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 study guide gives you an overview of ADHD, its nursing care management, interventions, and assessment.
What is 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.
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.
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.
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.
Although health care 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 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 care of a client with ADHD include the following:
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 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 for clients with ADHD include:
- Ensuring safety. Ensuring the child’s safety and that of others; stop 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.
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 in a client with ADHD include the following:
- Individual findings, including factors affecting, interactions, nature of social exchanges, 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.
Practice Quiz: Attention Deficit Hyperactivity Disorder
Nursing practice questions for Attention Deficit Hyperactivity Disorder (ADHD). For more practice questions, visit our NCLEX practice questions page.
1. Nurse Irish is aware that Ritalin is the drug of choice for a child with ADHD. The side effects of the following may be noted by the nurse:
A. Increased attention span and concentration.
B. Increase in appetite.
C. Sleepiness and lethargy.
D. Bradycardia and diarrhea.
1. Answer: A. increased attention span and concentration.
- Option A: The medication has a paradoxical effect that decreases hyperactivity and impulsivity among children with ADHD.
- Options B, C, and D: Side effects of Ritalin include anorexia, insomnia, diarrhea, and irritability.
2. Methylphenidate (Ritalin) is prescribed to an 8-year-old child for the treatment of attention deficit hyperactivity disorder (ADHD). The nurse will most likely monitor which of the following during the medication therapy?
A. Deep tendon reflex
B. Intake and output
C. Temperature and breath sound
D. Height and weight
2. Answer: D. Height and weight.
- Option D: Methylphenidate (Ritalin) may cause slow growth. The nurse will need to keep track of the client’s height and weight to make sure that there is a normal growth and development.
3. The parents of Suzanne, a child with attention deficit hyperactivity disorder, tell the nurse they have tried everything to calm their child and nothing has worked. Which action by the nurse is most appropriate initially?
A. Actively listen to the parents’ concern before planning interventions.
B. Encourage the parents to discuss these issues with the mental health team.
C. Provide literature regarding the disorder and its management.
D. Tell the parents they are overacting to the problem.
3. Answer: A. Actively listens to the parents’ concern before planning interventions.
- Option A: The nurse would encourage parents to fully discuss and describe their perception of the problem in order to assess the family system before determining appropriate interventions.
- Option B: the nurse has not explored the problem and is deciding before adequately assessing the situation that the mental team should be consulted.
- Option C: Providing literature regarding the disorder and its management may be useful intervention; however, the initial action needs to involve a more thorough exploration of the parents’ concerns.
- Option D: Telling the parents they are overreacting to the problem is inappropriate because it dismisses the parents’ legitimate concerns and belittles their feelings.
4. The school nurse assesses Brook, a child newly diagnosed with attention deficit hyperactivity disorder (ADHD). Which of the following symptoms are characteristic of the disorder? Select all that apply.
A. Constant fidgeting and squirming.
B. Excessive fatigue and somatic complaints.
C. Difficulty paying attention to details.
D. Easily distracted.
E. Running away.
F. Talking constantly, even when inappropriate.
4. Answer: A, C, D, and F.
- Options A, C, D, F: These behaviors are all characteristic of ADHD and indicate that the child is inattentive, hyperactive, and impulsive.
- Options B & E: B and E are signs of emotional distress in a child and could be associated with a number of different psychiatric diagnoses.
5. Which of the following statements about ADHD in children is false?
A. Black parents tend to be less sure of potential causes of and treatments for ADHD than white parents, and they are less likely to connect ADHD to their child’s school experiences.
B. Because of its frequent genetic etiology, ADHD in a child is likely foreshadowed by ADHD in other family members.
C. The chances of successful treatment are adversely affected if the parent responsible for implementing the treatment has untreated ADHD.
D. More than 40% of respondents in the recent National Stigma Study-Children (NSS-C) believe that children will face rejection in school for receiving mental health treatment and that negative ramifications will continue into adulthood. More than half expected psychiatric medications to cause a zombie-like effect.
E. The Multimodal Treatment Study of Children with ADHD suggests that pharmacological treatment of ADHD is as effective as behavioral therapy alone.
5. Answer: E. The Multimodal Treatment Study of Children with ADHD suggests that pharmacological treatment of ADHD is as effective as behavioral therapy alone.
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]