Addressing common psychiatric issues in children and adolescents: ADHD, Depression and Anxiety Sattaria ‘Tari’Dilks, DNP, APRN-BC, LPC Psychiatric Mental Health Nurse Practitioner Prepared for LASBHA Conference 2019 Professor and Co-Coordinator of Graduate Nursing Program McNeese State University and Private Practice at the Institute for Neuropsychiatry
Objectives • Participants will be able to discuss differential diagnosis as it relates to ADHD, depression and anxiety in children and adolescents • Participants will be able to discuss treatment issues related to treating these disorders in primary care • Participants will be able to list psychopharmacological interventions, side effects and implications for treatment of these disorders in a child or adolescent population • Participants will be able to enumerate the effect that adverse childhood experiences has on the development of medical and mental health problems
Dr. TariDilks has been a LPC since 1988 and Psychiatric Mental Health Nurse Practitioner (PMHNP) since 2006 in private practice in Lake Charles, LA. She also holds a FNP credential. She is a professor and Co-Coordinator of the Graduate Nursing Department and director of the PMHNP concentration in the CON at McNeese State University, part of the ICMSN. She has been a paid speaker for Otsuka. The material in this presentation has been put together by Dr. Dilks from a variety of sources and every effort has been made to assure its accuracy. Changes happen rapidly in this field and the material may become dated. Material in this presentation should not be perceived as a recommendation for patient care for anyone who is not a patient of DrDilks.
Adverse Childhood Experiences Study (ACEs) 1998 Drop out rate from Kaiser Permanete’s obesity clinic was about 50% in the 80’s despite successful weight loss. DrFelitti, conducted interviews with those who had dropped out and discovered that the majority had experienced adverse childhood experiences. Was weight gain a coping mechanism for depression, anxiety and fear?
Adverse experiences from first 18 years of life included: emotional abuse, physical abuse, sexual abuse, mother treated violently, household substance abuse, household mental illness, parental separation or divorce, criminal in household, emotional neglect or physical neglect
This led to surveying over 17,000 patient volunteers in Kaiser Permanente’s health maintenance organization. • Demographics • About half were female • 74.8% were white • Average age was 57 • 75.2% had attended college • All had jobs and good health care
Results: • 28% had experienced physical abuse • 21% sexual abuse • 2/3 reported at least one ACE and 87% of those individuals reported at least one additional ACE • ACE often occur together with almost 40% reporting two or more and 12.5% experienced four or more • Increasing number of ACEs are strongly correlated with adult high-risk health behaviors
There appears to be a dose-response effect between increased numbers of adverse childhood experiences and negative health outcomes across the lifespan. This includes increased risk for: MI, asthma, alcoholism, intimate partner violence, unintended pregnancies, STI, depression, smoking, disability, lower reported income, unemployment, lower educational attainment, stroke, CAD, DM, risk for sexual violence, and more. https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html http://www.ajpmonline.org/article/S0749-3797(98)00017-8/abstract
Having four or more ACEs was associated with a seven fold increase in alcoholism, doubling the risk of cancer diagnosis and four fold in crease in emphysema An ACE score above six was associated with a 30 fold increase in suicide attempts
Subsequent studies have confirmed the effects of multiple ACEs on health US states who have collected data using the CDCs Behavioral Risk Factor Surveillance System (BRFSS) have found similar results across states. There have been reports of more ACEs in places like urban Philadelphia and young mothers (below the age of 19). The National Survey of Children’s Health included a measure of economic hardship and found that it was the most common ACE reported in nationally https://www.childtrends.org/wp-content/uploads/2014/07/Brief-adverse-childhood-experiences_FINAL.pdf
An instrument was developed for international data gathering – Adverse Childhood Experiences International Questionnaire (ACE-IQ) International studies have been done in Romania, the Czech Republic, UK, China, Jordan, Canada, Norway and the Philippines, among others and have yielded similar results.
What can we do? • Work toward provision of a safe, stable and nurturing relationship with some of the following strategies: • Home visits to pregnant women and families with newborns • Parenting training • Intimate partner violence prevention • Social supports for parents • Parent support for teens and teen pregnancy prevention • Mental illness and substance abuse treatment • High quality child care • Sufficient income support for lower income families https://www.cdc.gov/violenceprevention/childabuseandneglect/acestudy/ace-graphics.html
Prevention of childhood adverse experiences is important. https://www.cdc.gov/violenceprevention/childmaltreatment/prevention.html - prevention and parenting tools http://www.who.int/violence_injury_prevention/violence/global_campaign/en/chap3.pdf - The WHO’s first comprehensive review of worldwide violence. This is the link to the chapter on child abuse
Updated recommendations AAP – preventive pediatric health care – please note the recommendations for developmental and behavioral health screenings: https://www.aap.org/en-us/documents/periodicity_schedule.pdf Screening tools for developmental issues in children: https://www.cdc.gov/ncbddd/autism/hcp-screening.html
THOUGHTS TO PONDER ADHD – a medical diagnosis or a different kind of normal? ADHD rates have tripled in the past twenty years or so according to Dr. D. Archer in “The ADHD Advantage”. He postulates that it could be a greater recognition of ADHD, particularly the more subtle presentations, but may also be a ‘fad’ engineered by misleading marketing, stressed parents and overworked teachers. Keep this in mind as we look at diagnostic and treatment considerations, including psychosocial interventions. Archer, D. (2015). The ADHD advantage: What you thought was a diagnosis may be your greatest strength. New York: Random House. (p. 2).
DSM 5 Diagnostic Changes DSM 5 was released in May, 2013. The chapter on disorders usually first diagnosed in infancy, childhood and adolescence – have been moved to other areas in the DSM 5. ADHD is found in the chapter on Neurodevelopmental Disorders The titling has been changed from a Roman numeral format to an Arabic numerical format to allow for future revisions (ex: 5.1, 5.2.4)
Neurodevelopmental disorders – • Intellectual developmental disorders – formerly MR • Communication disorders – new diagnoses include: language impairment, social communication disorder, childhood onset fluency disorder (formerly stuttering), voice disorder • Autism spectrum disorder • Motor disorders • Attention deficit/hyperactivity disorder • Learning disorders
Definition of ADHD - Neurodevelopmental disorder - impairing levels of inattention, disorganization and/or hyperactivity impulsivity - Inattention/disorganization includes the inability to stay on task, seeming not to listen, and losing material at levels that are inconsistent with age or developmental level - Hyperactity-impulsivity entails over-activity, fidgeting, inability to stay seated, intruding on other people’s activities, and inability to wait - symptoms must be excessive for age or developmental level. - Frequently overlaps with disorders that are often considered to be externalizing disorders, such as oppositional defiant disorders and conduct disorder. - Often persists into adulthood, with continued impairments of social, academic and occupational functioning American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Criteria in DSM-5 • Inattention– Children must meet at least six criteria and adults or older adolescents must meet five, lasting six months or more – not due to other disorders – must be inconsistent with developmental level and have a significant impact on social and academic/occupational functioning. • Often fails to give close attention to detailsor makes careless mistakes at school, work or other activities (overlooks or misses details, work is inaccurate) • Often has difficulty sustaining attention in tasks or play – (focus during lectures, conversations or lengthy reading) • Often does not seem to listen when spoken to directly (mind is elsewhere, even in the absence of an obvious distraction)
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (starts tasks but quickly loses focus and is sidetracked) • Often has difficulty organizing tasks and activities – (has difficulty with sequential tasks and keeping materials and belongings in order – work messy and disorganized – poor time management and fails to meet deadlines) • Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (schoolwork, homework, for older adolescents and adults - preparing reports, completing forms or reviewing lengthy papers) • Often loses things necessary for tasks or activities – (school assignments, books, wallets, keys, glasses, cell phone) • Easily distracted by extraneous stimuli (for adults may include unrelated thoughts) • Forgetful in daily activities, chores and running errands (for adults may include returning calls, paying bills and keeping appointments)
Hyperactivity and impulsivity – six or more of the following symptoms that have lasted at least six months to a degree that is inconsistent with developmental level and impact directly on social and academic/occupational activities and are not due to other disorders. In older adolescents and adults only five are necessary. • Often fidgetsor taps hands and feet or squirms in seat. • Is often leaves seat in situations when remaining seated is expected (may leave place in classroom, office or other workplace or in other situations that require remaining seated) • Often runs about or climbs in situations where it is inappropriate. In adolescents or adults it may be limited to feeling restless.
Is often unable to play or engage in leisure activities quietly • Often “on the go”, acting as if being “driven by a motor”. Uncomfortable being still for an extended length of time, as in restaurants, meetings, etc. Seem by others as being restless and difficult to keep up with . • Often talks excessively • Often blurts out answers before a question has been completed. Older adolescents and adults may complete people’s sentences and ‘jump the gun’ in conversations. • Has difficulty waiting his or her turn or waiting in line. • Often interrupts or intrudes on others (butts into conversations, games or activities; may use other people’s things without permission, adolescents or adults may take over what others are doing)
Several noticeable inattentive or hyperactive-impulsive symptoms must be present by age 12 Symptoms must be present in two or more settings There must be clear evidence that the symptoms interfere with or reduce the quality of social, academic or occupational functioning The symptoms do not occur exclusively within the course of schizophrenia or other psychotic disorder and are not accounted for by another mental disorder (mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal) Specify current presentation: Combined (314.01), predominately inattentive (314.00), predominantly hyperactive/impulsive presentation (314.01) Specify if in partial remission Specify severity – mild, moderate or severe
Prevalence • Variable findings depending on source – DSM 5 indicates 5 % of school age children in most cultures – 2.5% of adults • 2011 US data indicates that 11% of children 4-17 years are diagnosed with ADHD (6.4 million) – it was 7.8% in 2006 • The most common chronic health condition among children – estimate 4.5 million children between the ages of 3 – 17 – Actual number much higher in US • There is a wide variability of diagnosis from state to state – in children who were ever diagnosed with ADHD there ranging from 5.6% in Nevada to 18.7% in Kentucky. By contrast UK rates are less than 2% and France is 0.5% http://www.cdc.gov/ncbddd/adhd/prevalence.html
Difficult to establish diagnosis in children younger than age 4 as excessive motor activity may be normal in toddlers Average age of diagnosis – 7 Preschool the primary manifestation is hyperactivity, inattention during elementary school – adolescents and adults have less hyperactivity – tends to be more inattentiveness, restlessness and impulsivity Number of children in US on medication is 3.5 million up from 600,000 in 1990 – More common in males than females 2:1 in children and 1.6:1 in adults – Females tend to have predominantly inattentive features
Evidence from family genetic studies indicate that siblings of ADHD children have 2-3 times the risk of having ADHD. Families with ADHD children are more likely to have stress, feelings of parental incompetence, marital discord, marital disruption and social isolation. Approximately 80% of children have symptoms which persist into adolescence and up to 65% into adulthood Children with ADHD are more likely to experiment with drugs and develop significant substance abuse problems.
ADHD has multiple possible etiologies, including: neuroanatomic, neurochemical, genetic influences, environmental influences and CNS insults. • Behavior management may not be enough because the kids are already motivated. It is not that they won’t, it is that they can’t. • Leads to impairment in almost every aspect of the child’s life. The socioeconomic burden is vast. • 30% repeat a grade • 33% drop out before high school graduation • Only 5 – 10% complete college • Increased risk for unintentional injuries and risky behaviors • More frequent use of medical, mental health and educational services than non-ADHD peers • Increased familial stress burden and marital discord
Costs • One month supply of a stimulant medication costs can range from $15 -$220 per month depending upon dosing and type used. • Supportive individual or family therapy costs an average of about $100+ per hour and may be ordered weekly • Students with ADHD incur an average annual incremental cost to society of $5,007 compared to $318 of students in the comparison group in a 2011 study by Robb, et al. Robb, J., et al. (2011). The estimated annual cost of ADHD to the US educational system. Springer. Published online June 9, 2011.
Additional Concerns with ADHD • Some studies indicate that nearly ½ of all children with ADHD, particularly boys, have a co-morbid condition of oppositional/defiant disorder • One study found that 23% of ADHD children also had indicators of bipolar disorder • Every child with ADHD should also be screened for sleep disorders, anxiety, depression, behavioral disorders, and developmental disorders as these are often co-morbid conditions • Not all children with ADHD have an additional disorder – but when they do, it can seriously complicate the family and the child’s lives http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654.full.pdf
Failure to identify and effectively treat this disorder may result in academic failure, problems in maintaining relationships with peers, substance abuse and co-morbid mental health issues. This is a poor foundation in the development of effective skills as an adult. Additional co-morbid psychiatric disorders can include: anxiety disorders, depressive disorders, tic disorders, substance abuse and/or dependency, and sleep disorders.
Current Research • Worldwide variation – Hinshaw and Benson (2011) – variation of prevalence worldwide is due to different diagnostic practices and algorithms. It is recognized around the world as a chronic neurodevelopmental disorder that leads to impairment and the need for treatment. However countries differ on what is recommended first line for treatment – psychosocial and/or medication. Brazil and the UK advocate for psychosocial interventions first. In China medications can only be prescribed for two weeks. The US and Canada leave the decision about medication and psychosocial intervention is left up to the provider and the family. In Germany, parents must learn parent training strategies prior to medications being prescribed Hinshaw, A. & Benson, M. (2011). Different countries have different attitudes toward attention deficit/hyperactivity disorder. Psychiatric Services: 62:459-464
Zima, et al (2010) – Indicated that there was a substantial need for improved quality of care for Medicaid-funded ADHD treatment for children. A cohort study of more than 500 children (ages 5 – 11) in Los Angeles county with ADHD showed that clinical outcomes in the patient population were similar in children who remained in care and in children who received no care at all. Children seen by primary care received negligible follow-up visits of one to two per year. In contrast those children treated within a specialty mental healthcare group received some sort of psychosocial intervention, with about five visits per month, with less than one third of the being prescribed any stimulant medications.
There was a failure to meet the Institute of Medicine standard in both groups. The rates of stimulant medication treatment in primary care clinics was consistently 2.8 times greater than in the mental health specialty setting. 80-85% of the children were given a stimulant medication and 95-98% were given at least one psychotropic medication, with about 22-26% receiving both. In contrast 31-49% received stimulant medication in the mental health setting, with 90% of children receiving psychosocial interventions. Neither setting documented behavior therapy or parent training
“Care for children in the studied Medicaid program failed to meet the Institute of Medicines definition of quality that requires ‘consistency with current professional knowledge’ and ‘improved likelihood of destined health outcomes’”. 4.1 million additional children were expected to enter the Medicaid-funded healthcare systems by the year 2013. Zima, B., Bussing, R., Tang, L, Zhang, L., Ettener, S., Belin, T., & Wells, K. (2010). Quality of care for childhood attention-deficit/hyperactivity disorder in a managed care Medicaid program. J Am Acad Child Adolesc Psychiatry. 49: 1225-1237. https://doi.org/10.1016/j.jaac.2010.08.012
A 2013 ARHQ report examined 55 studies (1980 – 2011) in pre-school children comparing interventions – parent behavior training, combined school and home interventions and stimulant medication (methylphenidate). The parent behavior training interventions had better results for preschoolers at risk for ADHD, even though all were effective.
ADHD (and) texting seriously impair teenagers driving performances. Un-medicated ADHDers had significantly more traffic violations. Texting impaired all teenage drivers ability to react to traffic situations, but not cell phone conversations. Recommended 3 stage licensing. Charach, A., Carson, P.,Fox, S., Ali, M., Beckett, J., & Lim C. (2013). Interventions for preschool children at high risk for ADHD: a comparative effectiveness review. Pediatrics 131 (5):e1584-604. Narad, M., et al. (2013). Impact of distraction on the driving performance of adolescents with and without attention-deficit/hyperactivity disorder. JAMA Pediatrics, online August 12, 2013.
Ghuman (2011) – 100 children ages 4-8 with ADHD were divided into two groups. The study group were placed on an elimination diet (rice, meat, vegetables, pears, and water – complemented with potatoes, fruits and wheat). 17 children of 41 with no response to the diet were further restricted. At the end of nine weeks the intervention group showed significant improvement in 64% of children. Interesting study, but needs to be replicated. Ghuman, J. (2011). Restricted elimination diet for ADHD: The INCA study. Lancet. 377:446-448.
A Norwegian study (Karlstad, Furu, Stoltenberg, Haberg & Bakken, 2017) collected data which validated earlier studies from several countries that children who were youngest in their grade were the ones most likely to receive a diagnosis of ADHD. They also noted that differences became even more marked from grade three onwards. African American and Latino children, compared with white children in a 2016 study suggesting that disparities may be more related to underdiagnosis of AA and Latino children or overdiagnosis and overtreatment of white children. Karlstad, O, Furu, K., Stoltenberg, C., Haberg, S. & Bakken, J. (2017). ADHD treatment and diagnosis in relation to children’s birthmonth: Nationwide cohort study. https://doi.org/10.1177%2F1403494817708080 Coker, T., Elliot, M., Toomey, S., et al (2016). Racial and ethnic disparities in ADHD diagnosis and treatment. Pediatrics, 138:3, pp 1-9.
25-55% of parents report sleep problems in their children with ADHD – difficulty falling asleep, resistance to bedtime, night awakenings, and difficulty waking up. • Improving sleep problems is important • Sleep problems can worsen ADHD symptoms • Impacts quality of life for both families and children • Continued sleep problems can result in lack of quality sleep, daytime sleepiness, mood alterations, and issues with attention and behavior which can look like ADHD • Treatment of ADHD with stimulants as been shown to increase sleep efficiency and subjective feelings of restorative value of sleep in adults
Red flags for ADHD in children/adolescents • Academic underachievement • Repeated misconduct in school • Delinquent behaviors • Substance abuse • Frequent accidents/injuries (includes MVA’s) • Oppositionalism • Hot temper • Ingestion of prescription meds –either their own or family members • Sleep disorders • Aggression/violence • Family history (ADHD, alcoholism, depression, adoption – 80% in some studies) • Frequent otitis media • Allergies • Short attention or interest span • Fidgetiness • Thrill seeking • Dysfunctional voiding problems
Differential Diagnosis May be normal – child may be at high end of normal range of activity or have a difficult temperament Physical causes may include: impaired vision or hearing, seizures, sequalae of head trauma, acute or chronic medical illness, thyroid abnormalities, brain tumors, lead poisoning, poor nutrition or insufficient sleep Anxiety disorders Depression Abuse or neglect Intellectual disability
Learning disabilities • Various drugs (Phenobarbital) • Borderline intellectual functioning, PDD, Tourette’s, • Early onset mania or bipolar mixed • Stress, family issues, parenting issues • Co morbidity is present in as many as 2/3 with high presence of oppositional defiant disorder, conduct disorder as well as those previously listed
Assessing Children for ADHDClinical Practice Guidelines from the American Academy of Pediatrics (2011) • Establish that the child meets the diagnostic guidelines in more than one setting and should be viewed as a chronic condition. • Parent interview is core • Essential to obtain reports of behavior, learning, and attendance at school, as well as grades and test scores • Use parent and teacher rating scales • Medical evaluation should include complete medical history and physical exam and asses for other conditions that may exist – emotional or behavioral comorbidities, developmental issues, tics and sleep disorders. • ADHD is a clinical diagnosis, there are no definitive lab or psychological tests • Neuropsychological tests may be useful to evaluate specific deficits • EEG’s only in the presence of focal signs or suggestions of seizure disorders
Neurobiology, Neurotransmitters, Circuits and Genetics • It is important to understand the underlying pathology and treatment approaches it is helpful to understand the which brain circuits are implicated and their impact on other functions. • Primarily abnormalities are in norepinephrine and dopamine systems and nicotinic receptors – not serotonin • Nicotine may activate neurotransmission nonspecifically or via cholinergic activation to enhance attention and cognition
Brain circuitry • Malfunctioning pre-frontal cortex – affects selective attention (anterior cyngulate cortex), sustained attention (dorsolateral prefrontal cortex), hyperactivity (prefrontal motor cortex) and impulsivity (orbital frontal cortex) Downloaded from: http://photobucket.com/images/brain
ADHD is thought to be a genetically transmitted neurobiologic disorder of the dopaminergic and noradrenergic pathways – 50% concordance rate for first degree relatives • Agents which appear to elevate NE and DA appear helpful for ADHD • Stimulants – block reuptake, indirect acting • TCA’s – block reuptake of DA and NE • MAOI’s – reduce degredation of presynaptic NE and DA