Attention Deficit Hyperactivity Disorder (ADHD)
Etiology & Pathophysiology: The specific etiology is unknown. There are however known associations such as family history, genetics, and environmental factors. A specific gene has not been identified, but it is believed that a genetic predisposition in addition to the child’s environment contribute to the appearance of ADHD. The pathophysiology behind ADHD is also not completely understood. However, some children exhibit a deficit in dopamine and norepinephrine which lowers their threshold for stimulation (London, 2017).
DSM-V Criteria: The diagnostic criteria outlined in the DSM-V defines ADHD as “a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. Six or more of the outlined symptoms related to inattention and/or hyperactivity or impulsivity must be present before age 12, persist for at least six months, and evidently interfere with social, academic, or occupational functioning. ADHD can be specified by mild, moderate, or severe; also can present with predominately inattention, hyperactivity, or both (London, 2017).
Statistics: “Approximately 9.4% of children 2-17 years of age (6.1 million) had ever been diagnosed with ADHD, according to parent report in 2016 (CDC, 2018). Of that population, it is estimated that only about half are receiving treatment for their condition.
Signs & Symptoms: Inattentiveness can be manifested by overlooking details, difficulty following instructions, unmethodical organization, distractibility, poor time management, forgetfulness, and difficulty sustaining attention. Hyperactivity and impulsivity can appear as oppositional behavior, defiance, fidgeting, restlessness while in place, difficulty waiting, interruptive, and talking excessively at inappropriate times (London, 2018). The above listed are only general signs and symptoms which may manifest differently based on the child.
Therapies: Behavioral therapy is recommended for children under the age of six before the use of any medication. For children six and older, behavioral therapy and medication are often used conjointly (CDC, 2018). Behavioral therapy will require mainly efforts from the child’s caregivers. An examples of a behavioral modification plan is creating a reward system to praise the child for their efforts and accomplishments. Punishments generally include withdrawing privileges while remaining supportive to the child. A punishment should be relative to the act and should be implemented without delay so the child will associate the punishment with the behavior (London, 2017). Parents may need guidance and reassurance in utilizing behavioral plans.
Treatments: Pharmacologic treatment of ADHD typically includes stimulants which enhance catecholamine effects thus improving attention and inhibiting hyperactivity (Hogan, 2013). Commonly used medications are amphetamine salts, Adderall, Vyvanse, and Ritalin. These medications are all schedule II controlled substances, therefore parents should be educated on the importance of giving it to their child only as prescribed and safe storage within the household. Parents should also be taught to be aware of the common side effects of stimulants, such as anorexia, insomnia, and tachycardia. Stimulants should be given early in the day to prevent insomnia and anorexia can be managed by giving the medication after meals (London, 2018).
Psychopharmacology: Symptoms of ADHD are treated with stimulant drugs. The effects of the drugs increase attention and task-directed behavior, while reducing impulsivity and hyperactivity. The most commonly used stimulants are methylphenidate (Ritalin and others), mixed amphetamine salts (Adderall), and lisdexamfetamine (Vyvanse) because they are relatively safe. These controlled substances, however pose a risk for misuse and abuse among those for whom the medication was not intended for. A common side effect of taking stimulants is insomnia. A dose that is low and therapeutic is essential. Administering a dose no later than 4:00 pm or decreasing the last dose of the day can help. Formulated extended-release medications have improved dosing and scheduling. Long-acting formulations taken in the morning, along with sustained release medications taken throughout the day help to decrease incidences of insomnia. Other common side effects associated with stimulant drugs are headache, appetite suppression, abdominal pain, and lethargy.
Atomoxetine (Strattera) is a non-stimulant selective norepinephrine reuptake inhibitor. It may take up to 6 weeks to see therapeutic responses. This medication is an alternative if anxiety is increased while taking stimulants. This may be the drug of choice if comorbidities include anxiety, substance abuse disorders, or tics (Varcarolis, 2018). Gastrointestinal upset is a common side while taking Strattera. Other possible side effects include weight loss, loss of appetite, urinary retention, dizziness, fatigue, and insomnia. Blood pressure and heart rate may increase. It can also cause liver damage in some patients. Strattera should be used cautiously in patients who also suffer from depression as it may increase suicide ideation.
Initially indicated to treat hypertension, clonidine (Kapvay) and guanfacine (Intuniv) are used to manage the symptoms of ADHD. These two centrally acting alpha-2 adrenergic agonists are now FDA approved drugs to treat the pediatric population starting at the age of 6. Clonidine and guanfacine can be used alone or in conjunction with other ADHD medications. Side effects of clonidine include somnolence, fatigue, insomnia, nightmares irritability, constipation, respiratory symptoms, dry mouth, and ear pain. Common side effects of guanfacine include somnolence, lethargy, fatigue, insomnia, nausea, dizziness, hypotension, and abdominal pain.
Nursing Implications: ADHD is a chronic disorder that persists through adulthood, therefore, family support is essential. Children with ADHD need emotional support, as they may feel inadequate because of their condition. Parents also need support because their child with ADHD is potentially more challenging than other children (London, 2018).
The plan of care for a child with ADHD include: implementing memory retraining techniques; encouraging the child to express his or her frustration; emphasize the importance of pacing learning activities; monitor symptom patterns and severity; evaluate stress management techniques.
There are many nursing interventions for a child with ADHD. Accept the child as who they are. Acknowledge the child’s condition and communicate with him or her as equals. Interact with the child according to his or her developmental level. Use simple and direct instructions. Implement a routine schedule daily. Avoid environments with distractions or stimulations. Give positive reinforcement for every good deed done. Encourage exercise and an active lifestyle.
Cost to Society: According to Chacko, the annual societal cost of school age children with ADHD is over $42 billion (as cited in Pelham et al., 2007).
Lack of productivity: Children with ADHD often have trouble meeting expectations in their grade level. The signs and symptoms associated with ADHD cause disturbances that can be evident in a classroom setting. Inattentiveness related to ADHD causes difficulty concentration which often results in poor academic performance. Hyperactivity and impulsivity can also contribute to challenges in school. A child who presents with hyperactivity may be disruptive and defiant, creating challenges to their own learning and the learning of students around them. These problem also translate into a home setting, as the child will also have challenges complying to household structure.
Issues of ADHD relating to families: Symptoms associated with ADHD can adversely affect parents. Stress levels increase while parental role satisfaction may decrease. For some, it can cause depressive symptoms. Caregivers reported that it is challenging that their child is unresponsive to correction or instruction. Siblings of children with ADHD may feel jealousy or resentment due to lack of attention from caregivers. Their sibling may also feel that their brother or sister is favored because of the different approaches used to discipline the child. Younger siblings may imitate the inappropriate behavior. If the child is enrolled in extra tutoring, this may place a financial burden on families.
Healthy People 2020:
A government objective by Healthy People 2020, is to “increase the proportion of children with ADHD who receive recommended treatment. This initiative includes increasing behavioral treatment for children age four to five with ADHD. Additionally, for those ages six to seventeen with ADHD, increasing the amount of children who receive behavioral and/or pharmacological treatment (2014).
Evidence-based treatments proven to work
According to Chacko, the use of stimulants have shown efficacy in treating hyperactivity and inattentiveness in the short term. Additionally stimulants provide best results when used in conjunction with behavioral therapy. There is a lack of evidence supporting effectiveness of behavioral interventions alone. Moreover, these treatments tend to be more costly, results are hard to measure, and long term therapy is difficult to maintain (2014). Research by Evans, Owens, and Bunford support the conclusion that multimodal treatments are needed to address these problem areas. Their study suggests that a combination of parent training, behavioral school management, and social skills interventions are well-supported interventions (2014).
Evidence-based treatments proven not to work
Recommendations for future healthcare initiatives
Based upon the evidence-based treatments that are available, we recommend a multimodal approach to treating children with ADHD. Stimulant may be prescribed by their provider after the age of six, but it is also important to include behavioral therapy and parental guidance. As behavioral therapy is only a small fraction of time spent with the child, the greater results will come from the consistency of their home life. Parent’s may need support and guidance to create a routine that fosters the child’s most optimal growth. Nurses, behavioral specialists, and providers should be alert to parents struggling with their child’s ADHD so that they can offer resources or advice. Since environmental influences are known to contribute to ADHD, it is also important for healthcare workers to consider the child’s environment as part of their treatment.