Pediatric Primary Care (130 page)

•  Autism spectrum disorders.

•  Tic disorders.

G.  Physical findings.

1.  For diagnosis without comorbid conditions, physical examination is usually unremarkable.

2.  Behavior during physical examination is often inappropriate for age: refuses to cooperate; refuses to respond to questions.

3.  Dysmorphic features may be consistent with comorbid conditions.

4.  Neurocutaneous lesions may be consistent with comorbid conditions.

H.  Diagnostic tests.

1.  No specific diagnostic tests for definitive diagnosis.

2.  Diagnostics such as blood tests, brain scans, EEG, and psychological tests are not routinely necessary for children with AHDH without evidence of comorbid conditions.

3.  Laboratory tests that may assist in ruling out or verifying comorbid conditions.

a.  CBC with differential.

b.  Lead level (children 7 years and younger).

c.  Basic metabolic panel.

d.  Liver function panel.

e.  Thyroid studies including thyroid-stimulating hormone (TSH).

f.  ECG: to evaluate heart rate and QT interval (positive family history).

g.  EEG: recommended for all children who may be placed on medication therapy and have a past medical history of seizures and/or a family history of a seizure disorder.

4.  Diagnosis of ADHD.

a.  For definitive diagnosis, must use DSM-IV diagnostic criteria for ADHD (
Box 34-4
).

b.  AAP published evidenced-based guidelines for primary care diagnosis and clinical evaluation of children suspected of having ADHD. AAP guidelines require that a child meet the DSM-IV criteria.

c.  AAP guidelines require evidence directly obtained from the classroom teacher regarding the core symptoms of ADHD, the duration of symptoms, the degree of functional impairment, and coexisting conditions.

I.  Differential diagnosis.

1.  Because diagnosis has several significant comorbid conditions, comprehensive history and physical examination essential to establish definitive diagnosis and formulate treatment plan.

2.  Differential diagnosis included in
Table 34-2
.

J.  Treatment
(
Box 34-5
).

1.  Both medication and behavior therapy.

2.  Evidence suggests that discontinuing treatment leads to reemergence of symptoms.

3.  Aimed at alleviating major symptoms child displays and improving child's ability to function within family unit, social and educational environments.

4.  In addition, if child also displays symptoms of one or more comorbid conditions, treatment is highly recommended to reduce or alleviate these symptoms.

Table 34-2
Differential Diagnosis of ADHD

Box 34-5
Role of Nurse Practitioner in Managing Children with ADHD

1.  Office assessment identifying parental concerns and child's behavior patterns.

2.  Establish rapport with psychiatrist or psychologist to identify treatment plan.

3.  Include parents, child, and school personnel in the treatment plan.

4.  Monitor effects of stimulant medication to ensure desired treatment plan outcomes.

5.  Follow up should include biannual physical examinations and appropriate laboratory studies including hemoglobin, because anemia is a side effect.

6.  Emotional support measures for child and parents.

5.  Mental health referrals for all children suspected of having comorbid psychiatric conditions.

6.  Characteristics of treatment plan.

a.  Parent education.

•  Provide education about ADHD and appropriate comorbid condition.

•  Identify available resources and support groups for parents
(
Table 34-3
).

b.  School-based strategies.

•  Structured classroom setting.

•  Consistent instruction and application of rules of conduct.

Table 34-3
Evidence-Based Treatment Guidelines for the School-Age Child

Content removed due to
copyright restrictions

•  Meets educational needs of child as identified through in-school testing.

c.  Behavior modification.

•  Strategies are consistent and followed at home and at school.

•  Inform child of rules of acceptable behavior.

•  Rewards for demonstrating positive behaviors (positive reinforcement).

•  Consequences for failure to meet the goals (punishment).

•  Repetitive application of the rewards and consequences shapes behavioral changes.

d.  Medication therapy.

•  Basic principles.

i.  Begin with lowest dosage and increase dosage every 5-7 days based on parent and teacher assessment of child's response (changes in behavior) to medication.

ii.  Once positive response to medication therapy is reported, increase dose at least one more time.

iii.  Medication administered every 12 hours has been shown to be most effective in controlling symptoms of ADHD.

•  Drugs of choice.

i.  May use immediate-release tablets: methylphenidate (Ritalin), dextroamphetamine levoamphetamine (Adderall), dextroamphetamine (Dexedrine), atomoxetime (Strattera)–a nonstimulant medication.

ii.  May use sustained-release tablets: methylphenidate (Ritalin SR; Concerta; Metadate ER; Metadate CD), dextroamphetamine levoamphetamine (Adderall XR), dextroamphetamine (Dexedrine Spansule).

•  Potential side effects:

i.  Decreased appetite, weight loss.

ii.  Insomnia.

iii.  Tachycardia.