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Nurse Practitioners Diagnosing and Treating ADHD

ADHD

Learn how to combat ADHD diagnostic delays with the help of a psychiatric-mental health nurse practitioner expert.

According to the Centers for Disease Control and Prevention (CDC), an estimated 7 million children aged 3-17 years have been diagnosed with attention-deficit/hyperactivity disorder (ADHD) in the United States. The diagnosis of ADHD has increased dramatically in recent years, with the number of children who received an ADHD diagnosis in 2022 being 1 million greater than those diagnosed in 2016. More patients than ever are seeing nurse practitioners (NPs) and other mental health care providers for ADHD diagnosis and treatment, but what about the patients that aren’t getting diagnosed during their crucial childhood years?

Data show that boys are nearly twice as likely to receive an ADHD diagnosis than girls — leaving many young girls with ADHD struggling without treatment until they’re well into adolescence or adulthood. In fact, the CDC states that the “percentage of adolescent and adult females as well as male adults receiving prescriptions for stimulants used to treat ADHD symptoms increased during 2016–2021, particularly during the first two years of the COVID-19 pandemic (2020–2021).” In observance of National ADHD Awareness Month, the American Association of Nurse Practitioners® (AANP) spoke to AANP Psych and Mental Health Community co-chair Lisa Anderson DNP, APRN, PMHNP-BC, about her personal journey to get an ADHD diagnosis for her daughter, and how NPs can help combat these diagnostic delays in their communities.

Pushing for Diagnosis as Parent and Provider

Dr. Anderson works as a psychiatric mental health NP in an outpatient psychiatric clinic and an assistant professor for the psych mental health NP DNP program at UT Health San Antonio’s School of Nursing, but she first took an interest in the subject of ADHD when she noted it in her own daughter. “I've always seen it from day one. When she would go to school as this little third grader, her testing was just never up to par. It was always below the grade level, and that concerned me,” Anderson explained.

However, due to differences in how ADHD presents itself in girls compared to boys, others did not initially share Anderson’s concerns. “I knew she had ADHD, but nobody believed me,” she stated. Once her daughter was diagnosed in the 4th grade, her suspicions were validated, and her daughter received the treatment she needed. “We got her on medication and, oh my gosh, the difference that it made was night and day. She was able to focus and pay attention. It was amazing seeing the drastic results it had when it came to academic functioning.” The experience spurned Anderson to specialize in diagnosing and treating ADHD in her place of practice. “As a psychiatric NP, I thought ‘I want to do this. I want to be able to have that instant gratification, per se, of being able to treat a child with a medication and then see them blossom academically.’”

Recognizing the Full Spectrum of ADHD

How can providers help advocate for all patients with ADHD and make sure they receive a timely diagnosis? According to Anderson, “I think the number one difference that NPs can make is through education and understanding the differences between boys and girls with ADHD. Boys are twice as likely to be diagnosed compared to girls. So, that clearly states that there is a gendered difference here.” ADHD is characterized by two sets of behavioral issues: hyperactivity and inattentiveness, or an inability to concentrate. However, these two symptoms don’t always manifest for all patients — and when they do, they may manifest differently.

“When you look at how ADHD manifests in little boys, they are more likely to be hyperactive and impulsive,” Anderson explained. “So, they externalize their behaviors more and are more likely to be noticed, like when they’re disruptive in class. Sadly, in that same classroom is a little girl who is more internalizing in her behaviors. Her inattention and lack of focus are more likely to be missed by teachers.” Left unnoticed and untreated, ADHD in girls contributes to poorer self-esteem and self-image, difficulty socializing and mental health concerns like anxiety.

Anderson suggests the key to understanding how girls exhibit signs of ADHD goes beyond just externalizing behaviors. “You see the internalizing behaviors — the inattention, the daydreaming… you have to look for those subtle behaviors and be able to catch them. You're going to find out that girls with ADHD have a lot more anxiety when it comes to school. They might feel like they're a failure because they can't keep up with their classmates or are running low on their grades. So, being able to recognize the other symptoms that are correlated with ADHD, especially in little girls, matters,” explained Anderson. “NPs can really help by conducting a full examination while understanding the different ways patients project those ADHD symptoms and leveraging the holistic nursing model they know so well.”

Navigating Medication Shortages

Although medication for ADHD has been proven to be highly effective at improving patients’ quality of life, some patients may find themselves struggling to fill their prescriptions. On October 12, 2022, the U.S. Food and Drug Administration (FDA) announced a shortage of “the immediate release formulation of amphetamine mixed salts, commonly referred to by the brand name Adderall or Adderall IR.” As more time has passed, this ongoing shortage has led to a scarcity of both Adderall and other stimulant medications that have been prescribed in its place.

How has Anderson gotten around this shortage to continue to treat her patients with ADHD? “I've had to do so many medication changes over the last few years because of all the different shortages, but if your patient has insurance that's not government funded, then they can typically get a branded medication for relatively cheap with copay discount cards,” she explained. “Alternatively, switching patients to a non-stimulant is an option I've had a lot of success with. Non-stimulants are going to last 24 hours, so they're going to last throughout the whole entire day, as opposed to stimulants. These medicines have been shown to be effective for treating ADHD and are not under any kind of shortage.”

If a patient doesn’t desire any alternatives, then Anderson will “try to make their prescription as equivalent as possible. So, for example, Adderall XR patients can take short-acting Adderall or something similar like a branded disintegrating tablet which is equivalent to Adderall XR.” When patients have no choice but to wait, Anderson advises her psychiatric NP colleagues to “remember the power of psychotherapy, such as cognitive behavioral therapy, and leverage it to help with patients’ ADHD symptoms. Those organizational techniques in particular can really help patients make it through those gap days while they wait to get their stimulant.”

Delivering Holistic Care

When asked why NPs are best suited to improve outcomes for patients with ADHD, Anderson replied, “Whenever you have a prescriber for ADHD, you either have a physician, a physician assistant (PA) or an NP. The physician and PA follow the medical model. Generally speaking, these providers will do this due to a time limit. Psych NPs and primary care NPs typically spend more time with patients practicing that holistic approach for treatment, which is consistent with the patient-centered and holistic care NPs are trained to provide.”

Whole-person care is vital for discovering any comorbidities patients with ADHD might have — including learning disabilities. “October is also Learning Disabilities Month, and it goes hand-in-hand with ADHD,” stated Anderson. “You don't want to forget about how comorbid those two diagnoses are — if you have a learning disability, you are most likely going to have ADHD as well.” Similarly, patients with ADHD have a high likelihood of having a learning disability — with studies showing a mean comorbidity rate of up to 45%.

When it comes to the diagnosis and treatment of ADHD and any comorbidities that come with it, Anderson reiterates that “Implementing the biopsychosocial approach is what we do best. We want to know what impact ADHD has had on your mood, anxiety, sleep and explore that. We’ll ask patients, ‘How has ADHD affected you socially? Have you had trouble making friends or connecting with your coworkers? Do they think that you talk too fast? Are you interrupting others?’ I'm a firm believer that you have to treat the whole person.”

Improve Mental Health Outcomes With Help From the AANP Communities

If you’re interested in psychiatric-mental health, the AANP Psych and Mental Health Community offers a unique opportunity to collaborate with colleagues who share interest or clinical expertise in psychiatric care. As an AANP Community member, you’ll have access to a cutting-edge, online forum where you can engage in discussions, document sharing and knowledge exchange with your fellow NPs.

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