Attention Deficit Hyperactivity Disorder

Nurses and healthcare providers usually present a fundamental role in the management of children with Attention Deficit Hyperactivity Disorder (ADHD), a disorder that is characterized by a persistent pattern of inattention and/or hyperactivity/impulsivity that interferes with functioning or development which often persists into adolescence and adulthood. The diagnosis of ADHD demands thorough history taking, application of standardized rating scales, and close attention to the patient’s behavior and subjects’ reports.

This nursing guide highlights an overview of ADHD, its nursing care management, interventions, and assessment.

What is Attention Deficit Hyperactivity Disorder (ADHD)?
Statistics and Incidences
Causes
Criteria
Assessment and Diagnostic Findings
Medical Management
- Pharmacologic Management
Nursing Management
References

What is Attention Deficit Hyperactivity Disorder (ADHD)?

Attention deficit hyperactivity disorder (ADHD) is a developmental condition of inattention and distractibility, with or without accompanying hyperactivity.

ADHD is characterized by inattentiveness, overactivity, and impulsiveness.
ADHD is a common disorder, especially in boys, and probably accounts for more child mental health referrals than any other single disorder.
The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity and impulsivity more common than generally observed in children of the same age.

Statistics and Incidences

In 2016, an estimated 6.1 million US children aged 2-17 years (9.4%) were diagnosed with ADHD.

Of these children, 5.4 million currently had ADHD, which was 89.4 % of children ever diagnosed with ADHD and 8.4% of all US children 2-17 years of age.
According to a study by CDC researchers, more than 1 in 10 (11%) US school-aged children (4–17 years) had received an ADHD diagnosis by a health care provider by 2011, as reported by parents.
ADHD prevalence varies by race and ethnicity, with Mexican children having consistently lower prevalence compared with other racial or ethnic groups.
In children, ADHD is 3–5 times more common in boys than in girls.
The percentages in each group are not well established, but at least an estimated 15–20% of children with ADHD maintain the full diagnosis into adulthood.

Causes

The possible causes of ADHD are:

Genetics. Parents and siblings of children with ADHD are 2-8 times more likely to develop ADHD than the general population, suggesting that ADHD is a highly familial disease.
Environment. According to one study, exposure to second-hand smoke in the home is associated with a higher frequency of mental disorder among children.
Personality factors. Although there remains much evidence for the genetic etiology of ADHD, one study indicated that the contribution of personality aspects in combination with genetics may be significant.

Criteria

In DSM-5, people with ADHD exhibit a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development:

1. Inattention: Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of inattention have been present for at least 6 months, and they are inappropriate for developmental level:

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities.
Often does not seem to listen when spoken to directly.
Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
Often has trouble organizing tasks and activities.
Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted
Is often forgetful in daily activities.

2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:

Often fidgets with or taps hands or feet, or squirms in seat.
Often leaves seat in situations when remaining seated is expected.
Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
Often unable to play or take part in leisure activities quietly.
Is often “on the go” acting as if “driven by a motor”.
Often talks excessively.
Often blurts out an answer before a question has been completed.
Often has trouble waiting their turn.
Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
Several symptoms are present in two or more settings, (such as at home, school or work; with friends or relatives; in other activities).
There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:

Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity, but not inattention, were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.

All criteria must be met for a diagnosis of ADHD in adults:

Five or more symptoms of inattention and/or ≥5 symptoms of hyperactivity/impulsivity must have persisted for ≥6 months to a degree that is inconsistent with the developmental level and negatively impacts social and academic/occupational activities.
Several symptoms (inattentive or hyperactive/impulsive) were present before the age of 12 years.
Several symptoms (inattentive or hyperactive/impulsive) must be present in ≥2 settings (eg, at home, school, or work; with friends or relatives; in other activities).
There is clear evidence that the symptoms interfere with or reduce the quality of social, academic, or occupational functioning.
Symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder, and are not better explained by another mental disorder (eg, mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication, or withdrawal).

Assessment and Diagnostic Findings

The diagnosis requires the symptoms of ADHD to be present both in school and at home; furthermore, all patients must have a full psychiatric evaluation and physical examination.

Laboratory studies. The diagnosis of attention deficit hyperactivity disorder (ADHD) is based on clinical evaluation; no laboratory-based medical tests are available to confirm the diagnosis; basic laboratory studies that may help confirm diagnosis and aid in treatment are serum CBC count with differential, electrolyte levels, liver function tests, and thyroid function tests.
Imaging studies. Brain imaging, such as functional MRI or single photon emission computed tomography (SPECT) scans have been useful for research, but no clinical indication exists for these procedures because the diagnosis is clinical.

Medical Management

No one treatment has been found to be effective for ADHD; ADHD is chronic, goals of treatment involve managing symptoms, reducing hyperactivity and impulsivity, and increasing the child’s attention so that he or she can grow and develop normally.

Diet. For decades, speculation and folklore have suggested that foods containing preservatives or food coloring or foods high in simple sugars may exacerbate ADHD.
Activity. In one study of the effect of physical activity on children’s attention, researchers found that intense exercise has a beneficial effect on children with ADHD.

Pharmacologic Management

Although healthcare providers, parents, and teachers have hoped for effective therapies and methods that do not involve medications for children with attention deficit hyperactivity disorder (ADHD), evidence to date supports that the specific symptoms of ADHD are poorly treated without medication.

Stimulants. These agents are known to treat ADHD effectively.
Other psychiatry agents. Selective norepinephrine reuptake inhibitors have been shown to be effective in the treatment of ADHD.
Atypical antidepressants. Recent studies support the efficacy of venlafaxine and bupropion in ADHD; they may have a slower onset of action than stimulants but potentially fewer adverse effects.
Tricyclic antidepressants. Imipramine inhibits the reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT) at presynaptic neurons; it may be useful in pediatric ADHD.
Central-acting alpha 2 agonists. Centrally acting antihypertensives clonidine and guanfacine have been used to treat children with ADHD; inhibition of norepinephrine release in the brain may be the mechanism of action.

Nursing Management

Nursing care for a client with ADHD includes the following:

Nursing Assessment

During assessment, the nurse gathers information through direct observation and from the child’s parents, daycare providers (if any), and teachers.

History. Parents may report that child is fussy and had problems as an infant; or they may have not noticed the hyperactive behavior until the child was a toddler or entered daycare or school.
General appearance and motor behavior. The child cannot sit still in a chair and squirms and wiggles while trying to do so; he or she may dart around the room with little or no apparent purpose; the child may appear immature or lag behind in developmental milestones.
Mood and affect. Mood may be labile, even to the point of verbal outbursts or temper tantrums; anxiety, frustration, and agitation may be common.
Sensorium and intellectual processes. Ability to pay attention or to concentrate is markedly impaired; the child’s attention span may be as little as 2 or 3 seconds with severe ADHD or 2 or 3 minutes in milder forms of the disorder.

Nursing Diagnosis

Nursing diagnosis commonly used when working with children with ADHD include the following:

Risk for injury related to inability to remain still or seated for a short period of time.
Ineffective role performance related to being intrusive or disruptive with siblings or playmates.
Impaired social interaction related to inability to perceive the consequences of their actions.
Compromised family coping related to disruptive or intrusive behavior with siblings, which causes friction.

Nursing Care Planning and Goals

Treatment outcomes for clients with ADHD may include the following:

The client will be free of injury.
The client will not violate the boundaries of others.
The client will demonstrate age-appropriate social skills.
The client will complete tasks.
The client will follow directions.

Nursing Interventions

Nursing interventions for clients with ADHD include:

Ensuring safety. Ensuring the child’s safety and that of others; stopping unsafe behavior; provide close supervision; and give clear directions about acceptable and unacceptable behavior.
Improving role performance. Give positive feedback for meeting expectations; manage the environment (e.g. provide a quiet place free of distractions for task completion).
Simplifying instructions. Simplifying instructions/directions; get child’s full attention; break complex tasks into small steps; and allow breaks.
Promoting a structured daily routine. Structured daily routine; establish a daily schedule; and minimize changes.
Providing client and family education and support. The nurse must listen to parents’ feelings; including parents in providing and planning care for the child with ADHD is important.

Evaluation

Nursing goals are met as evidenced by:

The client was able to be free of injury.
The client was able to not violate the boundaries of others.
The client was able to demonstrate age-appropriate social skills.
The client was able to complete tasks.
The client was able to follow directions.

Documentation Guidelines

Documentation in a client with ADHD includes the following:

Individual findings include factors affecting, interactions, the nature of social exchanges, and specifics of individual behavior.
Cultural and religious beliefs, and expectations.
Plan of care.
Teaching plan.
Responses to interventions, teaching, and actions performed.
Attainment or progress toward the desired outcome.

References

Sources and references for this study guide for therapeutic communication, including interesting studies for your further reading:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub. [Link]
Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders. [Link]
Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins. [Link]

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