ATTENTION-DEFICIT/HYPERACTIVITY

DISORDER (ADHD)
DSM-IV
314.00 ADHD predominantly inattentive type
314.01 ADHD predominantly hyperactive-impulsive type
314.01 ADHD combined type
314.9 ADHD NO
!his disorder is associated "ith inattentive# impulsive# and hyperactive behavior
that is maladaptive and inconsistent "ith developmental level. !his behavior creates
clinically si$ni%cant impairment in social&academic 'unctionin$. Accurate dia$nosis is
di(cult# as symptoms resemble depression# learnin$ disabilities# or emotional
problems. !he dia$nosis is made throu$h e)tensive observation o' the child*s
behavior+ ho"ever# contact "ith health pro'essionals is limited and the child*s activity
may be misleadin$ durin$ short o(ce visits. ,eports 'rom parents and teachers are
o'ten used to ma-e the dia$nosis# and their observations may be distorted# as they
assume a problem e)ists and o'ten predetermine the dia$nosis themselves.
ETIOLOGICAL THEORIES
Psychodyna!cs
!he child "ith this disorder has impaired e$o development. .$o development
is retarded and mani'ested impulsive behavior represents unchec-ed id impulses#
as in severe temper tantrums. ,epeated per'ormance 'ailure# 'ailure to attend to
social cues# and limited impulse control rein'orce lo" sel'-esteem. ome theories
su$$est that the child is %)ed in the symbiotic phase o' development and has not
di/erentiated sel' 'rom mother.
G"n"#!c/$!o%o&!ca%
!he disorder may be $ender-lin-ed as the incidence is hi$her in boys than in $irls
03112. ADHD is also more prevalent amon$ children "hose siblin$s have been
dia$nosed "ith the same disorder. ,ecent studies have established that the 'athers
o' hyperactive children are more li-ely to be alcoholic or to have antisocial
personality disorders. A/ected children have sho"n the presence o' subtle
chromosomal chan$es and mild neurolo$ical de%cits "ith irre$ular brain 'unction
includin$ too little activity in the area that inhibits impulsiveness. Hyperactivity may
result 'rom 'etal alcohol syndrome# con$enital in'ections# and brain dama$e resultin$
'rom birth trauma or hypo)ia. 3o$nitive distractibility and impulsivity are associated
"ith other disorders involvin$ brain dama$e or dys'unction# such as mental
retardation# sei4ure disorder# and brain lesions.
5hysiolo$ical conditions that can mimic the symptoms include constipation#
hypo$lycemia# lead to)icity# and thyroid and other metabolic diseases.
Fa!%y Dyna!cs
!his theory su$$ests that disruptive behavior is learned as a means 'or a child to
$ain adult attention. 6t is li-ely that "hether or not the impulsive irritability seen in
individuals "ith ADHD "as present 'rom birth# some parental reactions tend to
rein'orce and thus maintain or increase its intensity. An)iety $enerated by a
dys'unctional 'amily system# marital problems# and so 'orth# could also contribute to
symptoms o' this disorder. 5arents become 'rustrated "ith the child*s poor response
to limit-settin$. 5arents may become overly sensitive or may $ive up and provide no
e)ternal structure.
CLIENT ASSESSMENT DATA $ASE
Ac#!'!#y/R"s#
7ery active# 8al"ays on the move#9 does not slo" do"n "hen should&must
Di(culty playin$ or en$a$in$ in leisure activities :uietly
E&o In#"&(!#y
.motional liability# hot temper# mood chan$es
Hy&!"n"
;or$et'ul in daily activities
N")(os"nso(y
,eports 'rom parents and teachers o'1
<ein$ easily distracted# unable to sustain attention to remain on tas- or complete
pro=ects
Havin$ di(culty sittin$ still# sometimes physically overactive# %d$ets "ith
hands&'eet# may en$a$e in disruptive behavior or dan$erous activities "ithout
considerin$ the conse:uences
Di(culty 'ollo"in$ instructions# or$ani4in$ tas-s&activities
Soc!a% In#"(ac#!ons
Does not seem to listen&attend to "hat is bein$ said
i$ni%cant distress or impairment in social# academic# or occupational 'unctionin$
T"ach!n&/L"a(n!n&
Onset be'ore a$e >
;amily history o' alcohol abuse
DIAGNOSTIC ST*DIES
0ADHD is a dia$nosis by e)clusion# and studies are done to rule out other conditions
havin$ similar symptoms.2
Thy(o!d S#)d!"s+ ?ay reveal hyperthyroid&hypothyroid conditions contributin$ to
problems.
N")(o%o&!ca% T"s#!n& (",&,- EEG- CT Scan)+ Determines presence o' or$anic brain
disorders.
Psycho%o&!ca% T"s#!n& as Ind!ca#"d+ ,ules out an)iety disorders+ identi%es $i'ted#
borderline-retarded# or learnin$-disabled child+ and assesses social
responsiveness and lan$ua$e development.
Ind!'!d)a% D!a&nos#!c S#)d!"s dependent on presence o' physical symptoms 0e.$.#
rashes# upper respiratory illness# or other aller$ic symptoms# 3N in'ection
@cerebritisA2.
N*RSING PRIORITIES
1. ;acilitate child*s achievement o' more consistent behavioral sel'-control and
improvement in sel'-esteem.
B. 5romote parents* development o' e/ective means o' copin$ "ith and
interventions 'or their child*s behavioral symptoms.
3. 5articipate in the development o' a comprehensive# on$oin$ treatment approach
usin$ 'amily and community resources.
DISCHARGE GOALS
1. Disruptive and&or dan$erous behavior minimi4ed or eliminated.
B. Able to 'unction in a structured learnin$ environment.
3. 5arents have $ained or re$ained the ability to cope "ith internal 'eelin$s and to
intervene e/ectively in their child*s behavioral problems.
4. 5lan in place to meet needs a'ter dischar$e.
N*RSING DIAGNOSIS COPING- INDIVID*AL- !n"."c#!'"/
COPING- d"/"ns!'"
May $" R"%a#"d #o+ ituational or maturational crisis+ denial o'
obvious problems
?ild neurolo$ical de%cits&retardation
,etarded e$o development+ lo" sel'-esteem
5ro=ection o' blame&responsibility+ rationali4ation
o' 'ailure
Dys'unctional 'amily system# ne$ative role
models+ abuse&ne$lect
Poss!0%y E'!d"nc"d 0y+ .asy distraction by e)traneous stimuli+ shi'tin$
'rom one uncompleted activity to another+
di(culty reality-testin$ perceptions
6nability to meet a$e-appropriate role
e)pectations
.)cessive motor activity+ cannot sit still
6nability to delay $rati%cation+ manipulation o'
others in environment to 'ul%ll o"n desires
D"s!("d O)#co"s/E'a%)a#!on C(!#"(!a1 Demonstrate a decrease in disruptive behaviors-
C%!"n# 2!%%+ e)pressin$ an$er in socially acceptable manner.
ho" improvements in attention span#
concentration# and appropriate activity level.
Delay $rati%cation "ithout resortin$ to
manipulation o/ others.
ACTIONS/INTERVENTIONS RATIONALE
Ind"3"nd"n#
5rovide :uiet atmosphere+ decrease amount o' ,eduction in environmental stimulation may
e)ternal stimuli. ?aintain atmosphere o' calm. decrease distractibility. 3alm approach helps
prevent transmission o' an)iety bet"een
individuals.
5rovide area and activities 'or $ross motor Appropriate outlets are necessary to dischar$e
movement 0e.$.# $ym and&or outdoor area 'or motor activity.
runnin$# lar$e balls# climbin$ e:uipment2.
,ein'orce attendin$# concentratin$# and completin$ Desired behaviors "ill increase "ith
positive
tas-s. rein'orcement.
et limits on disruptive behaviors 0e.$.# tal-in$ 3hild needs to -no" e)pectations and to learn
incessantly2+ su$$est alternative competin$ behaviors competin$ acceptable behaviors 0e.$.#
raisin$ hand
such as playin$ :uietly. vs. shoutin$ out# -eepin$ hands to sel' vs.
pushin$
others2.
.ncoura$e discussion o' an$ry 'eelin$s and identity Dealin$ "ith the 'eelin$s honestly and
directly
o' true ob=ect o' the hostility. helps discoura$e displacement o' the an$er onto
others.
.)plore alternative "ays 'or handlin$ 'rustration 5romotes learnin$ ho" to interact in society "ith
"ith client. others in more productive "ays.
5rovide positive 'eedbac- 'or tryin$ ne" copin$ upports e/orts and encoura$es use o'
acceptable
strate$ies. behaviors.
.valuate "ith client the e/ectiveness o' ne" As client has limited problem-solvin$ s-ills#
behaviors. Discuss modi%cations 'or improvement. assistance may be re:uired to reassess
and
develop strate$ies.
Assist client to reco$ni4e si$ns o' escalatin$ an)iety. Helps client reco$ni4e ine/ective
behaviors and
.)plore "ays client can intervene be'ore behavior develop ne" copin$ s-ills to e/ect positive
becomes disablin$. chan$e.
5rovide in'ormation and assist parents in learnin$ <ehaviors can o'ten be minimi4ed and&or averted
positive "ays o' handlin$ problem behaviors. by consistent# positive approaches.
6nvolve in individual counselin$. ?edication alone or in combination "ith a
behavior modi%cation pro$ram is insu(cient.
3hildren "ith ADHD do not out$ro" their
problems and many continue to have
di(culties
into adulthood. ,esearch su$$ests about BCD
o'
children "ith ADHD have or "ill soon develop
bipolar disorder "ith a volatile mi) o'
symptoms 0e.$.# distractibility# an)iety#
depression# irritability# and violent outbursts2#
o'ten re:uirin$ hospitali4ation. 3ounselin$
helps the individual modi'y their behavior#
"or-s to improve social s-ills and sel'-esteem#
and addresses depression or other emotional
issues.
Co%%a0o(a#!'"
Administer medication as indicated# e.$.1
methylphenidate @,italinA# imipramine @!o'ranilA# 5sychostimulants and antidepressants may improve
attention and reduce impulsiveness in
hyperactive
children.
pemoline @3ylertA# de)troamphetamine @De)edrineA+ Antian)iety medications provide relie'
'rom
dia4epam @7aliumA# chlordia4epo)ide @EibriumA# immobili4in$ e/ects o' an)iety# 'acilitatin$
alpra4olam @Fana)A. cooperation "ith therapy.
6nvesti$ate alternative treatments 0e.$.# diet# aller$y2. ome children seem to respond 'avorably
to
control o' re%ned su$ar# 'ood dyes# and aller$ens.
No#"+ 3urrent research has 'ailed to sho" a
correlation bet"een su$ar use and hyperactive
behavior&co$nitive problems.
N*RSING DIAGNOSIS SOCIAL INTERACTION- !3a!("d
May $" R"%a#"d #o+ R"#a(d"d "&o d"'"%o3"n#4 %o5 s"%/-"s#""
Dys'unctional 'amily system# ne$ative role
models+ abuse&ne$lect
May $" R"%a#"d #o (con#,)+ Neurolo$ical impairment+ mental retardation
Poss!0%y E'!d"nc"d 0y+ Discom'ort in social situations
Di(culty "aitin$ turn in $ames or $roup
situations+ interrupts or intrudes on others
Does not seem to listen to "hat is bein$ said
Di(culty playin$ :uietly# maintainin$ attention to
tas- or play activity+ o'ten shi'ts 'rom one activity
to another
D"s!("d O)#co"s/E'a%)a#!on C(!#"(!a1 6denti'y 'eelin$s that lead to poor social
3lient Gill1 interactions.
5articipate appropriately in interactive play "ith
another child or $roup o' children.
Develop a mutual relationship "ith another child
or adult.
ACTIONS/INTERVENTIONS RATIONALE
Ind"3"nd"n#
Develop trust relationship "ith child# sho" Acceptance and trust encoura$e 'eelin$s o' sel'-
acceptance o' child separate 'rom unacceptable "orth.
behavior.
.ncoura$e client to verbali4e 'eelin$s o' inade:uacy ,eco$nition o' problem is %rst step to"ard
and need 'or acceptance 'rom others. Discuss ho" resolution.
these 'eelin$s a/ect relationships by provo-in$
de'ensive behaviors such as blamin$ and manipu-
latin$ others.
O/er positive rein'orcement 'or appropriate social <ehavior modi%cation can be an e/ective
method
interaction. 6$nore ine/ective methods o' relatin$ to o' reducin$ disruptive behaviors in
children by
others+ teach competin$ behaviors. encoura$in$ repetition o' desirable behaviors.
Attention to unacceptable behavior may actually
rein'orce it.
6denti'y situations that provo-e de'ensiveness and 5rovides con%dence to deal "ith di(cult
role-play more appropriate responses. situations "hen they occur.
5rovide opportunities 'or $roup interaction and Appropriate social behavior is o'ten learned 'rom
encoura$e a positive and ne$ative peer 'eedbac- a$e-mates.
system.
Co%%a0o(a#!'"
Arran$e sta(n$s "ith other pro'essionals 0e.$.# 3ooperation and coordination amon$ those
social "or-ers# teachers2. 6nclude parents and child "or-in$ "ith these children enhance
treatment
"hen possible. pro$ram. 6ncludin$ child and parents provides
them "ith understandin$ o' the total problem and
proposed treatment pro$ram.
N*RSING DIAGNOSIS SELF ESTEEM d!s#)(0anc"
May $" R"%a#"d #o+ ,etarded e$o development
Eac- o' positive 'eedbac- "ith repeated ne$ative
'eedbac-
Dys'unctional 'amily system+ abuse&ne$lect+
ne$ative role models
?ild neurolo$ical de%cits
Poss!0%y E'!d"nc"d 0y+ Eac- o' eye contact
Dero$atory remar-s about sel'
Eac- o' sel'-con%dence+ hesitance to try ne"
tas-s
.n$a$ement in physically dan$erous activity
Distraction o' others to cover up o"n de%cits or
'ailures 0e.$.# actin$ the clo"n2
5ro=ection o' blame&responsibility 'or problems+
rationali4ation o' personal 'ailure# $randiosity
D"s!("d O)#co"s/E'a%)a#!on C(!#"(!a1 7erbali4e increasin$ly positive sel'-re$ard.
C%!"n# 2!%%+ Demonstrate be$innin$ a"areness and control o'
o"n behavior.
5articipate in ne" activities "ithout e)treme 'ear
o' 'ailure.
ACTIONS/INTERVENTIONS RATIONALE
Ind"3"nd"n#
3onvey acceptance and unconditional positive !his may help child to increase o"n sense o' sel'-
re$ard. "orth.
Assist child to identi'y basic e$o stren$ths&positive ;ocusin$ on positive aspects o' personality
may
aspects o' sel'+ $ive immediate 'eedbac- 'or acceptable help improve sel'-concept. 5ositive
rein'orcement
behavior. enhances sel'-esteem and increases li-elihood o'
repetition o' desired behavior.
pend time "ith client in 111 and $roup 3onveys to client that you believe he or she is
activities. "orthy o' time and attention.
5rovide opportunities 'or success+ plan activities "ith ,epeated successes can help improve sel'-
esteem.
short time span and appropriate ability level.
Discuss 'ears# encoura$e involvement o' ne" 3on'rontin$ concerns and en$a$in$ in ne" tas-s
activities&tas-s. promote personal $ro"th and ne" s-ills.
Help client set realistic# concrete $oals and determine 5rovides a structure to develop sense o'
hope 'or
appropriate actions to meet these $oals. the 'uture and 'rame"or- 'or reachin$ desired
$oals.
Co%%a0o(a#!'"
5rovide learnin$ opportunities# structured learnin$ uccess'ul school per'ormance is essential
to
environment 0e.$.# sel'-contained classroom# preserve a child*s positive sel'-ima$e.
individually planned educational pro$ram2.
N*RSING DIAGNOSIS FAMILY COPING- !n"."c#!'"+
co3(o!s"d/d!sa0%!n&
May $" R"%a#"d #o+ .)cessive $uilt# an$er# or blamin$ amon$ 'amily
members re$ardin$ child*s behavior
5arental inconsistencies+ disa$reements
re$ardin$ discipline# limit-settin$# and approaches
.)haustion o' parental resources due to
prolon$ed copin$ "ith disruptive child
Poss!0%y E'!d"nc"d 0y+ Hnrealistic parental e)pectations
,e=ection or overprotection o' child
.)a$$erated e)pressions o' an$er#
disappointment# or despair re$ardin$ child*s
behavior or ability to improve or chan$e
D"s!("d O)#co"s/E'a%)a#!on C(!#"(!a1 Demonstrate more consistent# e/ecti'"
Pa("n#(s)/Fa!%y 2!%%+ intervention methods in response to child*s
behavior.
.)press and resolve ne$ative attitudes to"ard
child.
6denti'y and use support systems as needed.
ACTIONS/INTERVENTIONS RATIONALE
Ind"3"nd"n#
5rovide in'ormation and materials related to child*s Appropriate -no"led$e and s-ills may
increase
disorder and e/ective parentin$ techni:ues. 0,e'er to parental e/ectiveness.
351 5arentin$.2
.ncoura$e individuals to verbali4e 'eelin$s and upportive counselin$ can assist 'amily in
e)plore alternative methods o' dealin$ "ith child. developin$ copin$ strate$ies.
5rovide 'eedbac- and rein'orce e/ective parentin$ 5ositive rein'orcement can increase sel'-
esteem
methods. and encoura$e continued e/orts.
6nvolve siblin$s in 'amily discussions and plannin$ ;amily problems a/ect all members and
treatment
'or more e/ective 'amily interactions. is more e/ective "hen everyone is involved in
therapy.
Co%%a0o(a#!'"
6nvolve in 'amily counselin$. ;amily therapy may help resolve $lobal issues
a/ectin$ the "hole 'amily structure. Disruption in
one 'amily member inevitably a/ects the rest o'
the 'amily.
,e'er to community resources as indicated includin$ Developin$ a support system can increase
parental
parent support $roups# parentin$ classes 0e.$.# 5arent con%dence and e/ectiveness. 5rovides
role
./ectiveness2. models&hope 'or the 'uture.
N*RSING DIAGNOSIS 6NO2LEDGE d"7c!# 8LEARNING NEED9
("&a(d!n& cond!#!on- 3(o&nos!s- s"%/ ca("
and #("a#"n# n""ds
May $" R"%a#"d #o+ Eac- o' -no"led$e+
misin'ormation&misinterpretation
?ild neurolo$ical de%cits+ associated
developmental learnin$ disabilities+ inability to
concentrate+ co$nitive de%cits
Poss!0%y E'!d"nc" 0y+ 7erbali4ation o' problem&misconceptions
5oor school per'ormance+ purpose'ully losin$
necessary articles to complete school"or- 0e.$.#
home"or- assi$nments# pencils# boo-s2
hi'tin$ 'rom one uncompleted activity to another
Hnrealistic e)pectation o' medication
mana$ement
D"s!("d O)#co"s/E'a%)a#!on C(!#"(!a1 7erbali4e understandin$ o' reasons 'or behavioral
C%!"n#/Pa("n#(S) 2!%%+ problems# treatment needs "ithin developmental
ability.
5articipate in learnin$ and be$in to as- :uestions
and see- in'ormation independently.
C%!"n# 2!%%+ Achieve co$nitive $oals consistent "ith level o'
temperament,
ACTIONS/INTERVENTIONS RATIONALE
Ind"3"nd"n#
5rovide :uiet environment# sel'-contained ,eduction in environmental stimulation may
classrooms# small-$roup activities. Avoid decrease distractibility. mall $roups may
enhance
overstimulatin$ places# such as school bus# busy ability to stay on tas- and help client learn
ca'eteria# cro"ded hall"ays. appropriate interaction "ith others# avoid sense
o'
isolation.
Iive instructional material in "ritten and verbal e:uential learnin$ s-ills "ill be enhanced.
'orm "ith step-by-step e)planations. 6nstruct child in problem-solvin$ s-ills# practice
situational e)amples. ./ective s-ills may increase
per'ormance levels.
.ducate child and 'amily on the use o' Hse o' psychostimulants may not result in
psychostimulants and behavioral response improved school $rades "ithout accompanyin$
anticipated. chan$es in child*s study s-ills.
3oordinate overall treatment plan "ith schools# 3o$nitive e/ectiveness "ill most li-ely be
collateral personnel# the child# and the 'amily. advanced "hen treatment is not 'ra$mented# nor
si$ni%cant interventions missed because o' lac-
o'
interdisciplinary communication.