NCP 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 NOS

This disorder is associated with inattentive, impulsive, and hyperactive behavior that is maladaptive and inconsistent with developmental level. This behavior creates clinically significant impairment in social/academic functioning. Accurate diagnosis is difficult, as symptoms resemble depression, learning disabilities, or emotional problems. The diagnosis is made through extensive observation of the child’s behavior; however, contact with health professionals is limited and the child’s activity may be misleading during short office visits. Reports from parents and teachers are often used to make the diagnosis, and their observations may be distorted, as they assume a problem exists and often predetermine the diagnosis themselves.

ETIOLOGICAL THEORIES

Psychodynamics

The child with this disorder has impaired ego development. Ego development is retarded and manifested impulsive behavior represents unchecked id impulses, as in severe temper tantrums. Repeated performance failure, failure to attend to social cues, and limited impulse control reinforce low self-esteem. Some theories suggest that the child is fixed in the symbiotic phase of development and has not differentiated self from mother.

Genetic/Biological

The disorder may be gender-linked as the incidence is higher in boys than in girls (3:1). ADHD is also more prevalent among children whose siblings have been diagnosed with the same disorder. Recent studies have established that the fathers of hyperactive children are more likely to be alcoholic or to have antisocial personality disorders. Affected children have shown the presence of subtle chromosomal changes and mild neurological deficits with irregular brain function including too little activity in the area that inhibits impulsiveness. Hyperactivity may result from fetal alcohol syndrome, congenital infections, and brain damage resulting from birth trauma or hypoxia. Cognitive distractibility and impulsivity are associated with other disorders involving brain damage or dysfunction, such as mental retardation, seizure disorder, and brain lesions.

Physiological conditions that can mimic the symptoms include constipation, hypoglycemia, lead toxicity, and thyroid and other metabolic diseases.

Family Dynamics

This theory suggests that disruptive behavior is learned as a means for a child to gain adult attention. It is likely that whether or not the impulsive irritability seen in individuals with ADHD was present from birth, some parental reactions tend to reinforce and thus maintain or increase its intensity. Anxiety generated by a dysfunctional family system, marital problems, and so forth, could also contribute to symptoms of this disorder. Parents become frustrated with the child’s poor response to limit-setting. Parents may become overly sensitive or may give up and provide no external structure.

CLIENT ASSESSMENT DATA BASE

Activity/Rest

Very active, “always on the move,” does not slow down when should/must

Difficulty playing or engaging in leisure activities quietly

Ego Integrity

Emotional liability, hot temper, mood changes

Hygiene

Forgetful in daily activities

Neurosensory

Reports from parents and teachers of:

Being easily distracted, unable to sustain attention to remain on task or complete projects

Having difficulty sitting still, sometimes physically overactive, fidgets with hands/feet, may engage in disruptive behavior or dangerous activities without considering the consequences

Difficulty following instructions, organizing tasks/activities

Social Interactions

Does not seem to listen/attend to what is being said

Significant distress or impairment in social, academic, or occupational functioning

Teaching/Learning

Onset before age 7

Family history of alcohol abuse

DIAGNOSTIC STUDIES

(ADHD is a diagnosis by exclusion, and studies are done to rule out other conditions having similar symptoms.)

Thyroid Studies: May reveal hyperthyroid/hypothyroid conditions contributing to problems.

Neurological Testing (e.g., EEG, CT Scan): Determines presence of organic brain disorders.

Psychological Testing as Indicated: Rules out anxiety disorders; identifies gifted, borderline-retarded, or learning-disabled child; and assesses social responsiveness and language development.

Individual Diagnostic Studies dependent on presence of physical symptoms (e.g., rashes, upper respiratory illness, or other allergic symptoms, CNS infection [cerebritis]).

NURSING PRIORITIES

1. Facilitate child’s achievement of more consistent behavioral self-control and improvement in self-esteem.

2. Promote parents’ development of effective means of coping with and interventions for their child’s behavioral symptoms.

3. Participate in the development of a comprehensive, ongoing treatment approach using family and community resources.

DISCHARGE GOALS

1. Disruptive and/or dangerous behavior minimized or eliminated.

2. Able to function in a structured learning environment.

3. Parents have gained or regained the ability to cope with internal feelings and to intervene effectively in their child’s behavioral problems.

4. Plan in place to meet needs after discharge.