7.16 Attention Deficit Hyperactivity Disorder

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is typically diagnosed in childhood and often lasts into adulthood. Children with ADHD demonstrate a persistent pattern of inattention and/or hyperactivity and impulsivity that interfere with functioning or development.^[1],[2]

The cause(s) and risk factors for ADHD are unknown, but research indicates that genetics plays a role. In addition to genetics, other possible risk factors include brain injury, exposure to environmental risks (e.g., lead) during pregnancy or at a young age, maternal alcohol and tobacco use during pregnancy, premature delivery, and low birth weight. Research does not support popularly held views that ADHD is caused by eating too much sugar, watching too much television, or ineffective parenting. Many of these factors can worsen symptoms, especially in genetically predisposed people, but the evidence is not strong enough to conclude that they are the main causes of ADHD.

Assessment (Recognizing Cues)

Nurses assess and document behaviors suggestive of inattention or hyperactivity/impulsivity.

Inattention

Examples of behaviors indicating inattention include the following^[3]:

• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities
• Often has difficulty sustaining attention in 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 workplace duties
• Often has difficulty organizing tasks and activities
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., homework, completing forms, preparing reports)
• Often loses things necessary for tasks activities (e.g., pencils, books, tools, keys, paperwork, glasses, mobile telephones)
• Is easily distracted by extraneous stimuli
• Is forgetful in daily activities (e.g., doing chores, running errands, returning calls, paying bills, keeping appointments)

Hyperactivity and Impulsivity

Examples of behaviors indicating hyperactivity and impulsivity include the following^[4]:

• 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 inappropriate situations (In adolescents or adults this may manifest as restlessness.)
• Often unable to play or engage in leisurely activities quietly
• Is often “on the go” as if “driven by a motor”
• Often talks excessively
• Often blurts out an answer before a question has been completed
• Often has difficulty waiting for their turn in line
• Often interrupts or intrudes on what others are doing

Diagnostic Process

Diagnosing a child with ADHD is a process requiring several steps by a mental health professional. There is no single test to diagnose ADHD, and many other problems such as anxiety, depression, sleep problems, and learning disorders can have similar symptoms as ADHD. The diagnostic process typically includes a medical exam; hearing and vision tests; and a checklist rating ADHD symptoms that is completed by parents, teachers, and the child.

Treatment

ADHD is treated with a combination of medications and behavior therapy.

Medications

Medication may be prescribed to help children aged six and older manage their ADHD symptoms and help them control behaviors that cause difficulties with family, friends, and at school. Stimulants like methylphenidate (Ritalin) and dextroamphetamine-amphetamine (Adderall) are considered first-line treatments. They have a paradoxical effect, meaning that for clients with ADHD, they reduce excessive physical activity and impulsivity and help them to focus and pay attention.

Stimulants are a controlled substance and require a Schedule II prescription. There is a risk for physical dependence, misuse, and drug diversion by the client or their family members.

If first-line treatment is not effective or the client has coexisting anxiety or depression, a selective norepinephrine reuptake inhibitor (SNRI) like atomoxetine is typically prescribed. Review information about and SNRI medications in the “Psychotropic Medications” section.

Psychotherapy

For preschool-aged children (4-5 years old) with ADHD, parent training with behavioral management is recommended as the first line of treatment before medication is prescribed. Behavioral management programs teach and encourage skillful parent or caregiver responses to disruptive child behaviors. Read information about behavioral management in the following box. Social skills training programs are also used to teach basic behavioral and cognitive skills, reinforce prosocial behaviors, and teach social problem-solving. Group sessions are more beneficial than individual sessions because of peer learning influences. These types of psychotherapy can improve a child’s behavior, self-control, and self-esteem.

Educational Approaches

A student with ADHD may have an individualized educational plan (IEP) or a Section 504 plan at their school. These plans outline support to help students achieve their full potential and include accommodations in the classroom like extra time to complete assignments, a quiet place to take tests, and the use of assistive technology, as well as access to support services at school. IEPs are created by an interdisciplinary team that includes the child’s parents, teachers, school staff, and case managers that meet annually and as needed to make changes in educational approaches to meet student needs. Nurses can encourage parents to contact their child’s school and request an educational assessment.

Nursing Interventions

In addition to reinforcing behavioral management strategies, nurses refer clients or parents of minor children to local and online ADHD support groups. Online support groups have grown in popularity because they allow caregivers to learn and network without traveling or additional time commitments. There are many reference books, periodicals, and podcasts that provide information about additional strategies for parents of children with ADHD. See links to additional resources and support groups in the following box.

Nurses also teach clients and/or the parents of minor children the following topics about prescribed stimulants:

Nurses reinforce with the client and their family members that the reason for the prescribed medication is to help with self-control and the ability to focus, but it may take one to three months to determine the best pharmacological treatment, dose, and frequency of medication administration. During this time, the child’s symptoms and adverse effects will be monitored closely and the medication dose adjusted accordingly.