

Since children with ADHD most likely have associated learning difficulties, exhibit difficult class room behaviors, show significant time-off task, and often fail to comply with instructions of the teacher, teachers have to spend a greater amount of time with them, compared to their peers. This can lead to conflicts in teacher-student relationships. As mentioned previously, children with ADHD have stressful and conflicting relationships with their parents because of behavior problems at home. This can have a negative impact on the parent-child relationship and the ability of parents to support their education.

Aside from the teacher-student and parent-child conflicts, parents and teachers themselves may not see eye-to-eye. This conflict most likely arises from parental dissatisfaction with the teacher due to the inability to meet the child’s educational needs. Additionally, the teacher’s concern for the child’s behavior in the class room can be interpreted negatively and subsequently lead to strained relations with the parents.

Treatments that support children with ADHD in school include the use of stimulant medications and psychosocial interventions, such as strategies to support home-school collaboration. Another example of a psychosocial intervention is strategies to improve both performance and skill deficits. Interventions aimed at performance deficits include environmental

48 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com adaptations and accommodations to intervene at the point of performance, such as techniques to modify the antecedents and consequences in the environment to change child behavior. Interventions aimed at addressing skills deficits include direct instruction and increasing opportunities for repeated practice of new skills.

Children with ADHD function poorly in unstructured and unpredictable environments. It is, therefore, advisable for teachers to keep the classroom structured and predictable. In a group, ADHD children are more likely to exhibit unruly behavior, but they may not require disciplinary interventions and are more likely to obey clear behaviour rules and a system of consequences if applied consistently. Two of these school approaches are: 1) Response to Intervention (RTI) and 2) Effective Behavioral Supports (EBS) or School-wide Positive Behavior Support (PBS).

Positive Behavioral Support (PBS) is defined as a systems approach to enhancing the capacity of schools to adopt and sustain the use of effective practices for all students. Primary strategies focus on implementing school- wide discipline, classroom-wide behavioral management, and effective instructional practices. For an effective program, the involvement of expert consultants in school such as school and clinical psychologists, child and adolescent psychiatrists and other behavioral health professionals in implementing evidence-based psychosocial interventions (EBI) in the school setting is crucial.

A key member of the PBS team is the PBS coach who has been extensively trained in applied behavioral analysis. The PBS coach can be trained to form school-home partnerships and to use conjoint behavioral consultation (CBC) in school-home relations. CBC is a structured problem-solving process

49 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com wherein parents and teachers work together as partners throughout the four stages of behavioral consultation, which are identified as:

• Problem identification • Problem analysis • Plan implementation • Plan analysis

The PBS coach, through a structured process, such as CBC, is specifically trained to provide support to behavioral health staff and teachers in the implementation of universal and individualised behavioral interventions for classroom and school.

Strategies to Support Individual Students

Teachers of students with ADHD have to adapt their classroom routine and expectations in order to minimize individual student’s deficits in performance. This is done by an individual education plan (IEP) which advises teachers on modifications to routine classroom work, tests, and homework assignments for children with ADHD. Modifications in the classroom include seating of the child with ADHD close to the teacher to avoid potential environmental distractions like doors, windows and other students, and allow the teacher to use a private attention cue to prompt the student to stay on task. Students with ADHD have to be given extended time for completing tests or allowed to take tests in a quiet room.

Students with ADHD often lag behind their peers in academic performance as well as acquisition of skills that affect academic productivity, classroom behavior and peer relations. They are also more likely to have impaired planning ability, poor sense of time and inaccurate time estimation, lack of

50 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com effort and motivation, poor self-regulation of emotion, greater problems with frustration tolerance which result in academic performance problems, disruptive classroom behavior, and peer difficulties.

Many behavioral interventions have been proven effective, but clinical gains are hard to sustain and only when they remain in place in the settings and during times of difficulties. Since most difficulties encountered by ADHD students occur because of performance defects, interventions are geared towards enhancing performance, such as improving impulse control and time given to a task. For children who lack skills, interventions are focused on teaching new skills like social and organisational skills. Most school-based interventions are geared to affect the antecedents/consequences of behavior. An example of antecedent is the way in which the teacher gives commands to the students.. Consequences, on the other hand, can be defined as responses that follow behaviors that can either increase or decrease the probability of them happening again.

Positive Reinforcements

Interventions based on modification of antecedents and consequences are used in schools. Teachers are taught how to alter the antecedents and contingencies in the environment to shape the behavior of children with ADHD. This includes components such as:

• Setting consistent limits and reasonable expectations • Giving instructions in a clear and consistent manner • Providing positive reinforcement contingent on appropriate behavior • Using effective and strategic consequences for specifically identified inappropriate behavior

51 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com One of the primary goals of behavioral intervention programs is to increase teachers’ use of positive reinforcement contingent upon appropriate behavior. Specifically, it allows teachers to provide differential attention, which is attention and verbal praise as positive reinforcement when students demonstrate expected behavior, and systematically ignore inappropriate behavior. Positive attending, which is making positive remarks in response to appropriate child behavior, is very effective in strengthening teacher- student relationships.

Token Economy or Token Reward System

In the Token Economy system, the teacher dispenses tokens, chips, stickers or points to any student in the class (as a class wide intervention) or to individual students with ADHD (individualised intervention) for exhibiting previously determined behavior. This intervention can be used to encourage on-task behavior and appropriate classroom behavior. It can be made more effective by coupling it with a reinforcement system in which the student can exchange the tokens or points to gain small prizes or preferred activities.

The token or point system is more effective when children are given a group of reinforcements to choose from and also when the system is made effective consistently. Some children respond to the token system only when it is combined with positive reinforcement and response cost. A response cost refers to the procedure wherein children earn points by doing specified desirable actions, but lose points when exhibiting undesirable behavior.

Daily Report Card (DRC)

The daily report card is a behavioral intervention with strong research support. This type of intervention requires planning that involves the school

52 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com and the family with inputs from children, implementation of elements involving the teacher and parents, and evaluation of implementation quality and outcomes. It is easy to keep track of the points children earn or the percentage of days they have achieved their goals. Below is an example of how to construct a daily report card of a child with ADHD.

Step 1 Identifying 2 or 3 target behaviours These should be adaptive behaviour for the classroom rather than non-adaptive responses. Consider including the child in the process to increase child investment. Step 2 Identify a method for recording child behaviour. Option 1: Tally the occurrence of target behaviour. Option 2: Rate the child’s behaviour on a 3- or 4-point scale at designated times. Step 3 Educate the parents about DRC. Set reasonable goals for child’s behaviour each day. Goals should be 10% higher than base-line performance. Reinforce the child for goal attainment. The child might earn privileges at home each time he gains a goal at school. Step 4 Educate the child about the DRC goals, parent, teacher, and child roles, and opportunities for rewards contingent on appropriate behaviour. Step 5 Monitor implementation and outcomes. Review complete DRC to ensure proper use by parents and teachers. Adjust goals according to child’s progress.

There is considerable evidence supporting the effectiveness of DRC intervention in children with ADHD behavioral problems. Moreover, this intervention is acceptable and feasible for teachers to use.

53 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Self-management

The self-management method is suitable for older children with ADHD and includes self-monitoring and self-reinforcement. Self-management is used in conjunction with an incentive system through which children can reward themselves for achieving certain goals.

In this intervention, the children are taught to recognize and record instances of on-task behavior. At first, the teachers help the children to keep the count, until such a time they become proficient enough to manage on their own.

Social Skills Training

Children with ADHD present with difficulty in maintaining family and peer relationships due to poor social interactive skills, which are necessary for developing and maintaining constructive social and personal relationships. Therefore, social skills training aims at teaching children social interactive skills like eye contact, smiling and appropriate body posture necessary for social interactions.

Social skills training use techniques from both cognitive and behavioral approaches and are conducted in groups. It teaches affected children how to self-regulate responses. The ability to self-regulate is the capacity to initiate, delay, modify or modulate the amount or intensity of a thought, emotion, behavior or psychological response. It also teaches children how to manage stressful events. Studies have shown that social skills training in children with ADHD consisting of an intense, multimodal behavioral intervention focusing on multiple areas of impairment and conducted within the child’s social milieu is very effective. It is conducted in clinical settings, away from

54 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com the environments where these children have relationship problems and are lacking social validity.

There is evidence that participation in intense social skills training sessions, such as those offered during summer treatment programs (STPs) and those used in the Multimodal Treatment Study for children with ADHD, results in long-lasting improvement in behavioral functioning, social skills, and peer relations. Such sessions usually last between 6–8 hours a day, five days a week, for a period of many weeks. The STP interventions involve social skills training followed by coached recreational activities and the use of contingency behavior management systems, such as token/point systems and concurrent home rewards given to the child by the parents for meeting goals related to peer relations. The behavioral effects of STPs on children’s propensity to externalize behavior and peer relations are comparable to those obtained through psychostimulant medication treatment.

Organizational Skills Training

Children with ADHD have organizational skills deficits, and unless they learn these, they will have difficulties during their secondary education and vocational performance. Although some children exhibit improvements in organisational skills with medication, many children with ADHD on medication still continue to have deficits in this area. Strategy training for improving organizational skills includes interventions targeted at the children’s ability to take accurate notes, organise study materials, and study more efficiently. They have to be taught how to take notes during classroom lectures, to write down homework assignments with accuracy, to organize their school binders and other school materials, and to memorize

55 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com information to help them study for tests and exams. The effectiveness of organizational skills training is enhanced with contingency reinforcement.

Behavioral Homework Intervention

Problems with homework completion are widely prevalent among children with ADHD. Strategies to improve homework performance are important as they can improve home-school relations and improve academic performance. Homework interventions have two elements of 1) antecedent strategies that create the content for homework performance, and 2) consequences which refer to contingencies of homework behavior.

Antecedent strategies involve assignment of a reasonable amount of homework given the children’s age and abilities as well as work that can be completed with minimal parental supervision. The place for homework should be free from distractions and time allotted for homework should be the time of the day when children are most attentive.

Computer Assisted Instruction

Children with ADHD have academic skill deficits, which include comprehension and retrieval of basic facts. If instructional tasks are novel and stimulating and if there is regular feedback, then children with ADHD exhibit increased academic success. Computer assisted instruction (CAI) supports the academic requirements of children with ADHD. It allows for lessons and specific goals to be tailored to each child’s instructional level. The learning environment tends to be more stimulating than typical paper and pencil classroom tasks, and children receive immediate feedback from the computer about the accuracy of their responses.

56 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Limitations of Behavioral Therapy in ADHD

Some studies have shown that, despite improvement in certain outcome targets with behavioral management, the core symptoms of inattention, hyperactivity, and impulsivity remain largely unchanged at the end of 8- months of behavioral therapy alone for ADHD children.

Current research evidence has not shown significant benefits of cognitive behavioral therapy in ADHD, despite cognitive processes to be strongly linked with ADHD. Whalen, Henker, and Hinshaw reviewed cognitive behavioral approaches in the literature, and concluded that evidence of benefit was weak for many studies. Kendall and Braswell found that CBT reduced impulsivity but had little effect on other features of ADHD. Abikoff and Gittleman compared the efficacy of CBT combined with medication to medication alone in ADHD and found limited advantage over the medication group.

Effectiveness of Behavioral Interventions in ADHD

Studies reveal that treatment with either medication or behavioral interventions have several drawbacks. Pelham suggests that these can be reduced when the two approaches are combined, and that the primary symptoms are most successfully treated by medication and the secondary symptoms by behavioral approaches. Gittleman and colleagues studied the efficacy of three treatment approaches, which are behavior modification plus placebo, behavior modification plus methylphenidate, and methylphenidate alone. The combination of behavior modification plus methylphenidate was the most effective followed by methylphenidate alone and then behavior modification plus placebo.

57 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Patients with ADHD exhibit impaired functioning, quality of life (QOL), adaptive skills, and executive function that often persist throughout their lives. Although ADHD symptoms are a core aspect of diagnosis, focusing on symptom improvement as a treatment outcome is insufficient, because symptoms represent only part of the outcome. When initiating a new treatment, it is appropriate to collect symptom ratings to assess response, because ADHD symptom ratings are most sensitive to treatment response in the short term. After stabilization of treatment, additional domains can be assessed for improvement. During initial titration, and during maintenance of treatment, ratings should be collected from multiple raters such as parents and teachers because the level of agreement among raters may be low.

The complex combination of primary, secondary, comorbid symptoms and social factors, should be considered for each individual child in order to plan and carry out the most effective treatment approaches. Pelham and Bender suggested that treatment approaches for children with ADHD should begin with behavioral management and parent training. Behavioral interventions are effective as a psychological intervention for controlling core symptoms and other aspects like behavior, conduct, emotional and learning problems.

Medication Management Of ADHD

The American Academy of Pediatrics (AAP) has collaborated with various notable organizations in creating the latest version of Clinical Practice Guidelines including. These organizations include:

• American Academy of Child and Adolescent Psychiatry • Child Neurology Society • Society for Pediatric Psychology

58 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com • 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) • Centers for Disease Control and Prevention (CDC)

The representatives from each of these organizations formulated together a series of research questions to direct an extensive evidence-based review for both diagnostic and treatment issues. The questions directed at the diagnostic issues were:

1. ADHD prevalence, specifically: (a) What percentage of the general U.S. population aged 21 years or younger has ADHD? (b) What percentage of patients presenting at pediatricians' or family physicians' offices in the United States meet diagnostic criteria for ADHD?

2. For co-occurring mental disorders of people with ADHD, what percentage has 1 or more of the following co-occurring conditions: sleep disorders, learning disabilities, depression, anxiety, conduct disorder, and oppositional defiant disorder?

3. What are the functional impairments of children and youth diagnosed with ADHD? Specifically, in what domains and to what degree do youth with ADHD demonstrate impairments in functional domains, including peer relations, academic performance, adaptive skills, and family functioning?

4. Do behavior-rating scales remain the standard of care in assessing the diagnostic criteria for ADHD?

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5. What is the prevalence of abnormal findings on selected medical screening tests commonly recommended as standard components of an evaluation of a child with suspected ADHD? How accurate are these tests in the diagnosis of ADHD compared with a reference standard (i.e., what are the psychometric properties of these tests)?

The questions directed at the treatment issues in particular were:

1. What new information is available regarding the long-term efficacy and safety of medications approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD (stimulants and nonstimulants) and, specifically, what information is available about the efficacy and safety of these medications in preschool-aged and adolescent patients?

2. What evidence is available about the long-term efficacy and safety of psychosocial interventions (behavioral modification) for the treatment of ADHD for children, and specifically, what information is available about the efficacy and safety of these interventions in preschool-aged and adolescent patients?

3. Are there any additional therapies that reach the level of consideration as evidence based?

According to the AAP guidelines, stimulant medications are very effective in decreasing the main symptoms of pediatric ADHD.114,115 Other non-stimulant medications have also shown promising results by demonstrating efficacy at symptom reduction. These are shown to be 1) Atomoxetine (selective

60 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com norepinephrine-reuptake inhibitor, and 2) Extended release selective α2- adrenergic agonists (guanfacine and clonidine).

Both classes of medications are fairly new in the field of pediatric ADHD treatment and the evidence that back their role in this disorder is smaller and weaker compared to the stimulant medications. Moreover, these medications have not received FDA approval for use in preschool-aged children. Below is a summary table of the currently FDA-approved medications for ADHD with their pharmacokinetic profiles and dosing schedules.118

Medication Initial Frequency Time to Duration Maximum (Generic name) titration dose initial effect dose

Mixed amphetamine 2.5-5 mg QD-BID 20-60 min 6 hours 40 mg salts Dextroamphetamine 2.5, 5 mg BID-TID 20-60 min 4-6 hours 40 mg Lisdexamfetamine 20 mg QD 60 min 10-12 hours 70 mg Methylphenidate 5 mg, 10 mg, QD 20-60 min 3-12 hours 54-60 mg 18 mg, 20 mg Dexmethylphenidate 2.5 mg, 5 mg BID 20-60 min 3-12 hours 20-30 mg Atomoxetine 0.5 mg/kg per QD-BID 1-2 weeks At least 10- 1.4 mg/kg day, then 12 hours increase to QD- BID for children >154 lbs Extended release 1 mg/day QD 1-2 weeks At least 10- 4 mg/day guanfacine 12 hours Extended release 0.1 mg/day QD-BID 1-2 weeks At least 10- 0.4 clonidine 12 hours mg/day

Among the most common adverse effects of stimulant medications are:

• Loss of appetite • Abdominal pain • Headaches • Sleep disturbance 61 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Other adverse effects of stimulant medications reported by studies include:

• Decreased growth velocity • Hallucinations and other psychotic symptoms • Cardiac death

The non-stimulant medication, atomoxetine, is also implicated in many adverse effects, including:

• Initial somnolence • Gastrointestinal tract symptoms (especially if the dosage is titrated upward too rapidly) • Decreased appetite • Increase in suicidal thoughts • Hepatitis (rare)

The non-stimulant α2-adrenergic agonists extended-release guanfacine and extended-release clonidine, are implicated in the development of somnolence and dry mouth.

Adjunctive therapy is an important part of managing pediatric ADHD. The FDA has approved only 2 medications for this use: 1) Extended-release guanfacine, and 2) Extended-release clonidine. Other medications mentioned as part of the management are off-label, with only anecdotal evidence for their safety or efficacy.

Psychostimulants

Stimulants are the first line of medications prescribed to children with ADHD. According to the CDC, 70-80% children diagnosed with ADHD who were

62 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com given stimulants responded positively. Although some of them have reported experiencing a funny feeling during the course of their treatment, psychostimulants at their therapeutic doses do not induce feelings of being high. To date, there are three type of stimulants that are commonly prescribed in treating ADHD: 1) Methylphenidate (Concerta and Ritalin), 2) Amphetamine (Adderall), and 3) Dextroamphetamine (Dexadrine). Stimulants are thought to exert their therapeutic effects by acting on the neurotarnsmitters in the brain. The result is more balanced levels of neurotransmitters and decreased inattention and hyperactivity.

The stimulants mentioned above are sympathomimetic compounds that do not share similar structures except for a phenylethylamine backbone with endogenous catecholamines. The mechanism of action of psychostimulants is primarily attributed to its blockade of catecholamine reuptake into presynaptic nerve endings, thus, preventing their degradation by the enzyme, monoamine oxidase. Additionally, amphetamine compounds are thought to initiate the retrograde release of catecholamines through the transporter as well as other actions on the vesicular storage of catecholamines.

Stimulants are contraindicated in the following conditions: • Any type of heart defect or disease • Hypertension • Hyperthyroidism • Glaucoma • Anxiety states • History of drug abuse

63 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Methylphenidate

The role of Methylphenidate in pediatric ADHD is that it corrects the hyperactivity and increases the attention span. It promotes nerve impulse transmission by releasing nerve terminal stores of norepinephrine.

Dose and Administration:

The tablet formulations are availabele in various doses, ranging from 2.5 - 20 mg. Clinicians usually start with very small doses that can be gradually titrated upward depending on patient response and tolerance to adverse effects.

Pediatric patients age 6 years and older usually start with 5 mg given twice daily; followed by a daily maintenance dose of 60 mg. These patients require frequent monitoring for adverse effects. Patients prescribed with the transdermal patch, Daytrana, are usually between 6 to 12 years old. They may apply one 10 mg patch to clean skin, preferrably on the hip and alter administration sites regularly.

Chemical Structure and Available Preparations:

Methylphenidate hydrochloride is methyl α-phenyl-2-piperidineacetate hydrochloride. Available preparations include: • Methylin: Oral solution 5 mg/5 ml, 10 mg/5 ml Tablets (chewable) 2.5 mg, 5 mg, 10 mg

• Ritalin: 5 mg, 10 mg, 20 mg Extended-release -

• Metadate CD: capsule 10 mg, 20 mg, 30 mg

• Ritalin LA: capsule 20 mg, 30 mg, 40 mg

64 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com • Concerta: tablet 18 mg, 27 mg, 36 mg, 54 mg

• Metadate ER, Methylin ER: tablet 10 mg, 20 mg Sustained-release -

• Ritalin SR: tablet 20 mg Transdermal system -

• Daytrana: patch 10 mg, 15 mg, 20 mg, 30 mg

Adverse effects:

Patients may frequently experience nervousness and sleeplessness. Others may experience weight loss and suppression of appetite. Dizziness, increase in blood pressure and gastrointestinal upset are also frequent adverse reactions of the drug. Life-threatening reactions include exfoliative dermatitis, uremia and thrombocytopenia.

FDA Warnings:

Due to its psychotropic effects, methylphenidate (Metadate CD) is often abused. This is why it is classified under the Schedule II controlled substances. Its sale and administration without valid prescription is illegal.

Elimination:

Methylphenidate is absorbed from the gastrointestinal tract and 40% is excreted unchanged in the urine.

Metabolism:

The drug undergoes extensive first-pass metabolism via de-esterification to form a minimally active metabolite. Its major metabolite is ritalinic acid.

65 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Contraindications:

Patients who are hypersensitive to methylphenidate, with a history of Tourette syndrome, seizures and motor tics should not be given the drug. It should not be given to pediatric patients who are 6 years old or below. Drug interactions:

Methylphenidate decreases the effects of decongestants and increases the effects of other ADHD drugs such as tricyclic antidepressants.

Dexmethylphenidate

The role if dexmethylphenidate in pediatric ADHD is that it increases the concentration of norepinephrine and dopamine by inhibiting their reuptake and stimulating their release from the presynaptic vesicles.

Dose and Administration:

Children who are 6 years and older and not on methylphenidate, are usually given 2.5 mg tablets which to be taken twice daily and 4 hours apart. The dose may be increased within a week by 2.5 mg to 5 mg daily. The maximum daily dose is 20 mg.

Chemical Structure and Available Preparations:

Dexmethylphenidate hydrochloride is methyl α-phenyl-2-piperidineacetate hydrochloride, (R,R’)-(+)-. Its empirical formula is C14H19NO2•HCl. Its molecular weight is 269.77. Available preparations include: Extended- release - Capsule: 5 mg, 10 mg, 20 mg; and Tablet: 2.5 mg, 5 mg, 10 mg.

66 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Adverse effects:

Children may experience headaches, feelings of jitterness, insomnia, tachycardia, twitching and other hypersensitivity reactions.

Elimination:

Studies showed that 90% of dexmethylphenidate is excreted in the urine. Metabolism:

Dexmethylphenidate is metabolized primarily to d-α-phenyl-piperidine acetic acid by de-esterification. It has little or no pharmacological activity.

Contraindications:

Dexmethylphenidate is contraindicated in patients who are hypersensitive to methylphenidate, its parent compound. It is also not prescribed to children with structural cardiac abnormalies or other serious heart problems.

Drug interactions:

Avoid using dexmethylmephenidate with antacids for it may alter the release of extended-release form. Patient must be monitored cautiously when used in conjunction with other centrally-acting alpha agonists.

Amphetamine-dextroamphetamine

The role of amphetamine-dextroamphetamine in pediatric ADHD is such that its specific mechanism of action of amphetamines and its derivatives in the management of ADHD is not very clear. It is a norepinephrine and dopamine reuptake inhibitor so it stimulates the release of monoamines into the extraneuronal space.

67 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Dose and Administration:

For children 6 years and older, a dose of 5 mg immediate-release tablet is given daily or twice daily. It may be titrated upward weekly by 5 mg until optimal response is seen. The daily dose should not exceed 40 mg.

For children between 3 years to 5 years old, a dose of 2.5 mg immediate- release tablet is initially given daily. It may be titrated upward on a weekly basis by 2.5 mg until optimal response is seen. The daily dose may be given 2 to 3 times separated by 4 to 6 hours interval.

Chemical Structure and Available Preparations:

Amphetamine products combine the neutral sulfate salts of dextroamphetamine and amphetamine, with the dextro isomer of amphetamine saccharate and d, l-amphetamine aspartate. Available preparations include: Tablet: 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg. In 2001, the FDA approved the extended-release capsule. The drug is contained within the tiny beads in the capsule; it provides 10-hour coverage.

Adverse Effects:

Children may experience palpitations, weight loss, and increased hyperactivity. Thrombocytopenia, uremia and exfoliative dermatitis are some of the drug’s life-threatening effects.

FDA Warnings:

Children under 3 years old and diagnosed with ADHD are not recommended to use amphetamines.

68 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Elimination:

The urinary recovery of amphetamine has been reported to range from 1% to 75%, depending on the urinary pH, with the remaining fraction metabolized in the liver.

Metabolism:

Amphetamine is reported to be oxidized at the 4 position of the benzene ring to form 4-hydroxyamphetamine, or on the side chain α or β carbons to form alpha-hydroxy-amphetamine or norephedrine, respectively.

Contraindications:

Patients with known hypersensitivity to sympathomimetic amines are not advised to use this drug. Sudden death has been reported in association with central nervous system (CNS) stimulant treatment at usual doses in children with structural cardiac abnormalities or other serious heart problems.

Drug interactions:

If used with gastrointestinal acidifying agents, a decrease in amphetamine absorption can be observed. It may also increase the effects of sympathomimetic or tricyclic agents if given concomittantly.

Dextroamphetamine sulfate

The role of dextroamphetamine sulfate in pediatric ADHD is that it releases stored dopamine and norepinephrine from nerve terminals in the brain and probably promotes nerve impulse transmission.

69 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Dose and Administration:

Children 6 years and older are given 5 mg tablets to be taken once or twice daily. It may be titrated upward on a weekly basis by 5 mg. The daily dose must not exceed 40 mg.

Chemical Structure and Available Preparations:

Dextroamphetamine sulfate is the dextro isomer of the compound d,l- amphetamine sulfate, a sympathomimetic amine of the amphetamine group. Chemically, dextroamphetamine is d-alpha-methylphenethylamine, and is present in all forms of dextroamphetamine sulfate extended-release capsules as the neutral sulfate. Available preparations include: • Capsules: 5 mg, 10 mg, 15 mg

• Tablets: 5 mg, 10 mg

Adverse effects:

Patients may experience nervousness, insomnia, tremor, headache, palpitations, diarrhea, anorexia, and other gastrointestinal problems.

Elimination:

It is eliminated renally. Excretion is enhanced by urine ph and 99% of each dose is ionized by glomerular filtration, with the remaining portion reabsorbed by the body.

Metabolism:

Single pharmacological doses of amphetamines produce peak plasma levels within 1-2 hours and are rapidly absorbed from the gastrointestinal tract.

70 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Contraindications:

It is contraindicated in patients with known hypersensitivity to sympathomimetic amines. It should also not be prescribed to children with structural cardiac abnormalities or other serious heart problems.

Drug interactions:

The central stimulant effects of amphetamine may be inhibited if given together with chlorpromazine.

Methamphetamine hydrochloride (Formulation: Desoxyn)

The FDA approved Desoxyn as treatment for ADHD, although it is not commonly prescribed and considered as controlled substance because of its abuse potential or propensity to cause a drug use and addiction disorder.

Non-stimulant Medication for ADHD

Non-stimulants include selective norepinephrine reuptake inhibitor (NRI) medication, such as atomoxetine.

Atomoxetine

Atomoxetine (Strattera) was approved in 2002 for the treatment of pediatric ADHD in children between 6 to 17 years old. It is the first non-stimulant approved for children diagnosed with ADHD, and its role is that it increases the levels of both dopamine and norepinephrine in the postsynaptic junction.

Dose and Administration:

71 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Children who weigh 70 kg or less, are given an initial dose of 0.5 mg/kg daily. After a minimum of 3 days, it may be titrated upward to a target daily dose of 1.2 mg/kg.

Chemical Structure and Available Preparations:

Its chemical designation is (-)-N-Methyl-3-phenyl-3-(o-tolyloxy)- propylamine hydrochloride. The molecular formula is C17H21NO•HCl, which corresponds to a molecular weight of 291.82. Available preparations include: Capsule: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg

Adverse effects:

Pediatric patients may experience headaches, dizziness, irritability, abnormal dreams, and sleep disturbances. Some may also experience palpitations, ear infection, urinary retention, and weight loss.

FDA Warnings:

The FDA warns that atomoxetine must be discontinued if the patient reports jaundice since the drug is associated with the development of liver injury. Latest studies show that patients under atomoxetine treatment are more likely to have suicidal thoughts than those who are not. Therefore, clinicians, guardians and parents need to pay close attention to the patient’s behavior and monitor any changes.

Elimination:

Atomoxetine is excreted via the kidneys, mainly as 4-hydroxyatomoxetine- O-glucuronide (greater than 80%). Less than 17% of the drug is eliminated via the feces and 3% usually remains unchanged.

72 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Metabolism:

The half life of atomoxetine is 21 ½ hours.

Contraindications:

The safety and efficacy of atomoxetine has not been established in patients younger than 6 years old.

Drug interactions:

Atomoxetine may increase cerebrovascular effects given concomittantly with albuterol.

Alpha-2 agonists

Alpha-2 agonists work by stimulating the neurotransmitter, norepinephrine, which is important for concentration. It may be used in conjunction with a stimulant or when psychostimulant drugs failed in pediatric patients with tics. The two most common alpha-2 agonists used in ADHD treatment are 1) Guanfacine hydrochloride, and 2) Clonidine.

Guanfacine hydrochloride

The role of guanfacine hydrochloride in pediatric ADHD is that it improves hyperactivity and insomnia symptoms. It decreases the symptoms of Tourette syndrome. It stimulates the neurotransmitter norepinephrine.

Dose and Administration:

The initial dose is usually 0.05 to 0.08 mg given once daily. A daily dose up to 0.12 mg/kg may provide additional benefit.

73 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Chemical Name And Available Preparations:

The chemical designation is N-amidino-2-(2,6-dichlorophenyl) acetamide monohydrochloride. The molecular formula is C9H9Cl. Available preparations include: Tenex; tablet; 1 mg, 2 mg.

Adverse Effects:

Patients on guanfacine may experience fatigue, dizziness, dry mouth, irritablity, and behavioral problems.

Advantage over other drugs used in pediatric ADHD:

Guanfacine is used to treat pediatric patients between 6 to 17 years old and may be used in conjunction with an ADHD stimulant.

In the latest studies relative Intuniv (which is Guanfacine, Extended Release form) in pediatric patients less than 6 years of age show that its safety and efficacy have not been established.

Metabolism:

After oral administration of Intuniv, the time to peak plasma concentration is approximately 5 hours in children.

Contraindications:

The drug is contraindicated in patients who are hypersensitive to guanfacine or other products containing guanfacine.

Drug interactions:

If taken with rifampin, guanfacin efficacy decreases.

74 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Clonidine

The role of clonidine in pediatric ADHD is that its another alpha-2 agonist used as an adjunctive treatment. It improves excessive hyperactivity and insomnia but does not improve inattention in children with ADHD. It decreases facial and vocal tics and has a positve side effect on defiant behavior.

Dose and Administration:

Initially, a dose of 0.05 mg is given at bedtime. The dosage may be increased cautiously over 2 to 4 weeks. For maintenance, the daily dose is usually 0.05 to 0.4 mg.

Chemical Structure and Available Preparations:

Clonidine hydrochloride is an imidazoline derivative and exists as a mesomeric compound. The chemical name is 2-(2,6-dichlorophenylamino)- 2-imidazoline hydrochloride. Available preparations include: • Patch releases 0.1 mg//24 hours, 0.2 mg/24 hours, 0.3 mg/24 hours

• Tablet 0.1 mg, 0.2 mg, 0.3 mg

Adverse effects:

Patients may experience drowsiness, dizziness, weakness and fatigue. Life threatening reactions include bradycardia and severe rebound hypertension.

FDA Warnings:

Children taking clonidine may be susceptible to hypertensive crisis because of is cardiac effects. Additionally, patients may experience gastrointestinal illness that leads to vomiting.

75 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Elimination:

About 40% -60% is eliminated in the urine.

Metabolism:

About 50% of the absorbed dose is metabolized in the liver. Its half-life is 6 to 20 hours.

Contraindications:

Children should be first examined by clinicians and once under treatment with the drug, must be cautiously monitored for any adverse reactions.

Drug interactions:

It must be used cautiously with antidepressants since it may increase CNS depression.

Antidepressants

Antidepressants are sometimes used for ADHD as off-label drugs. These drugs have not received FDA-approval but are still used sometimes by clinicians as adjuncts in ADHD treatment. Moreover, these drugs, such as bupropion, are also helpful in alleviating hyperactivity, anxiety, or serious sleeping problems.

Bupropion

The role of bupropion in pediatric ADHD is that it affects the reuptake of the serotonin, norepinephrine, and dopamine neurotransmitters.

76 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Dose and Administration:

No single dose of bupropion should exceed 150 mg. It should be administered 3 times daily, preferably with at least 6 hours intervals between successive doses.

Chemical Structure and Available Preparations:

It is designated as (±)-1-(3-chlorophenyl)-2-[(1,1-dimethylethyl)amino]-1- propanone hydrochloride. Available preparations include: • Wellbutrin tablet (extended-release) 150 mg, 300 mg

• Wellbutrin tablet (immediate-release) 75 mg, 100 mg

• Wellbutrin tablet (sustained-release) 100 mg, 150 mg, 200 mg

Adverse effects:

The side effects of bupropion include restlessness, agitation, sleeplessness, headache, and stomach problems.

Elimination:

About 87% of the drug is eliminated via the urine and 10% is excreted via feces.

Metabolism:

Its half–life is 8 to 24 hours.

Contraindications:

Patients with seizure disorder should not take bupropion. Bupropion can also induce suicide ideation in patients with no history of depression.

77 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Drug interactions:

Other antidepressants may lower the seizure threshold. Sun exposure may increase the risk of photosensitivity.

Tricyclic Antidepressants

Tricyclic antidepressants (TCAs) inhibit norepinephrine and serotonin reuptake at the postsynaptic nerve terminal, causing their levels to increase at the synaptic cleft and resulting in the potentiation of neurotransmitter action. TCAs are an older class of antidepressants that have proven to be beneficial but also loaded with many side effects.

These drugs, such as nortriptyline, can cause disturbances in heart rhythm which is why an electrocardiogram to rule out arrhythmias is necessary before starting the treatment.

Nortriptyline

The role of nortriptyline in pediatric ADHD is that at lower doses it improves symptoms within several days of starting therapy; however, it may take 1-3 weeks for full effect to be evident. Higher doses may improve depressive symptoms and mood swings.

Dose and Administration:

A low dose nortriptyline is usually initiated by the physician and gradually titrated upward until optimal response is seen.

78 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Chemical Structure and Available Preparations:

Nortriptyline hydrochloride is 1-propanamine, 3-(10,11-dihydro-5H- dibenzo[a,d] cyclohepten-5-ylidene)-N-methyl-, hydrochloride. Available preparations include: • Pamelor capsules 10 mg, 25 mg, 50 mg, 75 mg.

• Pamelor oral solution 10 mg/5 ml (contains alcohol)

Adverse effects:

Nervousness, sleep problems, fatigue, stomach upset, dizziness, dry mouth, and accelerated heart rate are some of the adverse effects of nortriptyline.

FDA Warnings:

The effectiveness and safety of nortriptyline has not been established in the pediatric population. Anyone considering the use of nortriptyline hydrochloride in a child or adolescent must balance the potential risks with the clinical need.

Metabolism:

The half-life of notriptyline is 18 to 24 hours.

Contraindications:

Nortriptyline is contraindicated in patients who are hypersensitive to it. It should be used cautiously in patients with history of seizure.

Drug interactions:

Nortriptyline may cause life-threatening hypertension when taken together with clonidine. 79 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Imipramine Hydrochloride

The role of imipramine hydrochloride in pediatric ADHD is that it is a tricyclic antidepressant that increases serotonin and norepinephrine in the CNS by blocking their reuptake by the presynaptic neurons.

Dose and Administration:

The effectiveness of the drug in children for conditions other than nocturnal enuresis has not been established.

Chemical Structure and Available Preparations:

Imipramine is a member of the dibenzazepine group of compounds. It is designated 5-[3- (dimethylamino)propyl]-10,11-dihydro-5H- dibenz[b,f]azepine monohydrochloride. Available preparations include: Tablet 10 mg, 25 mg, 50 mg

Adverse effects:

Children may experience drowsiness, dizziness and life-threatening effects such as seizures and stroke.

FDA Warnings:

A dose of 2.5 mg/kg/day of imipramine hydrochloride should not be exceeded. Pediatric patients given twice this amount can develop significant ECG changes.

Metabolism:

The half-life of imipramine is 18 to 25 hours.

80 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Contraindications:

Imipramines is contraindicated in patients who have a histroy of hypersensitivity to it.

Drug interactions:

Barbiturates and taken with other other CNS depressants may enhance CNS depression.

Desipramine Hydrochloride

The role of desipramine hydrochloride in pediatric ADHD is that it restores the normal levels of neurotransmitters by blocking the re-uptake of these substances from the synapse.

Chemical Structure and Available Preparations:

Desipramine hydrochloride, USP is an antidepressant drug of the tricyclic type, and is chemically:5H-Dibenz[b,f]azepine-5-propanamine,10,11- dihydro-N-methyl-, monohydrochloride. Available preparations include: Tablet 10 mg, 25 mg, 50 mg, 75 mg, 100 mg 150 mg.

Adverse effects:

Patients may experience drowsiness, dizziness, tachycardia, blurred vision, rash, urticaria and hypersensitivity reactions. Life threatening reactions include seizures, hypoglycemia, and sudden death in children. Recent studies show that there have been no suicides reported in any of the pediatric trials done.

81 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Elimination:

70% of the drug is excreted in the urine.

Metabolism:

Desipramine is rapidly absorbed from the gastrointestinal tract and metabolized in the liver.

Contraindications:

It should not be given if the patient is on treatment with other tricyclics. It is known to cause sudden death in some children. A patient with family history of arrhythmias should not be given desipramine.

Drug Interactions:

Desipramine may enhance CNS depression if used together with barbiturates and other CNS depressants. If used together with clonidine, it may cause life-threatening blood pressure elevations. Patients on this medication must avoid exposure to sunlight so as not to increase the risk of photosensitivity.

Special Considerations During Medication Management

Many of the medications for use in pediatric ADHD are approved only for patients more than six years old. Clinicians need to consider the risk versus benefit of using such medications on very young patients. One of the most important criteria in initiating drug therapy in this special subset of population is the severity of the ADHD symptoms. Current research data considers the use of medications on preschool children to only those who exhibit moderate to severe impairments. The factors deciding the severity of the symptoms include:

82 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com • Persistent symptoms of at least 9 months • Impairments in more than just one setting such as both the home and child care • Deficits that have failed to respond positively to behavior therapy

In addition to these, the clinician’s evaluation of the developmental impairment, safety risks, or consequences for school or social engagement that can lead to skipping medications can also play a role. Since the management of pediatric ADHD requires the cooperation of a multidisciplinary team, the clinician can look to a mental health expert to help with the assessment.

As mentioned previously, only dextroamphetamine is the medication approved by the FDA for use in children below 6 years old. However, the approval should not be taken for granted and heralded as a safe option since its approval was largely due to the strict regulations in force at the time of the medication’s approval rather than on concrete scientific evidence of its safety and efficacy in this particular subset of the population.

The majority of studies supporting the safety and efficacy of stimulant drugs in the treatment of ADHD in preschool-aged children came from methylphenidate. One multisite study of 165 children and 10 other smaller single-site studies included from 11 to 59 children (total of 269 children); 7 of the 10 single-site studies found stimulant medications to exhibit significant efficacy. Even though there is some data pointing out the safety and efficacy of methylphenidate in preschool-aged children, its use in this subset of the population is still off-label.

83 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Pediatric ADHD treatment usually involves behavioral therapy. This is why medications should only be prescribed if patients do not exhibit symptom improvement with behavior therapy. Additionally, there is evidence that suggests children between 4-5 years of age metabolize stimulant medications at a slower pace than their older peers, which is why they should only be given a low dose to start with, and allowed an increased dose gradually. On top of this, there are no studies on the drug’s safe maximum dose in this subset of the population.

When clinicians evaluate newly diagnosed adolescent patients for signs and symptoms of substance use and addiction, should the assessment be remarkable for substance use the assessment and treatment of this primary concern must precede treatment for ADHD. This is because these patients are at greater risk of misusing stimulants, using them other than for their intended medical purposes. Clinicians must not only monitor symptoms, they must also learn to monitor requests for prescription-refills and look out for signs of misuse or diversion of medications.

To discourage substance use and addiction, clinicians should also consider prescribing medications with no potential to misuse, such as atomoxetine, extended-release guanfacine, and extended-release clonidine; or, stimulant medications with less abuse potential, such as lisdexamfetamine, dermal methylphenidate, or OROS methylphenidate. Lisdexamfetamine is dextroamphetamine, which contains an additional lysine molecule, is only activated following oral administration when it is converted by red blood cells to dexamphetamine. The other preparations are difficult to chemically manipulate, making extraction of the stimulant also very difficult.

84 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Because many ADHD adolescents already have their driver’s license, it is important for clinicians to take into account the natural risks associated with it, particularly in providing adequate control of symptoms while driving.

DSM-5 or ICD Criteria

Medications are not indicated for children whose symptoms do not meet either the DSM-5 or ICD’s criteria for diagnosis of ADHD. Alternatively, children may benefit from behavior therapy, which does not require a specific diagnosis, and whose efficacy has been backed by numerous studies of children without specific mental behavioral disorders.

Food and Nutrition

Diet affects the mental state and behavior of children. Therefore, it makes sense to monitor and modify the type of diet, meal times, and amount of food that children with ADHD receive on a daily basis. Generally speaking, children with ADHD will benefit the most from fresh foods, regular meal times, and abstinence from junk food. These basic principles will help children with ADHD whose impulsiveness and distractedness often result in missed meals, disordered eating, and overeating.

As mentioned previously, children with ADHD are well known erratic eaters. Without proper parental guidance, they may not eat for hours and suddenly binge on anything they can get their hands on. This behavior towards food results in very poor physical and emotional well being of children. Parents can avoid unhealthy eating habits by setting routines or schedules for meals and snacks. Some of the ways they can ensure that such schedule is followed are by: 1) Eliminating junk food from the diet, 2) Discouraging intake of fatty and sugary foods when dining out, 3) Turning off the TV

85 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com shows that promote junk-foods, and 4) Ensuring that the daily vitamins and minerals requirements are fulfilled through a balanced diet and supplementation.

Lifestyle and Exercise

Adopting healthy lifestyle choices that includes regular exercise aids in improving a sense of overall wellbeing. Children with ADHD that follow regular exercise routine experience better outcomes to sleep habits and moods than those that does not.

Summary

Children diagnosed with ADHD experience a variety of related disorders or comorbidities. These comorbidities vary according to the prevailing type of ADHD, their severity, as well as the developmental stage of the child when they were first seen. These comorbidities are divided into two broad categories of learning disorders and psychiatric disorders. There are legal issues that need to be addressed and smoothened out prior to the start of evaluation and treatment. These issues are related to the child’s legal custody and responsibility, and legal duty by the clinician to report suspected child abuse.

Because of the complexity of the disorder, its therapy requires a multimodal approach. Psychotherapy, which includes behavioral interventions, and pharmacotherapy, which includes stimulants, are the two most effective approaches employed in the treatment and management of pediatric ADHD. The efficacy and safety of medications for ADHD have not been studied extensively in children below 6 years old, which makes the management of this particular subgroup primarily consist of psychotherapeutic interventions.

86 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Psychotherapeutic interventions are largely made up of behavioral interventions for the child, parent and teacher to help each one cope with each other’s burdens related to ADHD.

The first line of drugs used in pediatric ADHD is stimulants. They include amphetamine derivatives and methylphenidate. They demonstrate the greatest efficacy in symptom reduction. Other drugs used in the management and treatment of ADHD is atomoxetine and alpha adrenergic agonists.

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87 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 1. Attention deficit hyperactivity disorder or ADHD is

a. disease of the central nervous system. b. a neurological disorder. c. a rare brain disorder. d. a relatively common brain disorder.

2. As high as ____ of all children with ADHD have an associated learning disorder.

a. 15% b. 25% c. 30% d. 45%

3. Studies have shown that adverse side-effects of medications for ADHD may include:

a. suppression of growth b. sleep problems c. stomach upset d. All of the above

4. True or False: The role if nortriptyline in pediatric ADHD is that at higher doses it improves symptoms within several days of starting therapy.

a. True b. False

5. Atomoxetine (Strattera) is a non-stimulant medication approved for the treatment of pediatric ADHD in children between ______years old.

a. 2 to 17 b. 3 to 17 c. 6 to 17 d. None of the above

88 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 6. Learning disorders that are present in children with ADHD are

a. symptomatic of all children with ADHD. b. a comorbidity that may worsen the presence of ADHD. c. said to have a comorbid psychiatric disorder. d. due to excessive hyperactivity.

7. Hyperactivity and impulsivity and/or inattention are behaviors associated with ADHD

a. because children do not otherwise exhibit these behaviors. b. because they are present in all ADHD cases. c. because ADHD is a psychiatric disorder. d. if they persist over a long period of time.

8. Clonidine in pediatric ADHD improves excessive hyperactivity and insomnia but does not improve ______in children with ADHD.

a. impulsivity b. inattention c. anxiety d. facial tics

9. True or False: The existence of depression in children with ADHD usually occurs a few years after ADHD is diagnosed.

a. True b. False

10. To be diagnosed with ADHD, hyperactivity, impulsivity and/or inattention must continue for at least ______and be present in two environments such as home and school.

a. 3 months b. 6 months c. 1 year d. 2 years

89 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com

11. Medication therapy is the ______line of treatment and may be initiated for those school-age children with ADHD who present with ______levels of deficit.

a. second, moderate b. first, severe c. second, mild d. first moderate

12. ______is a non-stimulant medication that it increases the levels of both dopamine and norepinephrine in the postsynaptic junction.

a. Dexmethylphenidate b. Methamphetamine hydrochloride c. Atomoxetine (Strattera) d. Imipramine

13. There is moderate-to-high-level evidence that non- pharmacological interventions, like behavioral measures, ______managing the core ADHD symptoms.

a. are the only option in b. are not effective in c. can be effective in d. Answers a., and c., are correct

14. True or False: Children with ADHD will benefit the most from fresh foods, regular meal times, and abstinence from junk food.

a. True b. False

15. Children with ADHD are known mostly for their

a. dyslexia. b. neuropsychological deficits c. problems with phonetics. d. impulsivity and hyperactivity.

90 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 16. One of the most common problems and comorbid conditions in children who are diagnosed with ADHD and who also suffer from depression is

a. phobia from peer rejection. b. neuropsychological deficit. c. oppositional defiant disorder. d. suicidal ideation.

17. A child exhibiting aggression towards animals, who destroys things willfully, and who steals and violates rules is exhibiting

a. peer rejection. b. oppositional defiant disorder. c. conduct disorder. d. anxiety.

18. One of the most common psychiatric comorbidities associated with ADHD is ______, usually affecting around 60% of children with the condition.

a. phobia from peer rejection. b. oppositional defiant disorder. c. conduct disorder. d. anxiety.

19. When psychiatric and personality disorders or their associated symptoms occur in children and adolescents, children or adolescents with these symptoms are diagnosed with

a. ADHD. b. conduct or oppositional defiant disorders. c. anxiety disorder. d. depression and social isolation.

20. ______may be defined as a state of psychological and physical discomfort, which is focused on emotions, perceptions, feelings, and behavior necessary to deal with certain life issues.

a. Anxiety b. Phobia c. Hyperactivity

91 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com d. Tourette Syndrome

21. Two of the most common disorders that can be classified as neurodevelopmental and coexisting among ADHD patients are

a. depression and social isolation. b. guilt and anxiety. c. tic and Tourette Syndrome. d. impulsivity and hyperactivity.

22. True or False: Patients with ADHD are 20% less likely to start smoking cigarettes as compared to the rest of the population because of their obsessive behavior.

a. True b. False

23. ______is a psychiatric problem that is defined by the presence of intrusive thoughts.

a. Tourette Syndrome b. Conduct disorder c. Obsessive-compulsive disorder (OCD) d. Suicidal ideation

24. After a diagnosis of ADHD in a child of pre-school age has been made or confirmed, clinicians need to

a. determine the appropriate medication for the child. b. immediately refer the child to tertiary services for further care. c. contact the child's pre-school teacher regarding the diagnosis. d. advise parents/caregivers to enter a parent-training and education program.

25. The first line of treatment for school-age children with ADHD who present with moderate levels of deficit is

a. to place them under the supervision of a teacher, not parent. b. to remove them from the school classroom setting. c. the group-based parent-training and education program. d. medication therapy.

92 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com

26. School-age children and young people with severe ADHD may be given medication only with the consent

a. of the child’s teacher. b. and full cooperation of the child and parents or caregiver. c. of the child’s parents/caregiver. d. of a court.

27. True or False: Antidepressants are FDA-approved for ADHD treatment.

a. True b. False

28. The most commonly used cognitive modeling approach used for children with ADHD is

a. self-instructional training. b. negative reinforcement. c. positive reinforcement. d. the time out method.

29. ______are the first line of medications prescribed to children with ADHD.

a. Non-stimulants b. Antidepressants c. Stimulants d. Selective norepinephrine reuptake inhibitors

30. Due to their psychotropic effects, ______is often abused and is classified as a Schedule II controlled substances.

a. nortriptyline b. methylphenidate (Metadate CD) c. bupropion d. clonidine hydrochloride

31. True or False: Nortriptyline may cause life-threatening hypertension when taken together with clonidine.

a. True

93 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com b. False 32. Children who take ______may experience drowsiness, dizziness and life-threatening effects such as seizures and stroke.

a. imipramine b. atomoxetine c. nortriptyline d. bupropion

33. The FDA warns that ______must be discontinued if the patient reports jaundice since the drug is associated with the development of liver injury.

a. imipramine b. atomoxetine c. nortriptyline d. wellbutrin

34. The role of Methylphenidate in pediatric ADHD is that it corrects the hyperactivity and increases

a. the concentration of norepinephrine and dopamine. b. monoamines into the extraneuronal space. c. mood and energy. d. the attention span.

35. ______refers to the procedure wherein children earn points by doing specified desirable actions, but lose points when exhibiting undesirable behavior.

a. A response cost b. The token system c. The negative reinforcement method d. The daily report card (DRC)

36. True or False: Atomoxetine (Strattera) is the first non- stimulant approved for children diagnosed with ADHD, and its role is that it increases the levels of both dopamine and norepinephrine in the postsynaptic junction.

a. True b. False

94 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 37. ______is the only medication approved by the FDA for use in children below 6 years old.

a. Atomoxetine b. Nortriptyline c. Dextroamphetamine d. Bupropion

38. To discourage substance use and addiction, clinicians should also consider prescribing medications with no potential to misuse, such as

a. methamphetamine hydrochloride. b. atomoxetine. c. nortriptyline. d. lisdexamfetamine.

39. Social skills training use techniques from both cognitive and behavioral approaches and are conducted in

a. the home to teach self-regulation skills. b. the classroom setting. c. the environments where children have relationship problems. d. clinical settings.

40. The role of ______in pediatric ADHD is that it improves hyperactivity and insomnia symptoms, and it decreases the symptoms of Tourette syndrome.

a. methylphenidate b. chlorpromazine c. guanfacine hydrochloride d. methamphetamine hydrochloride

41. True or False: The effectiveness and safety of nortriptyline has been established in the pediatric population.

a. True b. False

95 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 42. Three key factors are helpful to clinicians in deciding the course of treatment to follow: ______, severity of symptoms and comorbid conditions.

a. self-regulation b. parent training c. side effects d. child’s age

43. Physical abuse is particularly linked to

a. externalizing problems. b. internalizing problems. c. autism. d. phobia from peer rejection.

44. Tricyclic antidepressants (TCAs) are an older class of antidepressants that

a. that have proven to be beneficial. b. many side effects. c. can cause disturbances in heart rhythm. d. All of the above

45. True or False: The etiologic roots of ADHD have genetic and neurodevelopmental origins, which means that school and social environments are not significant in the development or maintenance of ADHD.

a. True b. False

96 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com CORRECT ANSWERS:

1. Attention deficit hyperactivity disorder or ADHD is

d. a relatively common brain disorder.

“Attention deficit hyperactivity disorder or ADHD is a relatively common brain disorder that is often diagnosed at childhood and continues to adolescence and adulthood.”

2. As high as ____ of all children with ADHD have an associated learning disorder.

c. 30%

“It is important to remember that as high as 30% of all children with ADHD have an associated learning disorder of reading, writing, and/or mathematics.”

3. Studies have shown that adverse side-effects of medications for ADHD may include:

a. suppression of growth b. sleep problems c. stomach upset d. All of the above [Correct answer]

“Although pharmacological treatment is relatively safe, some patients experience significant functional impairment with psychiatric drugs. Studies have shown that adverse side-effects, such as, suppression of growth, sleep problems, tiredness, loss of appetite, stomach upset, headaches, nausea, and increases in heart rate and blood pressure can occur with long-term treatment.”

4. True or False: The role if nortriptyline in pediatric ADHD is that at higher doses it improves symptoms within several days of starting therapy.

b. False

“The role of nortriptyline in pediatric ADHD is that at lower doses it improves symptoms within several days of starting therapy; ....”

97 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 5. Atomoxetine (Strattera) is a non-stimulant medication approved for the treatment of pediatric ADHD in children between ______years old.

c. 6 to 17

“Atomoxetine (Strattera) was approved in 2002 for the treatment of pediatric ADHD in children between 6 to 17 years old.”

6. Learning disorders that are present in children with ADHD are

b. a comorbidity that may worsen the presence of ADHD.

“Comorbidities in the context of ADHD are those disorders that may worsen the presence of ADHD or cause it to have different presenting symptoms. Comorbidities are divided into two broad categories of learning disorders and psychiatric disorders.”

7. Hyperactivity and impulsivity and/or inattention are behaviors associated with ADHD

d. if they persist over a long period of time.

“Hyperactivity and impulsivity and/or inattention occur in children affected with ADHD. While these are behaviors that many children exhibit at some time during their childhood, in children with ADHD, these behavioral problems persist over a long period of time.”

8. Clonidine in pediatric ADHD improves excessive hyperactivity and insomnia but does not improve ______in children with ADHD.

b. inattention

“The role of clonidine in pediatric ADHD is that its another alpha-2 agonist used as an adjunctive treatment. It improves excessive hyperactivity and insomnia but does not improve inattention in children with ADHD. It decreases facial and vocal tics and has a positve side effect on defiant behavior.”

98 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 9. True or False: The existence of depression in children with ADHD usually occurs a few years after ADHD is diagnosed.

a. True

“The existence of depression in children with ADHD usually occurs a few years after ADHD is diagnosed. It is usually a result of the constant battle with stressors in the immediate environment, which may include peers, bullying, and academic pressures to perform well.”

10. To be diagnosed with ADHD, hyperactivity, impulsivity and/or inattention must continue for at least ______and be present in two environments such as home and school.

b. 6 months

“To be diagnosed with ADHD, such behaviors must continue for at least 6 months and be present in two environments such as home and school.”

11. Medication therapy is the ______line of treatment and may be initiated for those school-age children with ADHD who present with ______levels of deficit.

a. second, moderate

“Medication therapy is the second line of treatment and may be initiated for those school-age children with ADHD who present with moderate levels of deficit….”

12. ______is a non-stimulant medication that it increases the levels of both dopamine and norepinephrine in the postsynaptic junction.

c. Atomoxetine (Strattera)

“Atomoxetine (Strattera) was approved in 2002 for the treatment of pediatric ADHD in children between 6 to 17 years old. It is the first non-stimulant approved for children diagnosed with ADHD, and its role is that it increases the levels of both dopamine and norepinephrine in the postsynaptic junction.”

99 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 13. There is moderate-to-high-level evidence that non- pharmacological interventions, like behavioral measures, ______managing the core ADHD symptoms.

c. can be effective in

“There is moderate-to-high-level evidence suggesting that non- pharmacological interventions, like behavioral measures, can be effective in managing the core ADHD symptoms, conduct disorders, social skills, self-efficacy, and emotional outcomes at 6 months follow-up.”

14. True or False: Children with ADHD will benefit the most from fresh foods, regular meal times, and abstinence from junk food.

a. True

“Generally speaking, children with ADHD will benefit the most from fresh foods, regular meal times, and abstinence from junk food.”

15. Children with ADHD are known mostly for their

d. impulsivity and hyperactivity.

“Children with ADHD are known mostly for their impulsivity and hyperactivity.”

16. One of the most common problems and comorbid conditions in children who are diagnosed with ADHD and who also suffer from depression is

d. suicidal ideation.

“Suicidal ideation is one of the most common problems and comorbid conditions in children who are diagnosed with ADHD and also suffering from depression.”

17. A child exhibiting aggression towards animals, who destroys things willfully, and who steals and violates rules is exhibiting

c. conduct disorder.

“The main symptom associated with conduct disorder is the apparent aggression towards animals or even people, the habit to

100 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com destroy things willfully, engage in violation of rules both in school and in society, and stealing other peoples’ belongings.”

18. One of the most common psychiatric comorbidities associated with ADHD is ______, usually affecting around 60% of children with the condition.

b. oppositional defiant disorder.

“One of the most common psychiatric comorbidities associated with ADHD is oppositional defiant disorder (ODD), usually affecting around 60% of children with the condition.”

19. When psychiatric and personality disorders or their associated symptoms occur in children and adolescents, children or adolescents with these symptoms are diagnosed with

b. conduct or oppositional defiant disorders.

“The presence of psychiatric and personality disorders is usually acknowledged in adult ADHD patients. However, when these conditions or their associated symptoms occur in children and adolescents, they are simply put in the category of conduct or oppositional defiant disorders.”

20. ______may be defined as a state of psychological and physical discomfort, which is focused on emotions, perceptions, feelings, and behavior necessary to deal with certain life issues.

a. Anxiety

“Anxiety may be defined as a state of psychological and physical discomfort, which is focused on emotions, perceptions, feelings, and behavior necessary to deal with certain life issues.”

21. Two of the most common disorders that can be classified as neurodevelopmental and coexisting among ADHD patients are

c. tic and Tourette Syndrome.

“Two of the most common disorders that can be classified as neurodevelopmental and coexisting among ADHD patients are tic and Tourette Syndrome.”

101 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 22. True or False: Patients with ADHD are 20% less likely to start smoking cigarettes as compared to the rest of the population because of their obsessive behavior.

b. False

“… patients with ADHD are more prone to start smoking cigarettes as compared to the rest of the population by at least 20%.”

23. ______is a psychiatric problem that is defined by the presence of intrusive thoughts.

c. Obsessive-compulsive disorder (OCD)

“Obsessive-compulsive disorder (OCD) is a psychiatric problem that is defined by the presence of intrusive thoughts.”

24. After a diagnosis of ADHD in a child of pre-school age has been made or confirmed, clinicians need to

d. advise parents/caregivers to enter a parent-training and education program.

“Medication therapy is not recommended for pre-school children with ADHD. After a diagnosis of ADHD in a child of pre-school age has been made or confirmed, clinicians need to contact the parents or caregivers and obtain their consent to initiate contact with the child's pre-school teacher to explain the diagnosis and severity of symptoms and deficits, interventional plan, and special educational needs. Also, following the diagnosis, clinicians should advise parents or caregivers of pre-school children with ADHD to enter a parent-training and education program. On the other hand, if the parent-training and education programs and other treatment interventions have not been found to be effective to manage ADHD symptoms and associated deficits in pre-school children, clinicians must consider giving them a referral to tertiary services for further care.”

102 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 25. The first line of treatment for school-age children with ADHD who present with moderate levels of deficit is

c. the group-based parent-training and education program.

“Medication therapy is the second line of treatment and may be initiated for those school-age children with ADHD who present with moderate levels of deficit…. After a diagnosis of ADHD in a school- age child or young person has been made or confirmed, clinicians need to obtain the consent of parents or caregivers to contact the child or young person's teacher to discuss the following the diagnosis and severity of symptoms and deficit, interventional plan and special educational needs. It would be very beneficial to the family and the school systems if school-age children with ADHD are placed under the supervision of teachers who have received training about ADHD and its management so they can receive adequate behavioral interventions in the classroom.”

26. School-age children and young people with severe ADHD may be given medication only with the consent

b. and full cooperation of the child and parents or caregiver.

“When symptoms of ADHD and other associated deficits are severe, the first-line treatment for school-age children and young people is medication therapy. Medication therapy requires the consent and full cooperation of the child, parents or caregiver. If either one refuses it the clinician should advise them of the benefits and superiority of medication therapy. If it is still not accepted, a group parent-training and education program should be offered.”

27. True or False: Antidepressants are FDA-approved for ADHD treatment.

b. False

“Antidepressants are sometimes used for ADHD as off-label drugs. These drugs have not received FDA-approval but are still used sometimes by clinicians as adjuncts in ADHD treatment.”

103 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 28. The most commonly used cognitive modeling approach used for children with ADHD is

a. self-instructional training.

“Self-instructional training is the most commonly used cognitive modeling approach.”

29. ______are the first line of medications prescribed to children with ADHD.

c. Stimulants

“Stimulants are the first line of medications prescribed to children with ADHD.”

30. Due to their psychotropic effects, ______is often abused and is classified as a Schedule II controlled substances.

b. methylphenidate (Metadate CD)

“Due to their psychotropic effects, methylphenidate (Metadate CD) is often abused and is classified as a Schedule II controlled substances. Its sale and administration without valid prescription is illegal.”

31. True or False: Nortriptyline may cause life-threatening hypertension when taken together with clonidine.

a. True

“Nortriptyline may cause life-threatening hypertension when taken together with clonidine.”

32. Children who take ______may experience drowsiness, dizziness and life-threatening effects such as seizures and stroke.

a. imipramine

“Imipramine: ... Children may experience drowsiness, dizziness and life-threatening effects such as seizures and stroke.”

104 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 33. The FDA warns that ______must be discontinued if the patient reports jaundice since the drug is associated with the development of liver injury.

b. atomoxetine

“The FDA warns that atomoxetine must be discontinued if the patient reports jaundice since the drug is associated with the development of liver injury.”

34. The role of Methylphenidate in pediatric ADHD is that it corrects the hyperactivity and increases

d. the attention span.

“The role of Methylphenidate in pediatric ADHD is that it corrects the hyperactivity and increases the attention span.”

35. ______refers to the procedure wherein children earn points by doing specified desirable actions, but lose points when exhibiting undesirable behavior.

a. A response cost

“A response cost refers to the procedure wherein children earn points by doing specified desirable actions, but lose points when exhibiting undesirable behavior.”

36. True or False: Atomoxetine (Strattera) is the first non-stimulant approved for children diagnosed with ADHD, and its role is that it increases the levels of both dopamine and norepinephrine in the postsynaptic junction.

a. True

“Atomoxetine (Strattera) is the first non-stimulant approved for children diagnosed with ADHD, and its role is that it increases the levels of both dopamine and norepinephrine in the postsynaptic junction.”

105 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 37. ______is the only medication approved by the FDA for use in children below 6 years old.

c. Dextroamphetamine

“Dextroamphetamine is the only medication approved by the FDA for use in children below 6 years old.”

38. To discourage substance use and addiction, clinicians should also consider prescribing medications with no potential to misuse, such as

b. atomoxetine.

“To discourage substance use and addiction, clinicians should also consider prescribing medications with no potential to misuse, such as atomoxetine, extended-release guanfacine, and extended- release clonidine; or, stimulant medications with less abuse potential, such as lisdexamfetamine, dermal methylphenidate, or OROS methylphenidate.”

39. Social skills training use techniques from both cognitive and behavioral approaches and are conducted in

d. clinical settings.

“Social skills training use techniques from both cognitive and behavioral approaches and are conducted in groups…. It is conducted in clinical settings, away from the environments where these children have relationship problems and are lacking social validity.”

40. The role of ______in pediatric ADHD is that it improves hyperactivity and insomnia symptoms. It decreases the symptoms of Tourette syndrome.

c. guanfacine hydrochloride

“The role of guanfacine hydrochloride in pediatric ADHD is that it improves hyperactivity and insomnia symptoms. It decreases the symptoms of Tourette syndrome.”

106 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 41. True or False: The effectiveness and safety of nortriptyline has been established in the pediatric population.

b. False

“The effectiveness and safety of nortriptyline has not been established in the pediatric population.”

42. Three key factors are helpful to clinicians in deciding the course of treatment to follow: ______, severity of symptoms and comorbid conditions.

d. child’s age

“Behavior management (psychotherapy), and medication management (pharmacotherapy) are discussed in detail later on; however, certain criteria are first raised here that are helpful to clinicians deciding the course of treatment to follow based on three key factors of age, severity of symptoms and comorbid conditions.”

43. Physical abuse is particularly linked to

a. externalizing problems.

“Physical abuse is particularly linked to externalizing problems while sexual abuse is linked to childhood post-traumatic stress disorder symptoms and, later on, internalizing problems.”

44. Tricyclic antidepressants (TCAs) are an older class of antidepressants that

a. that have proven to be beneficial. b. many side effects. c. can cause disturbances in heart rhythm. d. All of the above [Correct answer]

“Tricyclic antidepressants (TCAs) ... are an older class of antidepressants that have proven to be beneficial but also loaded with many side effects. These drugs can cause disturbances in heart rhythm which is why an electrocardiogram to rule out arrhythmias is necessary before starting the treatment.”

107 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 45. True or False: The etiologic roots of ADHD have genetic and neurodevelopmental origins, which means that school and social environments are not significant in the development or maintenance of ADHD.

b. False

“Several studies in recent years suggest the etiologic roots of ADHD have genetic and neurodevelopmental origins. It does not mean, however, that school and social environments are not significant in the development or maintenance of ADHD.”

References Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. [This is Part 2 of a 2 Part series on Pediatric ADHD.]

1. National Institute of Mental Health. Attention Deficit Hyperactivity Disorder. Retrieved from http://www.nimh.nih.gov/health/publications/attention-deficit- hyperactivity-disorder/index.shtml 2. Crichton, A. (1798). An inquiry into the nature and origin of mental derangement: comprehending a concise system of the physiology and pathology of the human mind and a history of the passions and their effects. Cadell, T. Jr, Davies, W., London [Reprint: Crichton, A. (2008). An inquiry into the nature and origin of mental derangement. On attention and its diseases. Journal of Attention Disorder 12:200–204. 3. Bukstein, O. (2016). Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis. Up To Date. Retrieved online at https://www.uptodate.com/contents/attention-deficit-hyperactivity- disorder-in-adults-epidemiology-pathogenesis-clinical-features-course- assessment-and- diagnosis?source=search_result&search=adhd&selectedTitle=2~150 4. Diagnostic and statistical manual of mental disorders (DSM-II), 4th edn Text revision. Washington DC: American Psychiatric Association; 2000.

108 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 5. Still, G.F. (1902). Some abnormal psychical conditions in children: the Goulstonian lectures. Lancet, 1:1008–1012. 6. Brown, W.A., Bradley, Charles, M.D. (1998). American Journal of Psychiatry, 155:968. 7. Gross, M.D. (1995). Origin of stimulant use for treatment of attention deficit disorder. American Journal of Psychiatry, 152:298–299. 8. Centers for Disease Control and Prevention. (2010). Increasing Prevalence of Parent-Reported Attention-Deficit/Hyperactivity Disorder Among Children --- United States, 2003 and 2007. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5944a3.htm 9. Krull, K.R. (2016). Pharmacology of drugs used to treat attention deficit hyperactivity disorder in children and adolescents. Up To Date. Retrieved online at https://www.uptodate.com/contents/pharmacology-of-drugs-used-to- treat-attention-deficit-hyperactivity-disorder-in-children-and- adolescents?source=search_result&search=adhd%20and%20catechola mines&selectedTitle=4~150 10. Spinelli, S., Joel, S., Nelson, T.E., Vasa, R.A., Pekar, J.J., Mostofsky, S.H. (2011). Different neural patterns are associated with trials preceding inhibitory errors in children with and without attention- deficit/hyperactivity disorder. Journal of American Academy of Child and Adolescent Psychiatry, 50(7):705-715.e3. 11. Ducharme, S., Hudziak, J.J., Botteron, K.N., Albaugh, M.D., Nguyen, T.V., Karama, S. (2012). Decreased regional cortical thickness and thinning rate are associated with inattention symptoms in healthy children. Journal of American Academy of Child and Adolescent Psychiatry, 51(1):18-27.e2. 12. Krull, K. (2016). Attention deficit hyperactivity disorder in children and adolescents: Epidemiology and pathogenesis. Up To Date. Retrieved online at https://www.uptodate.com/contents/attention-deficit- hyperactivity-disorder-in-children-and-adolescents-epidemiology-and- pathogenesis?source=search_result&search=adhd%20and%20twins&s electedTitle=2~150. 13. International Classification of Diseases (ICD). World Health Organization. Retrieved 23 November 2010. 14. Holden, S., et al. (2013). The prevalence and incidence, resource use and financial costs of treating people with attention deficit/hyperactivity disorder (ADHD) in the United Kingdom (1998 to 2010). Child Adolesc Psychiatry Ment Health. 2013; 7: 34. Published online 2013 Oct 11. doi:10.1186/1753-2000-7-34. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3856565/. 15. National Resource Center on ADHD (2016). General Prevalence. Retrieved online at http://www.chadd.org/understanding-adhd/about- adhd/data-and-statistics/general-prevalence.aspx.

109 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 16. Bruchmuller, Katrin; Margraf, Schneider (2012). "Is ADHD diagnosed in accord with diagnostic criteria? Overdiagnosis and influence of client gender on diagnosis". Journal of Consulting and Clinical Psychology 80: 128–138. doi:10.1037/a0026582. 17. Krull, K. (2016). Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis. Up To Date. Retrieved online at https://www.uptodate.com/contents/attention- deficit-hyperactivity-disorder-in-children-and-adolescents-overview-of- treatment-and- prognosis?source=search_result&search=ADHD%20and%20inattentiv e&selectedTitle=1~150. 18. Mendiola, Lee MD (2013). Predominantly Hyperactive Impulsive Type. http://leemendiolamd.com/predominantly_hyperactive_impulsivetype. html 19. Lane, K. (2007). Academic Performance of Students with Emotional and Behavioral Disorders Served in a Self-Contained Setting. Journal of Behavioral Education 17:1 (March 2008), pp. 43–62; doi: 10.1007/s10864-007-9050-1 Copyright © 2007 Springer Science+Business Media, Inc. Retrieved online at http://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1044&cont ext=specedfacpub. 20. Mikami AY (June 2010). "The importance of friendship for youth with attention-deficit/hyperactivity disorder". Clin Child Fam Psychol Rev 13 (2): 181–98. doi:10.1007/s10567-010-0067-y. PMC 2921569. PMID 20490677 21. Racine, MB.; Majnemer, A.; Shevell, M.; Snider, L. (Apr 2008). "Handwriting performance in children with attention deficit hyperactivity disorder (ADHD)". J Child Neurol 23 (4): 399–406. doi:10.1177/0883073807309244. PMID 18401033 22. Bellani, M.; Moretti, A.; Perlini, C.; Brambilla, P. (Dec 2011). "Language disturbances in ADHD". Epidemiol Psychiatr Sci 20 (4): 311–5. doi:10.1017/S2045796011000527. PMID 22201208. 23. Walitza S, Drechsler R, Ball J (August 2012). "[The school child with ADHD]". Ther Umsch (in German) 69 (8): 467–73. doi:10.1024/0040- 5930/a000316. PMID 22851461. 24. Wender, P. H. (2000). Adult manifestations of attention deficit/hyperactivity disorder. In B. J. Sadock & V. A. Sadock (Eds.), Comprehensive textbook of psychiatry (7th ed., pp. 2688–2692). Philadelphia: Lippincott Williams & Wilkins. 25. Dobie, C (2012). Diagnosis and management of attention deficit hyperactivity disorder in primary care for school-age children and adolescents. Institute for Clinical Systems Improvement. p. 79.

110 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 26. National Institute of Mental Health (2008). "Attention Deficit Hyperactivity Disorder (ADHD)". United States: National Institutes of Health. 27. Black, D (2016). Treatment of antisocial personality disorder. Up To Date. Retrieved online at https://www.uptodate.com/contents/treatment-of-antisocial- personality- disorder?source=search_result&search=conduct%20disorders&selecte dTitle=4~59. 28. Pardini, D.A., Frick, P.J., & Moffitt, T.E. (2010) Building an Evidence base for DSM-5 Conceptualizations of Oppositional Defiant Disorder and Conduct Disorder: Introduction to the Special Section. Journal of Abnormal Psychology. 119(4) 683-688 29. Millichap, J.G. (2010). "Definition and History of ADHD". Attention Deficit Hyperactivity Disorder Handbook. Springer Verlag Gmbh. pp. 2–3. ISBN 978-1-4419-1409-5. 30. American Psychiatric Association (2013). Attention Deficit/Hyperactivity Disorder. Retrieved online at www.dsm5.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM- 5-ADHD.pdf. 31. Willcutt, E.G., Hartung, C.M., Lahey, B.B., Loney, J., & Pelham, W.E. (1999). Utility of Behavior Ratings by Examiners During Assessments of Preschool Children With Attention-Deficit/Hyperactivity Disorder. Journal of Abnormal Child Psychology, 27:463-472. 32. Petty, C.R., Monuteaux, M.C., Mick, E., Hughes, S., Small, J., Faraone, S.V., & Biederman, J. (2009). Parsing the familiality of oppositional defiant disorder from that of conduct disorder: A familial risk analysis. Journal of Psychiatric Research, 43:345-352. 33. Souza, I., Pinheiro, M.A., & Mattos, P. (2005). Anxiety disorders in an attention- deficit/hyperactivity disorder clinical sample. Arquivos de Neuro-psiquiatria, 63:407-409. 34. Fusar-Poli, P., Rubia, K., Rossi, G., Sartori, G., & Balottin, U. (March 2012). "Striatal dopamine transporter alterations in ADHD: pathophysiology or adaptation to psychostimulants? A meta-analysis". American Journal of Psychiatry, 169 (3): 264–72. doi:10.1176/appi.ajp.2011.11060940. PMID 22294258 35. Cortese, S. (2012). "The neurobiology and genetics of Attention- Deficit/Hyperactivity Disorder (ADHD): what every clinician should know". European Journal of Paediatric Neurology, 16(5): 422–33. doi:10.1016/j.ejpn.2012.01.009. PMID 22306277 36. Skirbekk, B., Hansen, B.H., Oerbeck, B., & Kristensen, H. (2011). "The Relationship Between Sluggish Cognitive Tempo, Subtypes of Attention-Deficit/Hyperactivity Disorder, and Anxiety Disorders".

111 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com Journal of Abnormal Child Psychology 39 (4): 513–525. doi:10.1007/s10802-011-9488-4. ISSN 0091-0627. 37. Sheldon, S. (2016). Medical disorders resulting in problem sleeplessness in children. Up To Date. Retrieved online at https://www.uptodate.com/contents/medical-disorders-resulting-in- problem-sleeplessness-in- children?source=search_result&search=gaba%20and%20adhd&selecte dTitle=1~150. 38. Nigg, J.T., Goldsmith, H.H., Sachek, J. (2004). Temperament and attention deficit hyperactivity disorder: the development of a multiple pathway model. Journal of Clinical Child and Adolescent Psychology, 33(1):42-53 39. McMillian, J et al. (2006). Oski's Pediatrics: Principles And Practice, Fourth Edition, Plus Integrated Content Website. Lippincott Williams & Wilkins. ISBN-13: 9780781738941. 40. American psychiatric association: Diagnostic and statistical manual of mental disorders. (2013). Attention-deficit/hyperactivity disorder (ADHD) Symptoms and diagnosis. Washington DC: Center for disease control and prevention. 41. Austin, M., Reiss, N. S., & Burgdorf, L. (2013). ADHD testing- Intelligence and achievement. Retrieved from Mental health care: http://www.mhcinc.org/poc/view_doc.php?type=doc&id=13859 42. Sargeant, J. (2005). Modeling Attention-Deficit/Hyperactivity Disorder: A Critical Appraisal of the Cognitive-Energetic Model. University of Amsterdam. 2005 Society of Biological Psychiatry. Published by Elsevier Inc. 43. Barkley, R. (2014). Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 4th Ed. Russell A. Barkley, Ed. (2014) New York: The Guilford Press. 44. Booth, J. H. (2013). Connor's rating scales revised. Retrieved from Encyclopedia of mental disorders: http://www.minddisorders.com/Br- Del/Conners-Rating-Scales-Revised.html 45. Brown, T. (2001). Brown ADD rating scales for children, adolescents and adults. San Antonio: Psych Corporation/Pearson. 46. Brown, T., Brams, M., Gao, J., Gasior, M., & Childress, A. (2010). Open-label administration of lisdexyamfetamine dimesylate immproves executive function impairments and symptoms of attention- deficit/hyperactivity disorder in adults. Postgraduate medicine, 122(5), 7-17. 47. Busch, B., Biederman, J., Cohen, G. L., Sayer, J. M., Monuteaux, M. C., Mick, E., & Faraone, S. V. (2002). Correlates of ADHD among children in pediatric and psychiatric clinics. Psychiatric services, 53(9). 48. Conners, K. C. (2008). Conners rating scales -3 (3rd ed.). Camberwell, Australia: Multi Health systems.

112 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 49. Conners, K. C. (n.d.). Conners continuous performance test II. MHS. 50. Dobie, C., Donald, W., Hanson, M., Heim, C., HUxsahl, J., Karasov, C., & Steiner, L. (2012). Diagnosis and management of attention deficit hyperactivity disorder in primary care for school age children and adolescents. Institute for Clinical systems improvement. 51. DuPaul, G. J. (2004). ADHD identification and assessment: basic guidelines for educators. National association of school psychologists, S8-17-S8-20. 52. Editorial staff at health communities. (2013). First brain wave test to assess ADHD. Retrieved from healthcommunities.com: http://www.healthcommunities.com/adhd/neuropsychiatric-eeg- based-assessment-aid-neba.shtml 53. Katusic, M. Z., Voigt, R. G., Coligan, R. C., Weaver, A. L., Homan, K. J., & Barbaresi, W. J. (2011). Attention-deficit/hyperactivity disorder in children with high IQ: Results from a population based study. Journal of developmental and behavioral pediatrics, 32(2), 103-109. 54. Krull, K. R. (2013). Attention deficit hyperactivity disorder in children and adolescents: Clinical features and evaluation. Retrieved from UpToDate: http://www.uptodate.com/contents/attention-deficit- hyperactivity-disorder-in-children-and-adolescents-clinical-features- and-evaluation 55. McQuade, J. D., Tomb, M., Hoza, B., Waschbusch, D. A., hurt, E. A., & Vaughn, A. J. (2011). Cognitive deficits and positively biased self- perceptions in children with ADHD. Journal of abnormal child psychology, 39(2), 307-319. 56. Nadeau, K., Littman, E., & Quinn, P. (1999). Understanding girls with ADHD. Maryland: Advantage books, Silver spring. 57. Pineda, D. A., Puerta, I. C., Aguirre, D. C., Garcia-Barrera, M. A., & Kamphaus, R. W. (2007). The role of neuropsychologic tests in the diagnosis of attention deficit hyperactivity disorder. Pediatric Neurology, 36(6), 373-381. 58. Rivers, S. (2013). FDA permits marketing of first brain wave test to help assess children and teens for ADHD. Retrieved from FDA.gov: http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm 360811.htm 59. Ross-Kidder, K. (n.d.). LD/ADHD Psycho/Educational Assessment. Retrieved from EPCS: http://home.gwu.edu/~kkid/testing.html 60. Sanchez, E. Z., Martinez-Cortes, J., Rio-Carlos, Y., Martinez-Wbaldo, M. C., & Poblano, A. (2010). Executive dysfunction screening and intellectual coefficient measurement in children with attention deficit hyperactivity disorder. Arquivos de Neuro-Psiquiatria, 68(4), 545-549. 61. Sandford, J. A., & Turner, A. (2004). Integrated visual and auditory continuous performance test. Retrieved from

113 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com biofeedbackonternational: http://www.biofeedbackinternational.com/smart/iva.htm 62. Sivonen, M. (2006). DyAdd-dyslexia and attention deficit disorder. Siltavuorenpenger: University of Helsinki. Retrieved from http://www.helsinki.fi/psykologia/english/introduction/location.htm 63. The ADD/ADHD support. (2013). ADHD Connors test. Retrieved from The ADD/ADHD support site: http://www.attentiondeficit-add- adhd.com/adhd-connors-test.htm 64. Tinius, T. P. (2003). The intermediate visual and auditory continuous performance test as a neuropsychological measure. Archives of clinical neuropsychology, 18(2), 199-214. 65. Tripp, G., & Schaughency, E. C. (2006). Parent and teacher rating scales in the evaluation of attention - deficit hyperactivity disorder: contribution ti diagnosis and differential diagnosis in clinically referred children. Journal of development and behavioral pediatrics, 27(3), 209-218. 66. Weschler, D. (2005). Weschler individual achievement test (2nd ed.). London: The psychological Corp. 67. White, N. J., Hutchens, T. A., & Lubar, J. F. (2005). Quantitative EEG assessment during neuropsychological task performance in adults with attention deficit hyperactivity disorder. Journal of adult development, 12(2-3), 113-121. 68. Koerth-Baker, M. “The Not-So-Hidden Cause Behind the A.D.H.D. Epidemic”. New York Times, October 15, 2013. 69. National Institute of Health and Care Excellence. (2008). Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. Retrieved from http://egap.evidence.nhs.uk/attention-deficit-hyperactivity-disorder- cg72/guidance#identification-pre-diagnostic-intervention-in-the- community-and-referral-to-secondary-services. 70. Sleator, E. K., & Ullmann, R. K. (1981). Can the physician diagnose hyperactivity in the office? Pediatrics, 67, 13-17. 71. Patel, N., Patel, M., & Patel, H. (2012). ADHD and Comorbid Conditions, Current Directions in ADHD and Its Treatment, Dr. Jill M. Norvilitis (Ed.), ISBN: 978-953-307-868-7 72. Sadock, B.J., & Sadock, V.A. (2009). Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 9th ed. New York: Lippincott Williams & Wilkins, 3560 – 3579. 73. Masi, G., Toni, C., Pergni, G., Travierso, M.C., Millepiedi, S., Mucci, M., & Akiskal, H.S. (2003). Externalizing disorders in consecutively referred children and adolescents with bipolar disorder. Comprehensive Psychiatry, 44: 184-189. 74. Barkley, R.A. (2006). ADHD, a hand book for diagnosis and treatment, Guiford Pres, New York.

114 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 75. National Institute for Health Care and Excellence. (2008). NICE Clinical Guidelines on Attention deficit hyperactivity disorder: Diagnosis and management of ADHD in children, young people and adults. Retrieved from http://egap.evidence.nhs.uk/attention-deficit-hyperactivity- disorder-cg72/guidance#ftn.footnote_7 76. Bilici, M., Yildirim, F., & Kandil, S. (2004). Double-blind, placebo- controlled study of zinc sulfate in the treatment of attention deficit hyperactivity disorder. Progress in Neuropsychopharmacology and Biological Psychiatry, 28:181. [PubMed] 77. Bradshaw, C.P., Mitchell, M.M., & Leaf, P.J. (2010). Examining the effects of school wide positive behavioral interventions and supports on student outcomes. Journal of Positive Behaviour Interventions, 12:133. 78. Camp, B., & Bash, M.A. (1981). Think Aloud: Increasing Social and Cognitive Skills - A Problem-Solving Program for Children: Primary Level. Champaign, Illinois: Research Press. 79. DuPaul, G.J., Helwig, J.R., & Slay, P.M. (2011). Classroom interventions for attention and hyperactivity. In: Bray MA, Kehle TJ, editors. The Oxford handbook of school psychology. New York, NY: Oxford University Press; p. 428. 80. DuPaul, G.J., & Stoner, G. (2003). ADHD in the Schools: Assessment and Intervention Strategies. 2. New York: Guilford. 81. DuPaul, G.J., & Stoner, G. (2010). Interventions for attention deficit hyperactivity disorder. In: Shinn MR, Walker HM, Stoner G, editors. Interventions for achievement and behavior problems in a three-tiered model including RTI. Bethesda, MD: National Association of School Psychologists; p. 825. 82. Evans, S., Pelham, E., & Grudberg, M. (1995). The efficacy of note taking to improve behavior and comprehension of students with attention-deficit hyperactivity disorder. Exceptionality, 5:1. 83. Epstein, J.N., & Weiss, M. (2012). Assessing treatment outcomes in Attention-Deficit/Hyperactivity Disorder: A narrative review. Primary Care Companion CNS Disorder, 14(6): PCC.11r01336. 2012. doi: 10.4088/PCC.11r01336. 84. Fabiano, G.A., Vujnovic, R.K., & Pelham, W.E. (2010). Enhancing the effectiveness of special education programming for children with attention deficit hyperactivity disorder using a daily report card. School Psychology Review, 39:219. 85. Gittleman, R., Abikoff, H., Pollack, E. (1980). A Controlled Trial of Behaviour Modification and Methyphenidate in Hyperactive Children In: Whelen C, Henken B (eds). Hyperactive Children: The Social Ecology of Identification and Treatment. New York: Academic Press.

115 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 86. Kendall, P., & Finch, A. (1978). A cognitive-behavioural treatment for impulsivity: a group comparison study. Journal of Consulting and Clinical Psychology, 46:110–118. [PubMed] 87. Mautone, J.A., DuPaul, G.J., & Jitendra, A.K. (2005). The effects of computer-assisted instruction on the mathematics performance and classroom behaviour of children with ADHD. Journal of Attention Disorders, 9:301. [PubMed] 88. National Collaborating Centre for Mental Health (UK). Attention Deficit Hyperactivity Disorder: Diagnosis and Management of ADHD in Children, Young People and Adults. Leicester (UK): British Psychological Society (UK); 2009. (NICE Clinical Guidelines, No. 72.) 7, PSYCHOLOGICAL INTERVENTIONS AND PARENT TRAINING. Available from: http://www.ncbi.nlm.nih.gov/books/NBK53656/ 89. Tresco, K.E., Lefler, E.K., & Power, T.J. (2010). Psychosocial Interventions to Improve the School Performance of Students with Attention-Deficit/Hyperactivity Disorder. Mind & Brain, the Journal of Psychiatry, 1:69. [PMC free article] [PubMed] 90. Vaughan, B.S., March, J.S., & Kratochvil, C.J. (2011). Evidence-based pharmacological treatment of ADHD. International Journal of Neuropsychopharmacology, 1-13. 91. Zablocki, E. (2011). For ADHD kids, parent training should be initial intervention. Managed Health Care Executive. Retrieved from http://managedhealthcareexecutive.modernmedicine.com/managed- healthcare-executive/news/adhd-kids-parent-training-should-be- initial-intervention#sthash.hN4ZCQ8y.dpuf 92. Agency for Healthcare Research and Quality (2011). Report Finds Parent Training Effective for Treating Young Children With ADHD. Retrieved from http://www.ahrq.gov/news/newsroom/press- releases/2011/adhd.html 93. Nursing 2016 Drug Handbook (2016). Lippincott William & Wilkins Springhouse Nurse’s Drug Guide 2016 (36th ed.). Ambler, PA: Lippincott William & Wilkins 94. Methylphenidate Hydrochloride Tablet (2013). Retrieved from http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=981a2ad8- 33f7-4678-9162-9df9685bd4a6#nlm34071-1 95. Dextroamphetamine – Compound Summary (n.d.). Retrieved from http://pubchem.ncbi.nlm.nih.gov/summary/summary.cgi?cid=5826 96. Strattera (atomoxetine hydrochloride) Capsule (2013). Retrieved from http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=309de5 76-c318-404a-bc15-660c2b1876fb#section-8.4 97. Atomoxetine - Compound Summary (n.d.). Retrieved from http://pubchem.ncbi.nlm.nih.gov/summary/summary.cgi?cid=54840

116 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com 98. Catapres (clonidine hydrochloride) Tablet (2012). Retrieved from http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=d7f569 dc-6bed-42dc-9bec-940a9e6b090d 99. University of Maryland-Medical Center (2013). Attention Deficit Hyperactivity Disorder. Retrieved from http://umm.edu/health/medical/reports/articles/attention-deficit- hyperactivity-disorder 100. Attention-Deficit/Hyperactivity Disorder (ADHD) (2013). Retrieved from http://www.cdc.gov/ncbddd/adhd/treatment.html 101. Mayo Clinic Staff. (2016). Attention-deficit/hyperactivity disorder (ADHD) in children. Retrieved from http://www.mayoclinic.org/diseases-conditions/adhd/diagnosis- treatment/treatment/txc-20196197 102. von Hahn, L. Eric (2016). Specific learning disabilities in children: Clinical features. Up To Date. Retrieved online at https://www.uptodate.com/contents/specific-learning-disabilities-in- children-clinical- features?source=see_link§ionName=Comorbidities&anchor=H18# H18. 103. Bridgemohan, C. (2016). The gifted child: Characteristics and identification. Up To Date. Retrieved online at https://www.uptodate.com/contents/the-gifted-child-characteristics- and- identification?source=search_result&search=hyperactivity%20and%20 learning%20difficulties&selectedTitle=7~150. 104. Hamilton, S. Sutton (2016). Reading difficulty in children: Clinical features and evaluation. Up To Date. Retreived online at https://www.uptodate.com/contents/reading-difficulty-in-children- clinical-features-and- evaluation?source=search_result&search=dyslexia&selectedTitle=1~2 4. 105. Thaper, A., et al. (2012). Depression in adolescence. Lancet. 2012 Mar 17; 379(9820): 1056–1067. Published online 2012 Feb 2. doi: 10.1016/S0140-6736(11)60871-4. Retrieved online at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3488279/ 106. De la Iglesia, M. and Sixto Oliver, José (2015). Risk Factors for Depression in Children and Adolescents with High Functioning Autism Spectrum Disorders. Scientific World Journal. 2015: 127853. Published online 2015 Aug 25. doi:10.1155/2015/127853. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562099/. 107. Suppes, T. and Cosgrove, V. (2016). Bipolar disorder in adults: Clinical features. Up To Date. Retrieved online at https://www.uptodate.com/contents/bipolar-disorder-in-adults- clinical-

117 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com features?source=search_result&search=ADHD%20and%20bipolar&sel ectedTitle=1~150. 108. Rosenberg, D. (2016). Obsessive-compulsive disorder in children and adolescents: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. Up To Date. https://www.uptodate.com/contents/obsessive-compulsive-disorder- in-children-and-adolescents-epidemiology-pathogenesis-clinical- manifestations-course-assessment-and- diagnosis?source=search_result&search=adhd%20and%20obsessive% 20compulsive&selectedTitle=1~150. 109. Middleman, A., et al. (2016). Confidentiality in adolescent health care. Up To Date. Retrieved online at https://www.uptodate.com/contents/confidentiality-in-adolescent- health- care?source=search_result&search=adhd%20and%20legal%20issues& selectedTitle=4~150. 110. Boos, S.C. (2016). Physical child abuse: Recognition. Up To Date. Retrieved online at https://www.uptodate.com/contents/physical- child-abuse- recognition?source=search_result&search=adhd%20and%20child%20 abuse&selectedTitle=2~150. 111. Huang, P., et al. (2016). Promoting safety in children with disabilities. Up To Date. Retrieved online at https://www.uptodate.com/contents/promoting-safety-in-children- with- disabilities?source=search_result&search=adhd%20and%20child%20a buse&selectedTitle=3~150 112. Cohen, J. (2016). Psychosocial treatment of posttraumatic stress disorder in children and adolescents. Up To Date. https://www.uptodate.com/contents/psychosocial-treatment-of- posttraumatic-stress-disorder-in-children-and- adolescents?source=search_result&search=adhd%20and%20child%20 abuse&selectedTitle=5~150. 113. Hadianfard, H. (2014). Child Abuse in Group of Children with Attention Deficit-Hyperactivity Disorder in Comparison with Normal Children. Int J Community Based Nurs Midwifery. 2014 Apr; 2(2): 77–84. Retrieved online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4201192/. 114. CDC (2016). Attention Deficit/Hyperactivity Disorder. Retrieved online at https://www.cdc.gov/ncbddd/adhd/guidelines.html. 115. American Academy of Pediatrics (2011). CLINICAL PRACTICE GUIDELINE ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/ Hyperactivity Disorder in Children and Adolescents. Retrieved online at

118 Nursece4Less.com Nursece4Less.com Nursece4Less.com Nursece4Less.com http://pediatrics.aappublications.org/content/pediatrics/128/5/1007.fu ll.pdf. 116. Physicians Desk Reference (2016). Retrieved online at http://www.pdr.net/browse-by-drug-name.

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