ADHD Adress Seoul National University Hospital 28 Yeongeondong

ADHD아동의 간호중재 권미경 서울대학교병원 소아정신과 Adress: Seoul National University Hospital 28 Yeongeon-dong, Jongno-gu Seoul, 110 -744, Korea Tel : (82)-2 -2072 -3533 Fax : (82)-2 -747 -2471 Email: Bright 0303@snuh. org 1

ADHD의 3대 핵심 증상 Inattention (주의력결핍) Hyperactivity (과잉행동) Impulsivity (충동성) ADHD아동의 간호중재 6

Impact of Untreated ADHD아동의 간호중재 16

ADHD 치료방법들 p Medication management p Behavioural treatment p Combined(medication/behavioural) treatment p Educating parents/patient about ADHD p Educational support services p MTA Result - Medication management was superior to behavioral treatment and routine community care for ADHD symptoms - Need 12 hour-long control ADHD아동의 간호중재 17

ADHD 치료약물 o Methylphenidate - central nervous system (CNS) stimulant - effects similar to, but more potent than, caffeine and less potent than amphetamines - notably calming and “focusing” effect on those with ADHD, particularly children o 상품화된 약품명 (U. S. Brand Names) Concerta® Daytrana™ Metadate® ER Metadate® CD Methylin® ER Methylin® Ritalin-SR® Ritalin® LA Ritalin® Penid(한국) ADHD아동의 간호중재 20

Methylphenidate의 효과 o 연구자들이 PET를 이용하여 성인 남성에서의 치료적 용량을 규명하기 위한 연구 o Methylphenidate가 dopamine signal이 약한 대상자 에게서 신경전달물질인 dopamine의 방출을 확대시켜, 집중력을 향상시킴을 발견 Volkow, N. D. , Fowler, J. S. , Wang, G. , Ding, Y. , and Gatley, S. J. (2002). Mechanism of action of methylphenidate: insights from PET imaging studies. J. Atten. Disord. , 6 Suppl. 1, S 31–S 43. ADHD아동의 간호중재 21

ADHD 약물치료 o Methylphenidate as first-line treatment NICE, SIGN, AAP, AACAP, European Guidelines, The MTA Cooperative Group. Methylphenidate Amphetamine Pemoline Tricyclic antidepressants Bupropion MAOI Clonidine/ Guanfacine % Responders 0 20 40 60 80 Wilens TE, Spencer TJ. Presented at Massachusetts General Hospital’s Child and Adolescent ADHD아동의 간호중재 Psychopharmacology Meeting, March 10 -12, 2000, Boston, MA. 100 24

Typical side effects of stimulants o Activation of the sympathetic nervous system - Pulse, palpitations or tachycardia - Blood pressure 상승가능성(5 mm Hg이하) - Dizziness - Seep problems (insomnia) 교감신경자극으로 인한 가장 흔한 부작용 - 대개의 경우 stimulant는 늦은 오후나 저녁시간의 투약을 제한 ADHD아동의 간호중재 25

Typical side effects of stimulants o Activation of the parasympathetic nervous system - Low appetite and stomach problems - Headaches - Allergic reaction 극히 드물지만 모든 약물은 알러지를 유발할 수 있으며, 대개는 stimulant 자체보다 tablet에 추가된 물질이 유발함 ADHD아동의 간호중재 26

CONCERTA® OROS® 18 mg 27 mg 36 mg ADHD아동의 간호중재 1174 1571 27

CONCERTA® OROS® Osmotic controlled Release Oral delivery System Laser-drilled hole Methylphenidate overcoat Methylphenidate compartment #1 Ratecontrolled membrane Water Methylphenidate compartment #2 Water Push compartment Before operation ADHD아동의 간호중재 During operation 28

CONCERTA®; Ideal Plasma Profile Smooth Plasma Profile : Initial Bolus+Ascending ADHD아동의 간호중재 29

CONCERTA®; New for ADHD Community Use Study: 100% Parent/caregiver treatment preferences* 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% CONCERTA® Previous MPH Previous Non-MPH No preference *Parent/caregiver treatment preference was assessed only for subjects receiving ADHD아동의 간호중재 30 medication immediately prior to enrolment (n = 842) Schnipper. Pediatr Res 2001; 40(4): 429 A

Easy to Convert from MPH IR ADHD아동의 간호중재 31

ADHD Child can learn Social Competency For o Trust, closeness, relationship building o Handling separation and independence o Handling joint decision and interpersonal conflicts ADHD아동의 간호중재 38

Child can learn Social Competency For o Dealing with frustration and unfavorable o events Cerebrating good things, feeling pleasure o Relaxing and playing o Cognitive processing o Adaptive sense of direction and purpose ADHD아동의 간호중재 39

Activity Programs o Daily Program Activities Of Daily Living Studying Short Walking Behavior Modification(BM) o Weekly Program Arts Balloon Art Cooking Outgoing Therapeutic Recreation Sing-along Dancing Shopping Seasonal Activities ADHD아동의 간호중재 40

Daily Time schedule 8: 00 Breakfast 1300~18: 00 Family Visiting 16: 00 Group 9: 30 Studying 18: 00 Dinner 10: 20 Break 19: 00 Activity for social 7: 50 Wake up exercise 10: 30 Therapeutic Activity Growth 20: 00 Snack 12: 00 Lunch 13: 00 Free Play & activity (Drink &fruits only) 21: 00 Unit jobs, TV off 22: 00 In rooms with low lights, bed time 2: 00 Snack ADHD아동의 간호중재 41

Unit Policy o Keep hands and feet to ourselves (Aggressive behavior not permitted) p Leave tobacco, lighters, matches, sharp objects, glass, cords, razors, expensive items o Respectful of others p Wear something on feet o No boys in girls rooms o No girls in boy rooms p People can’t loan other’s items p Visiting : 6: 00~7: 30 ADHD아동의 간호중재 42

Social Growth Program for Young Children o Group play - Active listening - Warm message - Asking questions - Sharing feelings - Standing up for me - Self-control ADHD아동의 간호중재 43

Stress Management for Adolescents o Group lecture& discussion - What is stress - Anger management - Coping Strategies ADHD아동의 간호중재 44

ADHD의 간호중재 Behavior Management o Nonrestrictive Interventions - To prevent the need for the more restrictive interventions(seclusion, restraint) - Ignoring peer provocations - Negotiating with peers - Processing with staff - Reward programs - Token economies - Self-directed time-out (30분 이내) ADHD아동의 간호중재 45

ADHD의 간호중재 Behavior Management o Behavior Modification (BM) - Positive Reinforcement - Target behavior & Goal setting with Child - Achievement Reward should be Planned with Child ADHD아동의 간호중재 46

ADHD의 간호중재 Behavior Management o Time-out - A process in which a child or adolescent can calm down usually by being quiet and disengaging from current stressors - The time-out may be conducted without removing a child from peers - It may be staff-directed or at the child’s request (self-directed) ADHD아동의 간호중재 47

Parents can learn Happy parenting(1) Enjoy parenting - They don’t endure it! o Refuel, Restore, Renew o Know that attitude is almost everything o Create a cozy atmosphere o Know that fathers are MVPs o Listen, listen o ADHD아동의 간호중재 56

Parents can learn Happy parenting(2) o o o o Know when to say yes Aren’t perfect Know that guilt is a waste of time Know that resentment poisons a family Your Children never stop growing Let your children get the best of them Romance Make happy memories ADHD아동의 간호중재 57

Pt M/15 (63 kg) Time Medication Concerta OROS tab 27 mg(methylphenidate) 1 tab[P. O] qd pc 9 A/Y Concerta OROS tab 18 mg(methylphenidate) 2 tab[P. O] qd pc 63 mg #4 9 A/Y Risperdal 2 mg tab (Risperidone) 1 tab[P. O] qd hs 9 P/ [Prn] Zyprexa Intra Muscular 10 mg(Olanzapine)1 via [IM] if irritable, violent [Prn] Ativan 4 mg inj (Lorazepam)0. 5 amp[IM] x 1 언어적 통제로 행동 조절 되지 않을 때X 0 Days M/15 (50. 5 kg) M/13 (70 kg) Concerta OROS tab 27 mg(methylphenidate) 1 tab[P. O] qd 7 A/Y, Concerta OROS tab 18 mg(methylphenidate) 7 A/Y, 1 tab[P. O] qd Lithan 300 mg tab 1 tab[P. O] bid q 12 h 비고 : 오전7시, 저녁7시 투약 7 A/Y, 7 P/ Solian 400 mg tab (Amisulpride) 1 tab[P. O] qd p pc 7 P/ Penid 10 mg tab (Methylphenidate) (4 -4 -2) tab [P. O] tid pc 100 mg, 저 녁약 4 p 9 A/Y, 1 P/ Y, 4 P/ Solian 400 mg tab 1 tab[P. O] bid a pc, hs 800 mg 9 A/Y, 9 P/ ADHD아동의 간호중재 62