​Kembara Xtra - Medicine - Pediatric Attention Deficit Hyperactivity Disorder

​Kembara Xtra - Medicine - Pediatric Attention Deficit Hyperactivity Disorder 
Attention deficit hyperactivity disorder (ADHD), a neurodevelopmental condition characterized by impulsivity, distractibility, hyperactivity, and/or inattention, first appears in early childhood.
There are three subcategories of ADHD: mixed (ADHDC), mainly inattentive (ADHD-I), or predominantly hyperactive (ADHD-H).

Nervous system(s) affected
Synonym(s): hyperactivity; attention deficit disorder

Predominant sex: male > female (2:1); ADHD-I is more common in girls. Predominant age: onset 12 years; lasts into adolescence and adulthood.
Prevalence
9 to 15% of kids ages 4 to 17

PATHOPHYSIOLOGY AND ETIOLOGY

Though not proven, hypothesized pathophysiology includes abnormalities in the anatomical makeup of the brain and an imbalance in catecholamine metabolism. Environmental factors are debatable.
Genetics
family resemblance

Family history and medical conditions (affecting brain development), such as preterm and fetal smoke exposure, are risk factors.

COMMONLY ASSOCIATED CONDITIONS Mood disorders, such as depression and anxiety, behavior disorders, such as oppositional defiant disorder and conduct disorder, autism spectrum disorder, physiologic disorders, such as sleep disorders and tics, and substance use disorders


DIAGNOSIS
DSM-5 criteria are suggested by American Academy of Pediatrics (AAP) recommendations to determine diagnosis.
DSM-5 criteria for children under the age of 17: six criteria for inattention and/or six criteria for hyperactivity/impulsivity.
The symptoms must be frequent, noticeable in more than two settings (such as the home and school), last longer than six months, be excessive for the child's developmental stage, and not be better explained by or co-occur with another mental disorder (such as depression, anxiety, or personality disorder).
Inability to focus for a long period of time or to stay organized. Lack of listening skills. Failure to follow through or complete activities. Avoidance of tasks requiring continuous mental effort. Loss of goods.
- Distracted by outside stimuli, forgetful in regular activities, forgetful
Hyperactivity or impulsivity - Fidgeting - Difficulty staying seated - Runs or climbs excessively or inappropriately; difficulty playing quietly - Acts as if "driven by a motor" or seems to always be "on the go" - Talks excessively - Blurts out answers before question is complete - Has difficulty waiting turn - Interrupts others
Children who experience great stress (such as divorce, illness, homelessness, or abuse) may exhibit ADHD-related behaviors as a result of the stress. The screening instrument developed by the American Academy of Child and Adolescent Psychiatry (AACAP) can be used to determine this.
Investigate the stressors in that setting if diagnostic behaviors are only seen there.
The diagnostic behaviors stand out more in activities that call for focus or boredom tolerance.


HISTORY includes information about a person's birth and growth, their family environment's psychosocial assessment, their school attendance and performance, their psychiatric history, and their cardiac history.

PHYSICAL EXAMINATION: Baseline measurements of weight, heart rate, and blood pressure are taken for later monitoring. Soft neurologic symptoms, such as tics, clumsiness, and mixed-handedness are noted.
Examine your vision and hearing.

DIFFERENTIAL DIAGNOSIS Age-appropriate activity level Abuse or a dysfunctional family Learning disability (such as dyslexia) Hearing/vision/language disorder Autism spectrum disorders Oppositional/defiant disorder or conduct disorder Seizure disorder Neurodevelopmental syndromes (such as fragile X syndrome) Lead poisoning Sequelae of central nervous system infection/trauma Medication effect 

DIAGNOSTIC TESTS & INTERPRETATION Behavior rating scales filled out by parents, guardians, and teachers before the start of therapy and then repeated after therapy Learning disability testing carried out by the school Initial examinations (lab, imaging)
Rarely necessary; weigh lead diagnostic procedures and other ECG results before prescribing stimulant medicine if there is a family history of early cardiovascular illness.

GENERAL MEASURES/TREATY
Establish treatment objectives based on the behaviors that are most detrimental to the development of the kid.
Align the home and school behavior strategy.

Behavioral therapies should start with kids between the ages of 4 and 5.
Ages 6 to 17: Start with behavioral therapy; if long-term behavioral goals are not achieved, consider medication.
Behavioral counseling, which includes parent training, academic training, and social training, can be helpful for both parents and children.
Behavioral modifications should include frequent positive reinforcement while minimizing critical remarks, reward schemes (such as star charts for young children and privileges for older children), environmental adjustments at both home and school (such as time outs and quiet periods), and a token economy (reward for positive behavior, loss of reward for negative behavior).


MEDICINE Stimulant drugs are frequently regarded as first-line treatments since they have the highest efficacy but also higher dangers.
Atomoxetine may be used as the first line of treatment, particularly if there is a chance of diversion in the household, there are worries about the child's growth (weak weight gain, irregular sleep patterns, etc.), or if the parents want to try a nonstimulant drug.
The selection of a stimulant should take into account price, formulary, convenience, and duration. If the first treatment is unsuccessful, a different kind of stimulant should be tried.
All stimulant pills (Note: Concerta is a pill) can be opened and sprinkled.

Methylphenidate, a short-acting stimulant, Ritalin, and Methylin, which take between three and five hours to take effect, are first-line options.
Metadate ER: long-acting, starts working in 20 to 60 minutes, and lasts for 8 hours.
Ritalin LA: 50% immediate release and 50% delayed release over 8 to 12 hours; Methylphenidate CD: 30% immediate release and 70% delayed release for duration over 8 to 12 hours (bimodal); Cotempla XR-ODT: 25% immediate release and 75% extended release for duration up to 12 hours; Quillivant XR: 20% immediate release and 80% extended release with duration up to 12 hours; Quillichew ER: continuous release over 6 to 8 hours with duration up to 13 Daytrana transdermal patch: onset 2 hours after application with duration of 9 to 12 hours. Jornay PM: Nighttime dosing where 5% of drug available within the first 10 hours of treatment with a peak concentration at 14 hours and gradual drop after 

Dexmethylphenidate is released over the course of 5 to 6 hours with Focalin, and over 10 to 12 hours with Focalin XR. 

Serdexmethylphenidatedexmethylphenidate-Azstarys: 70% prodrug delayed release and 30% instant release; onset in 1 hour and duration in 13 hours 

Amphetamine with instant release
Evekeo/Evekeo ODT: extended release; onset in 20 to 60 minutes; duration, 4 to 6 hours
Dyanavel XR offers a 13-hour blend of instant and prolonged release. Adzenys ER/ODT: a combination of immediate and delayed release lasting over 10 to 12 hours.

Immediate release dextroamphetamine
Dexedrine, ProCentra: extended release; onset in 20 to 60 minutes; duration, 4 to 6 hours
Dextroamphetamine SR is a drug that combines immediate and continuous release over the course of 8 to 12 hours. 

Short acting dextroamphetamine/amphetamine mixed salts
Adderall's long-acting effects begin within 20 to 60 minutes and last for 4 to 6 hours.
Adderall XR offers both an immediate and continuous release over the course of 10 to 12 hours. Mydayis combines two separate delayed-release beads with an immediate release for a duration of up to 16 hours. 

Lisdexamfetamine, the active ingredient in Vyvanse, is a prodrug that is metabolized to dextroamphetamine and has an impact lasting 10 hours.
– Some kids go through withdrawal (tearfulness, agitation) after missing a dosage or as the effects of the drug wear off. At 4 PM, a modest, rapidly acting dose may aid in preventing this.
– Stimulants are medications that can be abused, thus they need to be closely watched.
– Holidays from drugs are not advised, however they can be tried for weight loss or ADHD-I.
Common side effects include headache, anorexia, sleeplessness, growth retardation, GI problems, and CV symptoms. - Infrequent: psychosis, tics, priapism, and suicidal thoughts
The levels of anticonvulsants, SSRIs, tricyclics, and warfarin may increase. The negative effects of decongestants, energy drinks with high doses of caffeine, and albuterol inhalers may also increase.

The FDA reports that Daytrana patches can permanently discolor skin.

pregnant women's issues

Pregnancy Category C drugs: use with caution.

Second-line nonstimulant: Atomoxetine (Strattera), an SNRI, must be taken every day without interruption. Its effects last for at least 10 to 12 hours.
- Viloxazine (Qelbree): must be taken every day without exceptions and lasts all day.
 2-Agonist: High side effects, modest efficacy. Think about getting advice before using.
Duration of at least 10 to 12 hours with clonidine XR (Kapvay).
Guanfacine XR (Intuniv): minimum of 10 to 12 hours.

Similar to SSRIs, SNRIs come with a "black box" warning about the possibility of a worsening of suicidality. A close follow-up is advised.
Tics and priapism, which are uncommon stimulant adverse effects, as well as CV/GI side effects 
In a rare percentage of cases, associated with hepatic injury; if symptoms arise, examine liver enzymes.

QUESTIONS FOR REFERENCE
If there are any further mental health concerns, developmental problems, or a poor response to treatment, children should be referred.

ALTERNATIVE & COMPLEMENTARY MEDICINE

Although there is little evidence to support any remedy, surveys have indicated that parents of children with ADHD regularly (20–60%) use herbal and complementary treatments.

CONTINUING CARE AFTERCARE RECOMMENDATIONS
patient observation
Office visits to track effectiveness and side effects: Improved test scores, rating scales, family interactions, and peer interactions are the outcomes.
Keep an eye on your weight, HR, and blood pressure as you grow.

DIET "Inadequate evidence to suggest that dietary interventions reduce the symptoms of ADHD," according to the study.
The AAP advises a trial of a diet devoid of food coloring and preservatives as a suitable intervention.


Patient education: ADDitude toolbox for parents and teachers; CHADD's National Resource Center for teachers; Teacher's reference 
Points to remember as parents:
Find the child's strengths and accentuate them. Reward excellent behavior. Assign one task at a time. Quietly correct behavior. Co-ordinate homework with teachers. Have external organization tools, such as charts, timetables, and token systems. Together with the school, create an individualized education program (IEP). group therapy:
- CHADD: http://www.chadd.org (Children and Adults with Attention Deficit Disorder).
- Attention Deficit WareHouse: http://www.addwarehouse.com
- The Center for Parent Information and Resources (CPIR) can be found at https://www.parentcenterhub.org.

Relative impairments in intellectual and social functioning may linger until late adolescence/adulthood; plan for a transition at age 17; encourage job choices that allow for independence and mobility.

COMPLICATIONS If ADHD is left untreated, it can result in academic failure, parental abuse, social isolation, and low self-esteem.
Increased risk of substance abuse, which may reduce with treatment for ADHD, decreased pace of growth, possible withdrawal when medicine wears off, and a higher incidence of car accidents and injuries.