Attention-Deficit/Hyperactivity Disorder

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Chapter 6 Attention-Deficit/Hyperactivity Disorder

PATHOPHYSIOLOGY

Attention-deficit/hyperactivity disorder (ADHD) is a chronic neurobiologic disorder characterized by problems in regulating activity (hyperactivity), inhibiting behavior (impulsivity), and attending to tasks (inattention). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), outlines specific observable behavioral symptoms in these three areas (Box 6-1). To meet the criteria for ADHD, symptoms must be present across settings. In other words, if the child is hyperactive at home but not at school, ADHD is not diagnosed.

Box 6-1 Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder

A. Either (1) or (2):

(1) Six (or more) of the following symptoms of inattentionhave persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Inattention
(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
(b) Often has difficulty sustaining attention in tasks or play activities
(c) Often does not seem to listen when spoken to directly
(d) Often does not follow through on instructions, and fails to finish schoolwork, chores, or duties in the workplace (not as a result of oppositional behavior or failure to understand instructions)
(e) Often has difficulty organizing tasks and activities
(f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
(g) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
(h) Is often easily distracted by extraneous stimuli
(i) Is often forgetful in daily activities
(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
Hyperactivity
(a) Often fidgets with hands or feet or squirms in seat
(b) Often leaves seat in classroom, or in other situations in which remaining seated is expected
(c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
(d) Often has difficulty playing or engaging in leisure activities quietly
(e) Is often “on the go” or often acts as if “driven by a motor”
(f) Often talks excessively
Impulsivity
(g) Often blurts out answers before questions have been completed
(h) Often has difficulty awaiting turn
(i) Often interrupts or intrudes on others (e.g., butts into conversations or games)

B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

C. Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

E. The symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, or personality disorder).

Code based on type:

314.01: Attention-deficit/hyperactivity disorder, combined type: if both criteria A1 and A2 are met for the past 6 months

314.00: Attention-deficit/hyperactivity disorder, predominantly inattentive type: if criterion A1 is met but criterion A2 is not met for the past 6 months

314.01: Attention-deficit/hyperactivity disorder, predominantly hyperactive-impulsive type: if criterion A2 is met but criterion A1 is not met for the past 6 months

Coding Note: For individuals (especially adolescents and adults) who currently have symptoms that no longer meet full criteria, “in partial remission” should be specified

From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4, text revision (DSM-IV-TR), Washington, DC, 2000, The Association.

Although ADHD symptoms are present before age 7 years, a diagnosis is not usually made until the child begins school, when behavior interferes with academic and social functioning. Children with ADHD are prone to physical injury. Sensorimotor coordination may be impaired, and clumsiness and problems with spatial orientation are common. Disruptiveness, temper outbursts, and aimless motor activity often irritate peers and family members. Secondary problems such as oppositional behavior, mood and anxiety disorders, and communication problems are common. Learning may be delayed as a result of chronic inability to attend to educational tasks.

As children enter adolescence, observable symptoms are less obvious. Restlessness and jitteriness replace the excessive activity seen during childhood. Adolescents with ADHD have difficulty complying with behavioral expectations or rules normally observed in educational and work settings. Conflicts with authority figures are also noted. Symptoms may persist into adulthood. These individuals may be described as “on the go,” always busy, and unable to sit still.

No signal cause of ADHD exists. Genetic influences are likely, but to date, no specific genetic link has been found. Neurodevelopmental and genetic risk factors do exist. Most notable are fetal risk factors, which include exposure to alcohol, nicotine, and lead, and nutrient deficiencies (e.g., iron, calcium).

INCIDENCE

1. Studies suggest a higher incidence of ADHD in children with first-degree biologic relatives with diagnosed ADHD.

2. The incidence rate among school-aged children is 3% to 5%.

3. Incidence is higher in males than in females (roughly 3 times higher in boys than in girls).

CLINICAL MANIFESTATIONS

Clinical manifestations are listed in Box 6-1.

COMPLICATIONS

1. Secondary diagnoses—conduct disorder, depression, and anxiety disorder

2. Scholastic: academic underachievement, school failure, reading and/or arithmetic difficulties (frequently resulting from attentional problems)

3. Social: poor peer relationships (frequently due to impulsive behaviors such as aggressive behavior and verbal outbursts)

LABORATORY AND DIAGNOSTIC TESTS

1. For accurate diagnosis of ADHD, symptoms must meet specific criteria outlined in DSM-IV-TR (see Box 6-1).

2. Take behavioral history—obtain historical data from parents and teachers.

3. Use ADHD teacher and parent assessment tools (e.g., Conners Rating Scales—Revised; Swanson, Nolan, and Pelham-IV Questionnaire; SKAMP Rating Scale; ADHD Rating Scale IV; Vanderbilt ADHD Teacher Rating Scale and Vanderbilt ADHD Parent Rating Scale).

4. The following neuropsychologic tests may be used as a baseline and to assess and monitor treatment (no neuropsychologic instrument can be relied upon exclusively to diagnose):

• Continuous Performance Test
• Matching Familiar Figures Test
• Paired Associates Learning Task

5. Intelligence and achievement testing provides information about overall intellectual functioning and academic achievement (ADHD is likely to affect achievement and cognitive performance). The assessment report should include the child’s strengths and weaknesses.

MEDICAL MANAGEMENT

The treatment plan for ADHD should be carefully tailored to each child and includes no single intervention. Treatment options generally include medications (most commonly stimulants) and specific behavioral treatments. The various behavioral treatments include psychotherapy, behavioral therapy, social skills training, support groups, and parent skills training. Behavioral rating scales and neuropsychologic tests may be used for baseline measurement and monitoring of treatment effectiveness.

Medication

Stimulants are the most widely used medications for treating ADHD. Examples of stimulants approved by the United States Food and Drug Administration (FDA) for use in children include amphetamine (Adderall), methylphenidate (Concerta, Ritalin), and dextroamphetamine (Dexedrine). Stimulants reduce hyperactivity and impulsivity and improve ability to focus. They have been used for decades and are considered relatively safe. Newer sustained-release stimulants can be taken before school, and administration by the school nurse is therefore no longer required. Side effects from stimulants are usually related to dosage (higher doses produce more side effects). The most common side effects include decreased appetite, insomnia, and increased anxiety and/or irritablity. Mild stomach aches or headaches are also common. When taken as prescribed for ADHD, stimulants are neither addictive, nor do they lead to substance abuse.

For children who do not respond to or are unable to tolerate stimulants, atomoxetine (Strattera) a nonstimulant medication recently approved by the FDA for treatment of ADHD may be prescribed. So called “off label” such as antidepressant medications may also be used in such incidences. However, their safety and efficacy have not been established in children. Antidepressants may also be used to treat comorbid symptoms.

Parents may express concern about using medication. Risks and benefits of medication must be explained to parents, including prevention of potentially ongoing scholastic and social problems through the use of medications. For most children, medication alone may not be the best strategy.

NURSING ASSESSMENT

1. Assess family history via interview and/or genogram.

2. Assess child’s behavioral history.

NURSING DIAGNOSES

• Therapeutic regimen management, Ineffective

• Self-concept, Disturbed

• Parenting, Risk for impaired

• Social interaction, Impaired

• Violence, Risk for other-directed

• Injury, Risk for

NURSING INTERVENTIONS

Nursing interventions are generally implemented in outpatient and community settings.

1. Assist parents in implementing a behavior program, including positive reinforcement.

2. Provide daily structure.

3. Administer stimulant medication as ordered.

a. Stimulants may be temporarily discontinued on weekends and holidays.
b. Stimulants are not given after 3 or 4 PM.

Discharge Planning and Home Care

1. Educate and support parents and family members.

2. Collaborate with teachers and involve parents. Encourage parents to ensure that teacher and school nurse are aware of medication name, dosage, and times of administration.

3. Ensure that child receives necessary academic evaluation and tutoring. Placement in special education class is often required.

4. Monitor child’s progress and response to medication.

5. Refer to behavioral and parenting specialists to develop and implement a behavior plan.

6. Refer child or youth to child psychologist, counselor, or child mental health nursing specialist as indicated for ongoing counseling.

7. Refer child or youth as appropriate for social skills training and/or peer support groups.

CLIENT OUTCOMES

1. School performance will improve, as evidenced by classroom grades and work completed.

2. Improvement of child’s behavior according to teacher and parent rating will be noted.

3. Child will display positive peer relationships.

4. Child will acquire developmental appropriate competencies.

REFERENCES

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, ed 4. Washington, DC: The Association, 2000. text revision (DSM-IV-TR)

Daley D. Attention deficit hyperactivity disorder: A review of the essential facts. Child Care Health Dev. 2006;32(2):193.

Collett BR, O’Phan JL, Myers KM. Ten-year review of rating scales. V: Scales assessing attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2003;42(9):1015.

Magyary D, Brandt P. A decision tree and clinical paths for the assessment and management of children with ADHD. Issues Ment Health Nurs. 2002;23(6):553.

Prince JB. Pharmacotherapy of attention-deficit hyperactivity disorder in children and adolescents: Update on new stimulant preparations, atomoxetine, and novel treatments. Child Adolesc Psychiatr Clin N Am. 2006;15(1):13.

Strock M. Attention deficit hyperactivity disorder. National Institute of Mental Health, 2003. NIH Publication No. 3572

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