With ongoing shutdowns and disruptions to daily life, children may be asking many questions about the coronavirus disease 2019 (COVID-19), and what it means for them. Responding to their concerns calmly and truthfully is the key to assuaging their fears, said Dawn Maaks, PhD, CPNP-PC, PMHS, FFANP, during a session at the National Association of Pediatric Nurse Practitioners (NAPNAP) 2020 virtual meeting.

When it comes to handling children’s questions during the pandemic, Maaks said health care providers play a role in providing anticipatory guidance that is developmentally grounded. For example, preschool-age children crave reassurance and do not need in-depth details, while adolescents should be engaged in honest conversations about reducing the risk of contracting COVID-19.

For all ages, Maaks said it is important to be truthful, but answer the question asked instead of complicating the issue.

Discussions with preschool-age children should be fun and reassuring. Instead of dwelling on the lack of usual activities, for example, parents can emphasize games or puzzles that can be played at home and which may not be a part of the usual routine.

When discussing COVID-19 with school-age children, parents should identify their worries, and work to clarify their understandings. If they ask a question, answer that specific fear without overanalyzing it and adding unnecessary details that may confuse them further. Routines are also important, and Maaks recommended establishing a daily routine to ensure children feel secure.

Adolescent children present their own challenges. Maaks said adults should remember that adolescents feel invincible, and as a result may not take the virus and precautions as seriously as they should. To handle this, she suggested instilling a sense of responsibility. Remind teenagers that wearing a mask or taking other precautions are not only for their own safety, but also for the safety of others, such as their grandparents or other family members who may be more at risk.

“So much of what we’re doing with social distancing is about protecting us as individuals, but it’s seriously about protecting our most vulnerable populations,” Maaks said.

Like adults, many children may be experiencing fear and anxiety during the pandemic, Maaks said. When counseling parents on how to handle this, emphasize the importance of a healthy diet, physical activity, adequate sleep, and grounding or mindfulness techniques. Warning signs for anxiety in children can include developmentally inappropriate worries or sadness, altered sleep or appetite, excessive externalizing, or developmentally inappropriate separation anxiety.

“It’s normal to fear bad things happening to people you love in a pandemic, but that shouldn’t be consuming,” Maaks said. “And if it is, that’s a sign the child needs help.”

Maaks D. COVID-19 Pediatric Issues. Presented at: 2020 Virtual Conference on Pediatric Health Care; June 4-6, 2020; virtual. Accessed June 11, 2020.

Articles

With ongoing shutdowns and disruptions to daily life, children may be asking many questions about the coronavirus disease 2019 (COVID-19), and what it means for them. 

Discussing COVID-19 with Children and Adolescents 

The American College of Sports Medicine (ACSM) published a new expert consensus statement that provides guidance on training staff and establishing emergency plans to prevent cardiovascular events at fitness facilities, community and hotel fitness facilities, and sporting event venues, according to a press release.

The paper is an update to previous guidelines released by ACSM and the American Heart Association in 1998.

“Vigorous exercise is a double-edged sword in that it protects against but, in rare instances, can trigger acute cardiac events,” said Barry A. Franklin, PhD, FACSM, co-author and ACSM past president, in a press release. “This ACSM special communication provides health-fitness facility professionals with the latest information on the modulators of exercise risk, and how to reduce them, as well as key elements of a well-organized emergency response system."

The objective of the new statement is to further reduce the rare cardiovascular complications of exercise while removing unnecessary barriers to widespread participation in an active lifestyle, according to the press release. It seeks to minimize screening and other factors that may impede the use or availability of physical fitness facilities compared with the 1998 statement.

the increasingly recognized health benefits of even low levels of physical activity (PA).

cardiovascular events incited by physical activity among healthy adults and those with established cardiovascular disease.

some pre-exercise screening strategies that present a barrier to PA due to requiring additional medical testing for clearance.

immediate assistance provided by nonmedical personnel to help greatly reduce the morbidity and mortality of acute cardiac events (dialing 911, initiating bystander cardiopulmonary resuscitation, etc).

Further, the paper addresses the cardiovascular risks of physical activity, cardiovascular screening of prospective fitness facility members/users, and general recommendations for fitness-related facilities, according to the press release. This includes emergency response, staffing and training, automated external defibrillators, signage, member training, and mass participation sporting events.

“Publishing this updated statement aligns with ACSM’s mission to advance and integrate scientific research to improve education and the practical applications of exercise science and sports medicine,” said Lynette Craft, PhD, ACSM chief science officer and fellow, in a press release.

At the Heart of the Matter: ACSM Updates Recommendations to Prevent Cardiovascular Events at Fitness Facilities. ACSM. Published June 26, 2020. Accessed June 26, 2020.

The paper is an update to previous guidelines released by ACSM and the American Heart Association in 1998. 

ACSM Updates Recommendations to Prevent Cardiovascular Events at Fitness Facilities

Officials with the FDA have approved a 300 mg single-dose pre-filled pen for dupilumab (Dupixent, Regeneron) for certain patients 12 years of age and older who have atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis for at-home administration.

"Chronic type 2 inflammatory diseases such as atopic dermatitis, asthma and chronic rhinosinusitis with nasal polyps can be incredibly complex to manage, leaving patients burdened and apprehensive about their treatment options," said Regeneron president and CEO George D. Yancopoulos, MD, PhD, in a press release. "The Dupixent pre-filled pen was specifically designed to provide patients with an easy-to-use, convenient option so they can feel more comfortable administering their injections."

The dupilumab pen features a hidden needle and single-press auto-injection, along with visual and audio feedback to help with administration. The pre-filled syringe continues to be available in both 200 mg and 300 mg doses for use in a clinic or at home by self-administration, whereas the 300 mg dupilumab pen is expected to be available in the United States by Q3 2020.

Dupilumab has been studied in more than 10,000 patients across 50 clinical trials in various chronic diseases driven by type 2 inflammation. Further, dupilumab is being studied in a broad range of clinical development programs for diseases driven by allergic and other type 2 inflammation, including pediatric asthma, pediatric atopic dermatitis, eosinophilic esophagitis, and chronic obstructive pulmonary disease.

Serious adverse effects (AEs) may occur from dupilumab, including hypersensitivity, anaphylaxis, eye problems, and inflammation of the blood vessels. The most common AEs include injection site reactions, redness, swelling, cold sores of the mouth, itching, and insomnia.

FDA approves new Dupixent® (dupilumab) pre-filled pen designed to support more convenient self-administration. PR Newswire. https://www.prnewswire.com/news-releases/fda-approves-new-dupixent-dupilumab-pre-filled-pen-designed-to-support-more-convenient-self-administration-301080450.html. Published June 19, 2020. Accessed June 22, 2020.

The drug is indicated for certain patients 12 years of age and older who have atopic dermatitis, asthma, and chronic rhinosinusitis with nasal polyposis for at-home administration.

Dupilumab Pre-filled Pen Granted FDA Approval for More Convenient Self-Administration

By Marilyn Bulloch, PharmD, BCPS, FCCP; Fuller Currie, PharmD Candidate 2021; Allison Field PharmD Candidate 2021; and Pierce Gowan PharmD Candidate 2021

Multiple OTC products have been proposed to treat coronavirus 2019 (COVID-19), but their true role remains unclear. Vitamin C and zinc are among the adjuvant treatments being evaluated for patients with COVID-19 due to their various immune-enhancing properties and possible antiviral effects.

Vitamin C, at doses higher than usually seen in outpatient care, has been shown to improve mortality in sepsis and to have positive clinical results in patients suffering from viral infections.

 The exact mechanism of vitamin C’s beneficial effects is unclear; however, it is known that vitamin C is a potent antioxidant with immunomodulatory properties and significantly concentrates in important immune cells.



Studies have shown possible clinical benefits in patients with other viruses, including herpes zoster, varicella zoster, and influenza through an unclear antiviral mechanism.

 It is proposed this may occur with coronaviruses as well.

Zinc is naturally found in the body and is the second-most abundant trace element.

 It has been taken OTC for years to relieve symptoms of viruses such as the common cold or influenza. Unlike vitamin C, zinc’s antiviral mechanism is more established. It inhibits RNA-dependent RNA polymerase necessary for viral replication, including viruses such as influenza and COVID-19.



Although further studies are needed to establish a firm recommendation regarding the use of vitamin C and zinc in the treatment of COVID-19 positive patients, their past success in other viruses and sepsis, ease of access, relatively low price, and strong safety profiles makes them attractive choices as adjuvant therapies.

The data available are primarily limited to hospitalized patients. Whether they will be beneficial in outpatients with less severe disease also remains to be determined. As with so many other aspects of COVID-19, it is important for pharmacists to be aware of the ongoing studies and adapt accordingly as more robust information becomes available.

A version of this article was originally published by Pharmacy Times. Visit 

https://www.pharmacytimes.com/news/evaluating-the-efficacy-of-adjunctive-therapies-used-to-treat-covid-19-the-role-of--vitamin-c-and-zinc

Colunga Biancatelli RML, Berrill M, Marik PE. The antiviral properties of vitamin C. 

. 2020 Feb;18(2):99-101. doi: 10.1080/14787210.2020.1706483. Epub 2019 Dec 23.

Marik PE. Hydrocortisone, Ascorbic Acid and Thiamine (HAT Therapy) for the Treatment of Sepsis. Focus on Ascorbic Acid. 

. 2018 Nov 14;10(11):1762. doi: 10.3390/nu10111762.

Shittu MO, Afolami OI. Improving the efficacy of Chloroquine and Hydroxychloroquine against SARS-CoV-2 may require Zinc additives - A better synergy for future COVID-19 clinical trials. 

. 2020 Ahead of print Jun 1;28(2):192-197.

Evaluating the Role of Vitamin C and Zinc in Treating COVID-19

A new study shows that early signs of being more susceptible to type 2 diabetes (T2D) as an adult can be seen in children as young as age 8 years, decades before it is likely to be diagnosed, according to researchers from the University of Bristol.

Researchers looked at the effects of a genetic risk score for developing T2D as an adult on metabolism, measured from blood samples taken from participants in the study when they were aged 8, 16, 18, and 25 years.

Over 4000 participants were analyzed from the health study, “Children of the 90s,” which was established at the University of Bristol in the early 1990s. Researchers combined genetic information with an approach called metabolomics, involving measures of many small molecules in a blood sample to try and identify patterns that are specific to early stages of T2D development.

“We knew that diabetes doesn’t develop overnight. What we didn’t know is how early in life the first signs of disease activity become visible and what these early signs look like,” said lead investigator Josh Bell, MD, in a press release. “We addressed these by looking at the effects of being more genetically prone to type 2 diabetes in adulthood on measures of metabolism taken across early life.”

The study was conducted among younger people who were generally free of T2D and other chronic diseases to see how early in life the effects of being more susceptible to adult diabetes became visible. Certain types of high-density lipoprotein cholesterol were reduced at 8 years of age before other types of cholesterol including low-density lipoprotein were raised. Inflammation and amino acids were also elevated by 16 and 18 years of age, with these differences widening over time.

“We’re talking about the effects of susceptibility rather than of clinical disease itself,” Bell said in the press release. “This does not mean that young people ‘already have adult diabetes’; these are subtle differences in the metabolism of young people who are more prone to developing it later in life.”

These findings help reveal the biology of how diabetes unfolds and what features may be targetable much earlier on to prevent the onset of disease and its complications, according to the study authors.

“This is important because we know that the harmful effects of blood glucose, such as on heart disease, are not exclusive to people with diagnosed diabetes but extend to a smaller degree to much of the population,” Bell said.

Signs of being prone to adult diabetes are already visible at age 8 years old. University of Bristol. 

https://www.bristol.ac.uk/alspac/news/2020/early-signs-of-diabetes.html

. Published June 19, 2020. Accessed June 22, 2020.

Early signs of being more susceptible to type 2 diabetes (T2D) as an adult can be seen in children as young as age 8 years, decades before it is likely to be diagnosed, according to researchers from the University of Bristol.

Study: Signs of Adult Diabetes Already Visible by Age 8 Years

interviewed Shelley Johns, PsyD, a Regenstrief Institute research scientist and ​associate professor of medicine at Indiana University School of Medicine on ways in which practitioners can monitor for signs of anxiety and depression in patients when they come in for treatment.

The discussion includes a discussion of the main focus of Johns’ work as a clinical health psychologist, what adaptive coping is and how can it help patients who exhibit signs of anxiety or depression, and how the coronavirus disease 2019 (COVID-19) pandemic is affecting patients with pre-existing anxiety and depression.

Johns noted that at her clinic and the clinics of the 7 clinical psychology doctoral students who she supervises, the number of patients seeking mental health care has not gone up since the start of the COVID-19 pandemic.

She said, “That really worries me because I know just from talking with my friends and my neighbors, and other people in my social network, that problems are worsening. I just feel like everybody right now kind of chalks it up to ‘we're all under this stress so I need to just suck it up and deal with it,’ and that is really not going to be the best approach for people who have clinically significant symptoms of anxiety and depression. There are evidence-based treatments that can help reduce their suffering.”

Johns also discussed how anxiety or depression can appear or cause physical symptoms that a patient may be seeking treatment for, how a practitioner can potentially identify these symptoms as anxiety or depression, and some tools for practitioners to recommend to patients who are seeking treatment for these symptoms.

Videos

Contemporary Clinic® interviewed Shelley Johns, PsyD, a Regenstrief Institute research scientist and associate professor of medicine at Indiana University School of Medicine on ways in which practitioners can monitor for signs of anxiety and depression in patients when they come in for treatment. 

Monitoring for Signs of Anxiety and Depression in Patients During COVID-19

interviewed Susan Van Cleve, DNP, RN, CPNP-PC, PMHS, FAANP, FAAN, Clinical Professor and Primary Care Pediatric Nurse Practitioner program director, University of Iowa College of Nursing, on identifying and treating anxiety in children and teens who present comorbidities. The discussion includes whether medication is always a viable option for treatment and whether there are situations in which it is obvious that medication is the best option for children and teens.

Van Cleve noted that periodically, there are situations in which the best option is to pursue medication. She said, “There will be a patient who has received lots of therapy, and the therapist has been working with that child or the teen, and they feel that they're at a standstill, and that the only next step would be medication. That's when we would just start with medication and encourage that child to continue with a therapist.”

Van Cleve also discussed whether identifying anxiety as a disability in academic settings is important for the success of treatment, whether anxiety being seen as more commonplace today is advantageous or disadvantageous when approaching treatment, and how the treatment of anxiety in children and teens may be progressing in the future.

Contemporary Clinic® interviewed Susan Van Cleve, Clinical Professor and Primary Care Pediatric Nurse Practitioner program director, University of Iowa College of Nursing, on identifying and treating anxiety in children and teens who present comorbidities.

Approaching Medication as a Treatment for Children and Teens with Anxiety 

 Hi, I'm Alana Hippensteele from Pharmacy Times. Before we get started, one of our top articles today discusses how a recent study that is the first of its kind demonstrated that there has been a decline in cancer-related deaths following the adoption of the Affordable Care Act in states that adopted it. There’s more of that on PharmacyTimes.com.

Today, I’m speaking with Dr. Dawn Garcon Maaks, the Immediate Past President of NAPNAP and the Associate Professor at the University of Portland in the School of Nursing, on caring for children with ADHD in advance of her presentation on the subject at the 2020 Virtual Conference on Pediatric Health Care.

How has caring for children with ADHD changed over the years?

 I think it was just like I said when I was in my NP school. I remember, you know, 

Oh my gosh, we're gonna talk about ADHD now. That's mental health!

 So I think we've kind of gone from this stigma of not knowing what it is to the flip side, and now people come in and say, 

Well my teacher said she can’t tell me my kid has ADHD, but she thinks he does and he needs medicine.

have they done any school testing, have they figured out if this is a learning disorder?

Is this in fact happening in 2 domains because if it's just happening at school and it's not happening outside of school, that to me sounds like an intellectual or learning disorder and not an attention deficit disorder. Is it just happening at home and the kid does fine at school? In which case, there might be some interplay between the adults and the child in the home that might be contributing to some of those behaviors.

So, I think we've gone from not wanting to talk about it, talking about it like it’s a dirty word. I vividly remember the first couple of times I talked to parents about putting them on stimulants, they were like, 

I don't want my kid to be addicted, and he's gonna be a junkie.

 I don't think we feel that way now. I do feel like people are, and rightly so, a little concerned about what are the long-term effects, and 

I don't know that I want to subject my child to taking medication every day for the rest of their lives

, and that's where I think having conversations around if we can set them up with behavioral modification, as this child developmentally gets better, he may be able to get off medication for this isn't necessarily something they have to do their whole life. But if a child is not doing well socially, if their grades are poor, they're not learning what they need to learn, and we know they have increased injury risk and all the other comorbidities that we know of untreated ADHD, to me it sounds like if we can use a little bit of medication—and I am of the start low and go slow crew, I openly admit to that—if we can start with a low dose and a teeny amount, like you know 18 milligrams of extended-release methylphenidate, and it changes this kid's world, well that's the kind of kid that probably will grow up to the point that they may not need medication in the future, and we should celebrate that. We should celebrate that they develop the skills that they needed to be successful, and that they didn't have to be managed by medications.

 Yeah, absolutely. How do you see caring for children with ADHD progressing in the future?

 That's a question! There's a part of me that goes, you know, artificial intelligence is going to dramatically change health care in the next 5 to 10 years. Some of us are going to be replaced, honestly, and given the fact that in some instances, computers do better jobs at diagnosing in some circumstances, that may or may not be a bad thing. That's a coffee talk, 

. You can have that conversation on your own, and whatever your belief is on that.

So, I do see that happening, I could see better diagnostic precision, maybe over time as we do more of the psychiatric epidemiologic studies of really looking at the population level because anytime you just deal with people that are seen in clinic, you're getting the worst cut of any condition, you know, when you go out and you look at symptoms in the general population, then you see the full spectrum.

So, a lot of our recommendations and evidence are based on the worst of the worst that show up at an academic medical center because the majority of kids never step foot in an academic medical center their entire childhood. And so all of our recommendations are based on that population, so I could certainly see, you know, with like big data and data analytics starting to get a better idea of what that spectrum looks like and maybe identifying kids better. You know, I would love to see something that is as efficacious as the stimulants without the side effect profiles that come with them.

I think there is a financial incentive to the development of drugs that people will be on for a long time, and so I wouldn't be surprised that there aren't some exceptionally smart people that are working on that as we speak. So, I'm sure there will be different approaches. I just don't see human development evolving to the point that kids in 50 years are that much different than kids are today. So, I mean I think this always going to be an issue. In 50 years from now, are they gonna look back and go, 

You filled out a piece of paper and looked at what the teacher said and the parent said, and then you did this 20 minute interview, and that's how you figure it out

? I think some of that probably will be different, but I will tell your readers, I have made many a prediction in the 30 years I've been a nurse, and I'm rarely right. So, I certainly wouldn't go hedging any bets on what my opinion is today.

 It can be very hard to make accurate predictions about the future, specifically in relation to understanding mental health or AI or technology because we really have no idea.

 No we don’t. And I think, you know, there's a big push on psychogenomic analysis, and, as many of us are aware, there was testing for ADHD and then that proved not to be evidence-based, and so we got rid of that, and so we're not doing that anymore, but I'm pretty sure there's a company that's working on that right now. But I do have full faith and confidence that we're still gonna have kids with ADHD, we're still gonna have adults with ADHD, we're still gonna have companies that are trying to figure out a way to help us identify them, and help us figure out which medication works because, as we all know, this is not, you know, amoxicillin is a first-line for upper respiratory tract infections that 90% of the time is going to knock it out. There's a lot more personal variability as far as tolerance, as far as response to our psychoactive drugs. And so, I think 10 years ago we never would have talked about the prefrontal cortex, the amygdala, the nerves in the patients, this pathway and that pathway, and how this medication affects the GABA receptor versus the serotonin receptor. We never would have had that conversation 10 years ago because we've grown leaps and bounds in our understanding of the central nervous system and how it functions, and therefore understanding why these medications work.

But what I what I can guarantee is it's still going to be an issue. I think we're going to have a better understanding of how the brain works and why the brain works, and I think as we develop, we're going to do better and not have as much failure with our first lines as we do now because I think we'll be able to have more targeted approaches to that individual’s biology, if that makes sense. It would be a cool, like a Jetsons moment.

 I'm looking forward to getting some, I don't know, little tech thing to be able to tell me what's wrong and what needs to be fixed.

 That and I need Rosie to clean my house.

 I'm all for that. Alright well, thank you, Dr. Maaks, so much for taking the time out to speak with me today. Now, let's hear from some of our other MJH Life Sciences brands on their latest headlines.

Dawn Garcon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN, the Immediate Past President of NAPNAP and the Associate Professor at the University of Portland in the School of Nursing, discusses how caring for children with ADHD has changed and may progress in the future.

How Caring for Children with ADHD Has Changed, May Progress in the Future

 spoke with Robert Schumm, MBA, president of Ascensia Diabetes Care, about the challenges that patients with diabetes are facing during the coronavirus disease 2019 (COVID-19) pandemic.

Many challenges are the same for those with and without diabetes, Schumm said, including the isolation of stay-at-home orders and shortages of household items or other essentials.

“The thing is that for people with diabetes, sometimes these things have all that much more of an importance,” Schumm said.

For example, the loss of a job could not only add to financial strain, but it could make it impossible to get necessary medications, such as insulin. Increased stress can also impact blood glucose levels, Schumm said, leading to greater concerns around glycemic control.

There are some solutions, however. Schumm emphasized that patients should have enough supplies of their medications and equipment, whether that’s by getting a 90-day supply or asking their pharmacist for other solutions. Telemedicine has also proven to be extremely helpful during the pandemic, as patients with diabetes can still contact their providers with questions or concerns, while staying safely at home. Online options also offer a different way to obtain medical supplies that might normally be purchased at the pharmacy, Schumm said, and patients should become more comfortable with ecommerce options.

Contemporary Clinic spoke with Robert Schumm, MBA, president of Ascensia Diabetes Care, about the challenges that patients with diabetes are facing during the COVID-19 pandemic. 

Patients with Diabetes Face Unique Challenges During COVID-19 Pandemic

New research illustrates the importance of providing education and training to pediatric and family medicine providers regarding human papillomavirus (HPV) vaccines, according to a Boston Medical Center press release. This coincides with health care systems changes, including starting an HPV vaccination series before the age of 11, which improves the overall rate of HPV vaccinations among adolescent patients.

The study results show improvements at each stage in the HPV vaccination series. These improvements were sustained beyond the conclusion of the intervention period, demonstrating that these types of programs could be used to help produce long-term increases in HPV vaccination rates, as mentioned in the journal 

.

DOSE HPV (Development of Systems and Education for HPV) is a multilevel inter-professional provider training program aimed at improving HPV vaccination rates, according to the press release. The program educates providers on how best to communicate with parents and caregivers about HPV vaccinations, as well as how to use data in their practices to address barriers to access and completion rates of the vaccine series for their patients.

Information from 16,136 individuals between the ages of 9 and 17 years from 5 pediatric primary care or family medicine practices was included in the research. Data about the pre- and post-intervention HPV vaccination series initiation and completion were analyzed for patients with at least 1 visit to a clinical site and 1 HPV vaccination dose or a completed HPV vaccine series.

The vaccine series initiation increased from 75% before the intervention to 90% after the intervention, and the entire series completion rate increased from 60% before the intervention to 69% after the intervention, according to the press release. Rates continued to rise for 6-18 months after the intervention was completed.

The 11 to 12 years of age group was analyzed separately with a vaccine initiation increase from 83% before the intervention up to 93% afterwards. Vaccine series completion rates increased from 54% pre-intervention to 69% post-intervention.

“Vaccination rates have significantly decreased due to COVID-19, and interventions to rapidly restore rates are needed to prevent epidemics of other vaccine-preventable diseases,” said lead researcher Rebecca Perkins, MD, MSc, in the press release. “The results of this study can help shed light on the importance of arming providers with the skills necessary to best communicate with families on the importance of getting vaccinations to help decrease the chances of other disease outbreaks in children and young adults.”

Further, the key program components included educating providers on how to better communicate with families, decreasing missed opportunities for vaccination, and beginning the HPV vaccine series prior to 11 years of age.




Multilevel interventions improve HPV vaccination rates of series initiation and completionation and completion. Boston Medical Center. 

https://www.bmc.org/news/press-releases/2020/06/15/multilevel-interventions-improve-hpv-vaccination-rates-series

. Published June 15, 2020. Accessed June 18, 2020.

New research illustrates the importance of providing education and training to pediatric and family medicine providers regarding human papillomavirus (HPV) vaccines.

Study: Multilevel Interventions Improve HPV Vaccination Rates

Dawn Garcon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN, the Immediate Past President of NAPNAP and the Associate Professor at the University of Portland in the School of Nursing, discusses the realities of clinical primary care management for children with ADHD symptoms.

So, what are some of the realities of clinical primary care management for children with ADHD symptoms?

 So, I think, you know, first, I have a one-word answer to that: It's reimbursement. If you talk to those of us who work in this space, it's like, you know, our system is set up right now to be a volume-based system. I don't think any of us that work in the clinical arena feel that that's the best thing, but it's the reality of it. In pediatrics, our margins are particularly poor compared to other subspecialties, and so, you know, if I'm a primary care provider, I'm hoping to do this assessment of this kid, if I'm lucky, in a 30-minute visit, but I might be trying to do it in a 15 to 20 minute visit. If you see me in behavioral health, my intakes are an hour and a half. I get to go back to this kids’ development, I get to really assess, you know, symptoms that are suggestive of maybe an autism spectrum disorder, where maybe they're just regulating because they're overwhelmed because of sensory input, and not necessarily that they're impulsive or inattentive in the traditional sense.

So, I think some of it is just the timing of it. I think the other thing that is really hard for people in primary care, like I said, is I know within my FQHC, I had two pediatricians that will not diagnose or manage these kids. They don't feel like they had the training that they needed for it, they don't feel like they have the time for it, and so, you know, I think those of us who work in pediatric primary care, whether it's as family practitioners or as pediatric specialists, that we really understand the gift and the responsibility of taking care of children with developing brains. And so if we don't feel that we don’t have sufficient education to be comfortable with it, if we don't have systems that are in place to allow us the time once we do have the education and know the right way of doing it, then I think that's what leads to people saying, 

If you fail the first line, you need to go out and get in the 6 to 12-month line.

 And that's why I feel like these conversations like the one we're having at our virtual conference are so important because these are direct conversations for people in primary care about increasing their competence and their confidence in this space. So maybe when they fail that first line, they're willing to look at a second line and try that before they send them out, or if there's something more serious that's happening, they recognize that, 

Hold on, I probably shouldn't monkey with this for two or three other drugs, this is a kid that might have something more severe I need to get him out and get him the care that they deserve

 Right, right. So, you were talking about how the mild to moderate symptoms may not require medication. In terms of moderate to severe, what are some potential symptoms, except I don't want to be too broad with it, but what are some potential symptoms where it becomes very obvious that medication is the only route?

 I personally never feel like medication is the only route for ADHD, and I'm pretty clear with my families about that because I feel like, in public disclosure, I live with someone who openly admits he has ADHD, and he's a 50-something year-old man who struggled with this for years, and I've watched him develop really good coping skills that use the theory of behavioral economics. And basically what that says is: You and I probably didn't spend a lot of time thinking about what we were going to put on today, like I knew I was doing this interview, and so I needed to look professional, and so I knew a t-shirt probably wasn't appropriate, but beyond that I don't know that I said to him that, 

, or let's really like, I was standing in my closet and I went, 

Okay this is the professional section of my clothing

I'm gonna grab something, put it on, does it feel good? I'm wearing this today.

 It wasn't like some great thought out thing. I got up this morning, I had breakfast, I made my egg whites like I always do, I made my coffee the way I always do. Did I really stand there and think about how much cream I was putting in my coffee? No, I automated it.

What we know is that human only have so much processing bandwidth in their brain. And so, for people with ADHD, the worst thing you can do is take them to a Chinese restaurant with a 10-page menu because there's so many choices there they just get completely overwhelmed. And so like, a great coping mechanism is, if you go to a restaurant and there's like 5 pages of things, knowing that food style, what's something that you like that's pretty sure to be on the menu, and then you don't have to get overwhelmed by the menu. Like, you know, I'm a General Tsao's chicken person. I openly admit that that's my jam, and so, if I have ADHD and I'm sitting there getting overwhelmed by 5 different styles of egg foo yung, my brain just goes, 

Alright, I'm going to make this decision,

 because it needs that bandwidth for the fact that, if I have ADHD, while you and I are having this conversation, the back of my brain is having a whole separate conversation, and I'm thinking about something that has nothing to do with what we're talking about right now. You don't ask kids with ADHD to make repeated kind of boring everyday decisions, you simplify things for them. The child has a uniform, okay in the winter, you need to wear long pants, and a long shirt, you need socks on your feet, you need a closed-toe shoe. In the summer, you need a short sleeve shirt, you're gonna wear, you know, this color shorts, and pretty much when you go out and you buy stuff for your child, you put it all in the same color range so that everything is kind of mix-and-match. Almost, if you think of like your garanimals, if you remember your garanimals, they were kids clothing where like the lion tag always went with the lion pants, and the tiger shirts always want with the tiger pants.

We know that we as humans don't always think about the things that we do repetitively. We've all been in our car going home or walking home after commute, and we're like, 

 Because we were thinking about something else. Well, that's their life all day, every day. So if we know that's what it's like for these kids, then teaching them behaviors and skills that they can put into place to make them be successful, teaching them organizational skills, teaching them documenting skills of where they can save things that they can retrieve at a later date, so something like the Evernote app is an amazing thing for somebody with ADHD because I can create subfolders where I keep important things that I need to remember. So, somebody says to me, 

 I have a piece of paper that I can pull up on the computer that I can immediately go to that and not have to trust that my brain that has 5 different things going to have the bandwidth to process that additional thing. Teaching parents that sleep matters, if your child has bad sleep habits, and if they're not sleeping well, their behavior is going to be more disregulated. Teaching them that physical activity, running around, getting hot, stinky, and sweaty makes the difference. Michael Phelps became a swimmer because he had god-awful ADHD, and his mom needed to be able to burn some of that energy off. Sticking them in the backyard or going out on a bike ride with them or letting him run around a park and burn that energy off, those are as effective in some cases as medication.

So, if I have a parent who comes in with a kid whose grades are really good, it bothers them cause, frankly, if it doesn't bother the kid it doesn't bother me. I don't treat parents’ concerns with medication, I treat if it disturbs the child. So if I have a kid who comes in and they're kind of worried about it, but they're not sure if they want to take medicine, I'm always like, 

Great, let's go connect you with one of our therapists, let's work on some behavioral strategies, some behavioral modification, let's see how that works

. And then the other conversation when it comes to medication is: These are medications that I'm going to be able to tell you if they're going to help you in 3 days because of their short half-lives. You're going to go home, you're going to take this medication, you're going to notice a difference within a week, and you know what, if you have bad side effects, if you say yeah I can't sleep, stop it, the next night you're going to be able to sleep because it will have worked out of your system. This isn't like, you know, SSRIs and other drugs that have a long ramp up until we see treatment response, and then a long time to get them out of their systems. And so what I think is important is that pharmacists and nurse practitioners and physicians and PAs and nurses and anybody who are mental health people that are working in this space have these conversations with parents about what their concerns are and helping them understand that the very pharmacokinetics of these agents means that we can stop and pivot relatively quickly, at least when it comes to the stimulus. You know, the alpha-adrenergics, not the same thing the, you know, atomoxetine is not the same thing, but at least kind of the first line drug. We've got some wiggle room to deal with the issues that come up and be able to do some education around that, and then pivot and respond if issues develop.

 Yeah, absolutely. Alright well, thank you, Dr. Maaks, so much for taking the time out to speak with me today now let's hear from some of our other MJH Life Sciences brands on their latest headlines.

Dawn Garcon Maaks, PhD, CPNP-PC, PMHS, FAANP, FAAN, the Immediate Past President of NAPNAP, discusses the realities of clinical primary care management for children with ADHD symptoms.

The Realities of Clinical Primary Care Management for Children With ADHD

A new, multi-ethnic study found older adults with low vitamin K levels were more likely to die within 13 years compared with those whose vitamin K levels were adequate. The data suggest that vitamin K, a nutrient found in leafy greens and vegetable oils, may offer protective health benefits as people get older, according to the researchers.

A meta-analysis was conducted, involving approximately 4000 Americans from 54 to 76 years of age, one-third of whom were non-white. The participants were categorized according to their vitamin K levels and heart disease. However, those with the lowest vitamin K levels had a 19% higher risk of death, compared with those whose vitamin K levels reflected adequate vitamin K intake.

Participants on the blood thinner warfarin were excluded because vitamin K counteracts the anti-clotting effects of warfarin, according to the study authors. Additionally, all participants were free of heart disease at baseline and had vitamin K levels measured during a single medical exam that was part of each study’s regular protocol.

“The possibility that vitamin K is linked to heart disease and mortality is based on our knowledge about proteins in vascular tissue that require vitamin K to function. These proteins help prevent calcium from building up in artery walls, and without enough vitamin K, they are less functional,” said study author Kyla Shea in a press release.

The limitations to the study include that circulating phylloquinone was measured from a single blood draw, rather than from repeated blood tests over time. Further, there were fewer heart disease events compared with total deaths, which may have limited researchers’ ability to detect statistically significant risk of heart disease.

The study authors concluded that this study cannot establish a causal relationship between low vitamin K levels and risk of death because it is observational, although the study adds existing evidence that vitamin K may have protective health benefits.

Multi-ethnic study suggests vitamin K may offer protective health benefits in older age. TuftsNow. 

https://now.tufts.edu/news-releases/multi-ethnic-study-suggests-vitamin-k-may-offer-protective-health-benefits-older-age

. Published June 15, 2020. Accessed June 16, 2020.

The data suggest that vitamin K, a nutrient found in leafy greens and vegetable oils, may offer protective health benefits as people get older, according to the researchers.

Study Suggests Vitamin K May Offer Protective Health Benefits in Older Age

The authors of an editorial published in the 

 call for rapid policy reform and investment in nurses and nursing in order to leverage the skills of the nursing workforce, according to a press release from the University of Pennsylvania School of Nursing.

The editorial outlines the following areas for improvement:

Multisectoral investments to redesign and innovate existing health services.

Forge supportive regulations and legislation for nurses.

Optimize nursing contributions to best meet global public health needs and increase the potential to contain and manage the pandemic and future public health and humanitarian crises.

“The far-reaching consequences of COVID-19 have shown that we need widespread, rapid, and intelligent investment in nursing through informed action that fully leverages the health care workforce,” said study author William E. Rosa, PhD, MBE, NP-BC, FAANP, FAAN, and Linda H. Aiken, PhD, RN, FAAN, FRCN. “Our communities and the health of populations worldwide depend on these urgently needed policy reforms and increased investment in nursing now more than ever.”

The recommendations in the editorial are based on a 2018 World Innovation Summit for Health report and include implications for nurses and advanced practice nurses, policy makers, governmental and nongovernmental health partners.

Calling for Nursing Support Amid COVID-19 Pandemic. Penn Nursing. 

https://www.nursing.upenn.edu/live/news/1687-calling-for-nursing-support-amid-covid-19-pandemic

The recommendations in the editorial are based on a 2018 World Innovation Summit for Health report and include implications for nurses and advanced practice nurses, policy makers, governmental and nongovernmental health partners. 

Nursing Support, Policy Reform Needed Amid COVID-19 Pandemic

Contemporary Clinic® spoke with Brigit VanGraafieland, DNP, CRNP, FAAN, assistant professor and director of the Fuld Program at the Johns Hopkins School of Nursing, about telehealth visits for pediatric patients.

VanGraafieland said that telehealth has taken off immensely and has become more mainstream in response to the coronavirus disease 2019 (COVID-19). Although the beginning required a lot of onboarding and training for some health care providers, she has seen telehealth being utilized on multiple different levels in her outpatient setting.

VanGraafieland also discussed the health care in the rural and urban setting, screening for adverse childhood experiences in childcare, and the future of telehealth.

Contemporary Clinic® spoke with Brigit VanGraafieland, DNP, CRNP, FAAN, assistant professor and director of the Fuld Program at the Johns Hopkins School of Nursing, about telehealth visits for pediatric patients.



Telehealth in the Pediatric Patient Setting

A survey found that 18% of people living with diabetes in Denmark needed a referral for a psychologist, but had not been offered one, and 36% said they did not receive the support they needed to cope with their emotions related to diabetes. The data comes from the largest nationwide Danish survey to characterize a major need for better access to psychological and other nonmedical diabetes care.

Results of the study, “Psychological Impact and Need for Psychological Care and Support: What Do People with Diabetes and Caregivers Say? Results of a Scientific Survey of 9,869 People with Diabetes and Caregivers in Denmark,” were presented Friday during the 

American Diabetes Association’s® (ADA’s) 80th Virtual Scientific Sessions

.

The Danish Diabetes Association, Steno Diabetes Center North Denmark, Aalborg University Hospital, and Aalborg University, Aalborg, Denmark designed a national diabetes survey, “Life with Diabetes 2019,” to benchmark impact to daily life, access to care and access to technology and services in order to discover top desires and priorities. Researchers sent out email invitations to 38,820 members of the Danish Diabetes Association. Responses to the survey represented all Danish regions, and the age and gender of respondents were similar to the characteristics of the national population.

Responses from 8918 people with diabetes and 761 caregivers were analyzed. Of the participants with diabetes, 71% had type 2 diabetes, and 26% had type 1 diabetes.
The responses showed:

Although most participants reported generally having access to quality medical diabetes care, approximately 20% of people with diabetes said they experienced a psychological negative impact due to their diabetes “most or all of the time.”

About 19% of people with diabetes reported feeling that “diabetes is taking up too much of their daily life,” and 18% of people felt they needed a referral for a psychologist yet had not been offered one.

Approximately 36% of people with diabetes and 21% of caregivers indicated they are not getting the “support they need to deal with diabetes-related emotions.”

19% of respondents saw a need for a major system-wide improvement in support for dealing with the mental aspect of living with the condition.

Women made up 51% of total respondents and were twice as likely as men to feel they needed a psychologist (24% vs. 12%).

“We also found that people who are involuntarily unemployed, people using insulin for type 2 diabetes, and people who have multiple health issues are at higher risks for negative psychological outcomes,” said Soren E. Skovlund, MsC, the study’s lead author, and senior research scientist, Steno Diabetes Center North Denmark, Aalborg University Hospital and the Department of Clinical Medicine, Aalborg University.

Additional analyses of more than 1100 open text responses revealed that people with diabetes suffer psychosocial affects due to gaps in multiple aspects of care, including access to new technology, quality care in a primary practice setting, and local support for overall well-being.

“Our study highlights that efforts to support vulnerable populations should be multi-pronged and include a psychologist’s care”, said Skovlund. “The psychological impact of diabetes and the opportunities that exist to mitigate it, including optimal access to novel technologies, better individual medical care and person-centered self-management support services should not be underestimated. Integration of psychosocial aspects of living with diabetes is a prerequisite for improving the long-term health and quality of life outcomes for many people with diabetes and their families.”




One in Three People with Diabetes Do Not Receive Support Needed to Deal with Emotional Aspects of Living with Diabetes [news release]. Chicago, IL; June 12, 2020: ADA [email]. Accessed June 13, 2020.

A study of self-reported data from more than 9000 people found overall need for better access to psychological and other non-medical diabetes care for people living with diabetes and their caregivers.

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