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Etiology & Pathophysiology: The specific etiology is unknown. However, several known associations, such as family history, genetics, and environmental factors, exist. No specific gene has been identified, but a genetic predisposition combined with the child’s environment is believed to contribute to ADHD’s manifestation. The pathophysiology behind ADHD is not fully comprehended, but some children exhibit a deficit in dopamine and norepinephrine, reducing their stimulation threshold (London, 2017).
DSM-V Criteria: The DSM-V diagnostic criteria define 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 the age of 12, persist for at least six months, and interfere explicitly with social, academic, or occupational functioning. ADHD can be classified as mild, moderate, or severe and can present predominately with 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 a 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 may manifest as overlooking details, difficulty following instructions, erratic organization, distractibility, poor time management, forgetfulness, and attention sustaining issues. Hyperactivity and impulsivity can appear as oppositional behavior, defiance, fidgeting, unrest while stationary, difficulty waiting, interruptions, and inappropriate excessive talking (London, 2018). These are general indications and symptoms, the manifestation of which may vary based on the child.
Therapies: For children under six, behavioral therapy is recommended before using medication. For those six and older, medication and behavioral therapy are often used together (CDC, 2018). Behavioral therapy will require significant effort from the child’s caregivers. An example of a behavioral modification plan may include a reward system to praise the child’s efforts and achievements. Punishments most often involve withdrawing privileges while maintaining support for the child. Such punishments should be proportionate to the behavior and implemented immediately, so the child associates the punishment with the behavior (London, 2017). Parents may need guidance and reassurance in executing behavioral plans.
Treatments: Pharmacological treatment for ADHD usually involves stimulants that enhance catecholamine effects, thereby improving attention and curtailing hyperactivity (Hogan, 2013). Frequently used medications include amphetamine salts, Adderall, Vyvanse, and Ritalin. All are schedule II controlled substances; parents need education on administering as prescribed and safe storage. Parents should also be made aware of common side effects, such as anorexia, insomnia, and tachycardia. To prevent insomnia, stimulants should be administered early in the day, and to manage anorexia, medication should be given post 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. A common side effect of taking stimulants is insomnia. A low and therapeutic dose 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 decrease incidences of insomnia. Other common side effects associated with stimulant drugs are a headache, appetite suppression, abdominal pain, and lethargy.
Atomoxetine (Strattera) is a non-stimulant selective norepinephrine reuptake inhibitor and it may take up to 6 weeks to see therapeutic responses. This medication is an alternative if anxiety increases while taking stimulants. It may be the drug of choice if comorbidities include anxiety, substance abuse disorders, or tics (Varcarolis, 2018). Gastrointestinal upset is a common side effect 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. Strattera can cause liver damage in some patients and should be used cautiously in patients who also suffer from depression as it may increase suicidal 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 are potentially more challenging than other children (London, 2018).
The plan of care for a child with ADHD includes implementing memory retraining techniques; encouraging the child to express his or her frustration; emphasizing the importance of pacing learning activities; monitoring symptom patterns and severity; evaluating stress management techniques.
There are many nursing interventions for a child with ADHD. Accept the child for 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-aged children with ADHD is over $42 billion (as cited in Pelham et al., 2007).
Lack of Productivity: Children with ADHD often have trouble meeting grade-level expectations. The signs and symptoms associated with ADHD cause disturbances evident in a classroom setting. Inattentiveness related to ADHD leads to difficulties with concentration, often resulting in poor academic performance. Hyperactivity and impulsivity can also contribute to challenges in school. A child exhibiting hyperactivity may be disruptive and defiant, creating challenges for their own learning and that of students around them. These problems also translate into a home setting as the child may also struggle with adhering to household structure.
Issues of ADHD Relating to Families: Symptoms associated with ADHD can adversely affect parents, increasing their stress levels while potentially decreasing parental role satisfaction. For some, it can cause depressive symptoms. Caregivers reported finding it challenging that their child is unresponsive to correction or instruction. Siblings of children with ADHD may feel jealousy or resentment due to the perceived lack of attention from caregivers. They may also feel that their sibling with ADHD is favored due to the different disciplinary approaches used. Younger siblings may imitate inappropriate behavior. Additionally, if the child is enrolled in extra tutoring, this may place a financial burden on the family.
Healthy People 2020: A government objective outlined by Healthy People 2020 is to “increase the proportion of children with ADHD who receive recommended treatment.” This initiative includes increasing behavioral treatments for children aged 4 to 5 with ADHD and for those aged 6 to 17, 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 has shown efficacy in treating hyperactivity and inattentiveness in the short term. Additionally, stimulants provide the best results when used in conjunction with behavioral therapy. However, there is a lack of evidence supporting the effectiveness of behavioral interventions alone. Moreover, these treatments tend to be more costly, results are difficult to measure, and long-term therapy is challenging 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 on the available evidence-based treatments, we recommend a multimodal approach to treating children with ADHD. Physicians may prescribe stimulants after the age of six, but it’s also important to include behavioral therapy and parental guidance. Since behavioral therapy constitutes only a small fraction of time spent with the child, greater results will stem from maintaining consistency at home. Parents may need support and guidance to establish a routine that fosters optimal growth for the child. Nurses, behavioral specialists, and healthcare providers should remain alert to parents struggling with their child’s ADHD in order to offer resources or advice. Considering environmental influences are known to contribute to ADHD, healthcare workers should also take the child’s environment into account during treatment.
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