Attention deficit hyperactivity disorder

76 Attention deficit hyperactivity disorder

Overview/pathophysiology

Attention deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder involving developmentally inappropriate behavior. ADHD is a common chronic illness in children and one of the most commonly diagnosed mental health conditions among children in the United States. The statistics per the number of school-age children affected vary depending on source and population. The American Academy of Pediatrics in 2000 estimated that 4%-12% of school age children were affected. The National Health Interview Survey conducted in 2008 noted that 8% of children ages 3-17 yr of age had ADHD. Although the exact etiology is unknown, it probably involves a combination of biologic, genetic, and psychologic factors. It is seen more often in children who have a family member with ADHD, particularly the father, brother, or uncle. Chromosomal or genetic abnormalities such as fragile X syndrome have been seen in some children with ADHD. ADHD commonly occurs in association with oppositional disorder, conduct disorder, depression, anxiety disorder, and many developmental disorders, such as speech and language delays and learning disabilities. Recent literature notes that although ADHD may occur alone, about 20% also have bipolar disorder (Stokowski, 2009). ADHD is more common in males than females and many children affected continue to demonstrate symptoms into adolescence and adulthood. There is some belief that ADHD is not “outgrown” but that people learn to compensate.

Health care setting

Primary care.

Assessment

Includes standard history and physical examination, neurologic examination, family assessment, and school assessment.

Signs and symptoms:

The behaviors exhibited are not unusual aspects of any child’s behavior. The difference lies in the quality of motor activity and developmentally inappropriate inattention, impulsivity, and hyperactivity displayed. The symptoms vary with developmental age and may range from a few to numerous different symptoms. The core symptoms include inattention, hyperactivity, and impulsivity. Children may experience significant functional problems such as school difficulties, academic underachievement, troublesome interpersonal relationships with family members and peers, and low self-esteem.

Physical assessment:

Physical examination includes vision and hearing screening and a detailed neurologic examination that will help rule out any severe neurologic disorders.

Guidelines for the diagnosis of ADHD (published by the american academy of pediatrics in may 2000 (not scheduled for revision until 2013):

1. Use of specific criteria for the diagnosis using the Diagnostic and Statistical Manual of Mental Health Disorders, 4th edition (DSM-IV) criteria.

2. Importance of obtaining information concerning the child’s symptoms/behavior in more than one setting (especially from school).

3. Evaluation for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning.

Diagnostic tests

ADHD is a diagnosis of exclusion. There is no definitive test for ADHD.

Nursing diagnosis:

Disturbed sensory perception

Desired Outcomes: Within 1 mo of this diagnosis, child completes activities of daily living (ADLs) and shows behavioral improvement in the school setting. Within one semester, child shows improvement in academic activities.

ASSESSMENT/INTERVENTIONS	RATIONALES
Encourage parents/teachers to provide a structured environment and consistency.	Structure and consistency offer opportunity for children to focus on areas that need improvement.
Promote ongoing communication between parents and teachers.	Consistency among family and teachers in reinforcing same guidelines improves the child’s ability to concentrate.
Encourage parents/teachers to decrease stimuli when concentration is important.	Children with ADHD are easily distracted by extraneous stimuli. Removing those stimuli should improve concentration. For example, parents/teachers should have child do homework in a quiet area without TV or radio on or sit in a quiet section of the classroom, not near an open door or window.
Advise parents to work with school in determining if child is eligible for care under Individuals with Disabilities Education Act (IDEA) and therefore an Individualized Education Plan (IEP) or for Section 504 eligibility.	Many parents are unaware of the rights of disabled children. Environmental accommodation and appropriate classroom placement help children with ADHD reach their maximum potential by concentrating better, controlling impulses, and improving organizational ability. For example, for a child with ADHD, the desk may be placed in the front and on the quieter side of the classroom, and the child may be given extra time to complete tests.

Nursing diagnosis:

Chronic low self-esteem

Desired Outcome: Within 1 mo of this diagnosis, the child achieves at least one goal, lists strengths, and elicits fewer negative responses from others.

ASSESSMENT/INTERVENTIONS	RATIONALES
Assess the child’s interactions with others.	This assessment helps determine existence/degree of negative responses from other people.
Reward positive behavior and provide limit setting as needed. Avoid negative comments and giving attention for negative behavior.	Positive reinforcement is an effective way to improve behavior and self-esteem.
Help the child set goals that are age appropriate, realistic, and achievable. Set timetable to achieve step-by-step progress until he or she accomplishes overall goal.	Achieving goals increases self-esteem. If the child has difficulty completing assignments, divide the assignment into manageable tasks. For example, for an essay assignment: day 1, make outline; day 2, begin literature search; day 3, begin writing paper; day 4, finish paper and have someone review it; day 5, finalize paper.
Encourage the child to make a list of his or her strengths. Teach self-questioning techniques (e.g., What am I doing? How is that going to affect others?). Encourage positive self-talk (e.g., I did a good job with that!). Provide feedback accordingly.	These activities encourage positive self-thought and build self-esteem.

Nursing diagnosis:

Risk for trauma

Desired Outcome: Child remains free from signs of trauma.

ASSESSMENT/INTERVENTIONS	RATIONALES
Reinforce to parents the importance of the child using appropriate safety equipment/protective device (e.g., seat belt, bicycle helmet).	Using this equipment/device decreases likelihood of trauma.
Encourage parents to model the use of appropriate safety equipment/protective devices.	Children are more likely to wear a seat belt or bicycle helmet if parents wear them also.
Encourage parents to set clear limits on where the child may ride a bike or play and to offer choices from several safe areas child can go.	Clear, simple guidelines are easier for a child with ADHD to focus on and follow. Allowing the child some choice improves compliance, which decreases likelihood of injury.
Encourage child’s participation in active play rather than in passive activities (e.g., playing softball rather than playing video games).	Active play helps children grow physically and cognitively. It also helps the child with ADHD to redirect energy in a safe and effective manner, thus decreasing risk of injury.
Reinforce importance of parents monitoring child’s activities frequently.	Adequate supervision decreases likelihood of injury.
Teach parents to reinforce positive behavior with feedback and intermittent rewards.	This encourages appropriate behavior and activity, thereby decreasing risk of injury.

Nursing diagnosis:

Deficient knowledge

Desired Outcome: Within 1 mo of this diagnosis, child and/or parents verbalize accurate understanding of the chronic condition of ADHD and possible treatments.

ASSESSMENT/INTERVENTIONS	RATIONALES
Assess parents’ and child’s understanding (depending on child’s age) of ADHD. As indicated, teach them about the disorder, including the fact that it is chronic.	This assessment enables development of an individualized teaching plan. Accurate knowledge about the condition facilitates understanding of the need for treatment and ways to manage it realistically.
Discuss different treatment strategies.	This information promotes understanding that no single treatment strategy is the answer and that there are multiple strategies that may help the child, such as medication, behavioral/psychosocial interventions (parent training and education, behavior modification, teacher training/proper classroom placement and management, counseling, psychotherapy), combined or multimodal treatment, and biofeedback.

ASSESSMENT/INTERVENTIONS

RATIONALES

Assess parents’ and child’s understanding (depending on child’s age) of ADHD. As indicated, teach them about the disorder, including the fact that it is chronic.

This assessment enables development of an individualized teaching plan. Accurate knowledge about the condition facilitates understanding of the need for treatment and ways to manage it realistically.

Discuss different treatment strategies.

This information promotes understanding that no single treatment strategy is the answer and that there are multiple strategies that may help the child, such as medication, behavioral/psychosocial interventions (parent training and education, behavior modification, teacher training/proper classroom placement and management, counseling, psychotherapy), combined or multimodal treatment, and biofeedback.

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