Attention deficit hyperactivity disorder (ADHD) prevalence can be as high as 7%, according to Sayal, Parsad, Daley, Ford, and Coghill (2018). While this number may seem small, there is a concern that ADHD is often underdiagnosed in children, which could lead to a more significant incidence of patients who are not receiving appropriate care. The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-V) (American Psychiatric Association [APA], 2013) describes the incidence of ADHD in children at approximately 5%. The National Institute of Mental Health’s (NIMH, 2017) most recent report suggests that the rate of ADHD has increased 42% over eight years. The average range of initial diagnosis is 4-7 years of age (NIMH, 2017). Statistics indicate that millions of children have been diagnosed with ADHD since the initial identification of the disorder, and the trend continues with more children being diagnosed annually (Centers for Disease Control and Prevention [CDC], 2019). The American Academy of Pediatrics (AAP) first addressed the care of the child with ADHD in 2000; since that time, revisions were made and released in 2011. Since 2011, little changes have been made (Wolraich, 2019).
Diagnostic Criteria for ADHD
The criteria used to diagnose ADHD are complex. Children must be professionally evaluated to make a clear distinction between ADHD and other childhood mental health conditions. The CDC (2019) recommends that a mental health professional or pediatrician evaluate the child. The process of making this diagnosis involves multiple steps and requires interviewing several key individuals to gather information on behavior in different settings. Evaluation of the child should be completed when the child exhibits a lack of attention or impulsivity. Interviews with individuals who have witnessed these behaviors in the child in both the home and school settings can follow the initial evaluation. Rating scales are then used to evaluate the child's symptoms further, and other conditions with similar symptomatology are ruled out. Screenings for other disorders are completed due to the fact that many of the symptoms of ADHD are in other mental health conditions (CDC, 2019).
The DSM-V (APA, 2013), outlines the diagnostic criteria that must be met to establish a diagnosis of ADHD. Children must have a pattern of lack of attention combined with hyperactivity or impulsivity that have been ongoing for at least six months and be considered excessive for their developmental age. Symptoms must be negatively impacting the child’s home life and school performance. The criteria of attention and hyperactivity are further broken down. Inattention symptoms include not paying attention to details at home or in school, inability to hold attention during games, appearing not to listen, failing to keep things organized (schoolwork), losing things frequently, and being easily distracted. Hyperactivity/impulsivity is the second component of the diagnostic criteria. Symptoms include the inability to stay still, getting out of their seats when others are seated, running around or climbing during inappropriate times, talking excessively, and interrupting frequently. Other symptoms that may correlate to a diagnosis of ADHD could be a delay in social skills or language. Children with ADHD may become very frustrated and appear irritable. As the child gets older, a risk for suicidal ideations becomes a concern; this primarily occurs when ADHD occurs alongside other emotional disorders Additional symptoms can be found in the DSM-V manual (APA, 2013).
Assessment should include determining whether the disorder is a combined disorder, predominantly inattentive, or predominantly hyperactive. ADHD can then be categorized by severity, which can be mild, moderate, or severe. When evaluating the child for inattention and hyperactivity, the evaluator must also determine if the child has any other mental disorder(s) that could have similar symptoms to ADHD. For example, anxiety disorders, personality disorders, or mood disorders could be similar in their presentation to ADHD. Therefore, an evaluation of those other conditions is warranted (APA, 2013).
Additionally, the child's symptoms must be exhibited in more than one setting. For example, they should be seen in the home and at school, or at work if the child is older. Therefore, informants must be interviewed who would have information regarding the individual's symptoms in those settings, such as a teacher or a school nurse. ADHD is a complicated diagnosis to make accurately; the child may not exhibit symptoms if they are in a setting where there is less stimulation or there are rewards given for tasks completed. A language or social delay may manifest itself in the school setting, so an interview with the teacher could elicit that information. The child may be frustrated by their inability to concentrate at school when others are doing so (APA, 2013).
Parents are generally good historians regarding the child's behavior. Usually, parents state that their child first became challenging regarding activity in toddlerhood. However, toddlers tend to be enthusiastic, and it is often difficult to make a diagnosis of ADHD during that time. It is through the school-age years when the ADHD becomes more apparent. Students will have an impairment in learning and often become frustrated with their inability to exceed expectations. As the child grows older, into adolescence, parents and others may notice a worsening of symptoms and the development of behaviors that are considered antisocial (APA, 2013).
Because ADHD begins in childhood, the diagnosis is typically made during that time. The symptoms of ADHD must be present before the age of 12 years for a diagnosis of ADHD. Adults may recall periods during their childhood when they may have exhibited inattentiveness or impulsivity. However, those reports by the adult can be unreliable and should not be used to make a diagnosis of ADHD in adulthood. There will need to be other supporting information brought forth by the adult to better understand the onset of symptoms. While the number is unclear, it is possible many children with ADHD continue to experience symptoms into their adult years. The characteristics of inattentiveness will lessen into the adult years, but patients will state that they feel restless (APA, 2013).
Risk Factors Associated with ADHD
According to Sciberras, Mulraney, Silva, and Coghill (2017), ADHD is thought to be mostly genetic. There is a higher incidence of ADHD in individuals with a first degree relative with ADHD. ADHD occurs more often in males versus females in approximately a 2:1 ratio. However, females are more likely to be diagnosed with predominately inattentive disorders (APA, 2013).
There is also a certain percentage associated with environmental issues. Risk factors that occur prenatally are substance use, excessive stress during the pregnancy, and infancy complications. Prematurity is a risk factor according to a Norwegian study which recently found a correlation between prematurity and ADHD in children. A similar study in the United States was not able to find a correlation between prematurity and ADHD. A comparison study of children who were born late preterm found a relationship between ADHD and late preterm birth. Another risk factor identified in this study was the presence of a hypoxic condition in utero. This can occur with placental separation or any other complication which causes temporary hypoxia. Ischemic injury in utero may partially explain the correlation between prematurity and ADHD (Sciberras et al., 2017).
Mothers who use substances that are considered teratogenic in utero also have children with a higher incidence of ADHD. Mothers who use alcohol during pregnancy have a higher rate of children with ADHD when compared to mothers who abstain during pregnancy, and this risk becomes even more significant if the mother has an alcohol use dependency problem. Mothers who smoke or use nicotine replacement products during pregnancy report that they notice an increase in ADHD-like behavior in their children around the school-age years. The researchers concluded that there is a relationship between nicotine and ADHD. Firstborn children and those born to younger mothers or fathers are at higher risk for ADHD than others (Sciberras et al., 2017).
Mothers who experienced excessive stress during their pregnancy had a higher incidence of children with ADHD. It's important to note, however, that the increased stress experienced during pregnancy could be related to other psychosocial factors that could influence the risk for ADHD. In the social sciences, this is called a confounding variable. Mothers with a diagnosis of hyperthyroidism after the birth of their child had a higher incidence of children with ADHD found during school-age years. Furthermore, individuals who have experienced brain injury have a higher incidence of ADHD (NIMH, 2016a). Overall, more research is needed in the area of ADHD and risk factors (Sciberras et al., 2017).
Risk factors presented in DSM-V are like those in the above study. Additionally, they list the child’s temperament as well as a history of abuse, neglect, or neurotoxin exposure, such as lead , as potential risk factors(APA, 2013).
Physical Effects of ADHD on a Child
Peasgood et al. (2016) conducted a study in the United Kingdom looking at children with ADHD and the siblings of children with ADHD. They looked at the overall effects that ADHD had on the child's body and how it impacted the sibling. The study found that children with ADHD get less sleep than their peers. Overall, they found about 39 minutes difference between the control group and the group that was diagnosed with ADHD. The study also found that siblings were more likely to bully the sibling with ADHD. This will be discussed later in the module. Children who lived in homes with a single parent had more impact on their sleep than children who lived with two caregivers (Peasgood et al., 2016).
Cook, Li, and Heinrich (2015) looked at children who had a confirmed diagnosis of ADHD to determine if the diagnosis correlated with weight gain, lack of physical activity, and sedentary behaviors. The authors state that impulsivity may lead to poor decisions and unhealthy eating. Overeating to create immediate feelings of gratification can lead to weight gain. The child may attempt to self-soothe in order to cope with their dysfunctional behaviors by overeating. Children with ADHD may have difficulty planning, starting, or remaining engaged in physical activities (Cook et al., 2015).
Interestingly, Cook et al. (2015) also found that there are times when caregivers will use sugary or fattening food as a reward for children who may have a disability. One way to lessen the incidence of obesity in children is through physical activity. This study found that children with ADHD are less likely to engage in physical activity than children of the same age who do not have a diagnosis of ADHD; children not medicated for their ADHD were more likely to be inactive than their medicated peers. The study found that children with ADHD experience poor health outcomes more often than their peers, and this is related to higher rates of obesity and a lack of physical activity (Cook et al., 2015). Children with ADHD are also more frequently injured secondary to impulsivity and a failure to pay attention to the basic safety rules (APA, 2013).
Emotional Effects of ADHD on a Child
While physical effects that revolve around ADHD are related to obesity and a sedentary lifestyle, the emotional impact of ADHD on a child are varied. DSM-V discusses some of the effects of ADHD in children. Children with ADHD often have lower academic performance secondary to inattention and may be rejected by their peers due to their hyperactivity. Some children with ADHD may also experience other emotional disorders. For example, children with ADHD may have oppositional defiant disorder, conduct disorder, a learning disability, or anxiety as a secondary diagnosis. If children with ADHD develop other emotional disturbances, this increases the likelihood that the children will become disengaged from their peers, and bullying could occur. Peer bullying and the inability to perform well academically can have pronounced psychological impact on children (APA, 2013).
Comorbidities Found with ADHD
ADHD brings with it other comorbidities. For example, oppositional defiant disorder, conduct disorder, depression, and anxiety often occur in children with ADHD in varying degrees. Oppositional defiant disorder is when a child resists being controlled by the individuals he/she is most familiar with, such as parents or teachers. They may appear irritable, argue and lose their temper often, and have a low frustration tolerance. It generally manifests itself in the school-age years and disappears in adolescence. In children with conduct disorder, more common in older children and adolescents, they may be aggressive towards individuals or animals, destroy property intentionally, and have an unemotional interpersonal style. Often children with conduct disorder get into legal trouble and then find themselves trapped in the legal system. This pattern may continue through adulthood. Anxiety and depression can also cause difficulties in children with ADHD. ADHD and anxiety share similar symptoms, such as inattentiveness, but in ADHD, the child is less likely to worry repeatedly over the same things (APA, 2013; CDC, 2019). Other disorders that can be seen in children with ADHD are obsessive-compulsive disorder, tic disorders, and autistic spectrum disorders. While many of the disorders mentioned above can be seen with ADHD, it does not mean that all children with ADHD will have one of these disorders. Children who have additional comorbidities with ADHD are more difficult to treat and may have more challenges in academic and home environments (APA, 2013).
Treatment Options for the Child with ADHD
The AAP Clinical Practice Guidelines for ADHD (Wolraich et al., 2019), reminds providers that ADHD is a chronic condition that requires effective treatment. The AAP (Wolraich et al., 2019) suggests the use of behavioral management before the onset of pharmacological treatments in children diagnosed with ADHD in their preschool years. According to the CDC (2019), this is largely because younger children have more adverse effects from the medications used to treat ADHD. However, should behavioral therapy not be effective, or if significant improvements are not seen, then the provider must consider the use of medication. The provider should keep in mind that the introduction of medication(s) carries associated some risk, such as weight loss with stimulant use, that can be harmful in developing children. All of this should be taken into consideration and discussed with the patient and/or the guardian before the treatment plan is started (Wolraich et al., 2019).
ADHD manifests itself both at school and at home, so parents need to engage in a behavioral management program. Therapy can be the key to a child’s success. When deciding on a therapist for behavioral management, a therapist who will actively involve the parents in the care management of the child is ideal. The therapist should have a parent training program to teach parents how to use positive reinforcement and consistency to help the child manage their hyperactivity or impulsivity. Therapy should include regular follow up appointments to re-evaluate the child and the interventions to ensure the effectiveness of the treatment plan. A collective effort from the parents, teachers, therapist, and the child will best assist the child in reaching their maximum potential. Per the CDC (2019), behavioral management can work as effectively as medication with appropriate parental training.
For older children, the use of behavioral therapy and medications can be a useful model of treatment for ADHD. The CDC (2019) encourages providers who are considering prescribing a medication to treat ADHD in a young child that they only use FDA-approved medicines. The NIMH (2017) reports that more than 65% of children with ADHD are prescribed a medication to treat the disorder, with males using more than females. The AAP suggests that the provider consider delaying pharmacological treatment until the school-aged years, ideally the ages of 6 to 11. However, behavioral therapy should remain a part of the treatment plan in this age group. Parents should learn the behavioral therapy components to utilize those when at home, and the teacher should stress the behavioral therapy components during school hours. Once the child reaches adolescence, medications are often utilized, but behavioral therapy may still be a useful adjunct. Medication should be started at the lowest dose possible and titrated up as needed until the child reaches their maximum benefit while avoiding any significant adverse effects. It is important to understand that if the child has a “medication vacation” and is not taking their medicine for a period, such during a school break, the dose should be adjusted down when the medication is restarted again and then titrated back up slowly (Wolraich et al., 2019).The most common medications used to treat ADHD are stimulants. Most children (70-80%) who are diagnosed with ADHD and are medicated with a stimulant have significant improvement in their ADHD behaviors (CDC, 2018, 2019). They work to increase available norepinephrine and dopamine in the brain, which are neurotransmitters that affect thinking and attention. Stimulants have been used in children with ADHD since 1937, with hundreds of controlled trials incorporating over 6,000 patients to establish their safety and efficacy. However, long-term studies (more than a few years) are lacking as withholding treatment from hundreds of patients over many years to serve as a control group in these studies is considered unethical. The most common stimulants include methylphenidate (Ritalin, Concerta, Metadate, Focalin), dextroamphetamine (Dexedrine, Dextrostat), and mixed salts of single entity amphetamine (Adderall, Adderall XR). There are short-acting formulas (last about 4 hours) or long-acting formulas (variable from 6-12 hours). Long-acting formulas are said to reduce the “ups and downs” caused by fluctuating medication levels during the day and avoid medication doses during school/work hours. Stimulants are Schedule II medications with a high potential for abuse, so extensive education and patient counseling should accompany the prescription for any stimulant. The specific dosage and timing will vary widely by patient and should be based on a medication trial, whereby a low dose of the medication is gradually increased every three to seven days until maximum benefits/minimal adverse effects are established. Parents and teachers should be especially observant during a medication trial regarding symptoms, severity, behavior, and adverse effect reports form the child (Children and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD], 2018). Adverse effects of stimulants may include increased heart rate and blood pressure, decreased appetite/weight loss, anxiety, personality changes, sleep disturbances, headaches, stomach pain, or tics (NIMH, 2016a, 2016b). Most of these effects dissipate with time, are mild in severity, and can be avoided by starting with a very low dose and increasing the dose very slowly. Some patients experience negative mood, fatigue, or hyperactivity as the medication is wearing off, called a “stimulant rebound”, which can be managed by adjusting the dose, altering the schedule, or transitioning to a long-acting formula. Studies on weight and height loss from stimulants indicate that this effect is short term in most children. The tics seen in stimulant-medicated children are thought to be made more noticeable or obvious by the medication, not actually caused by the medication (CHADD, 2018).
Some children cannot tolerate stimulants or do not obtain satisfactory results. For those children, nonstimulants approved for the treatment of ADHD in the early 2000s can be utilized. The main difference between stimulants and non-stimulants is that non-stimulants last longer but may take longer to work (CDC, 2019). They may also be used in combination with stimulants to enhance effects by improving focus and attention and reducing impulsivity (NIMH, 2016b). Nonstimulant medications are not controlled substances and are not associated with a potential for abuse. Atomoxetine (Strattera) selectively inhibits the reuptake of norepinephrine. It may take up to four weeks to reach its full effectiveness. Antidepressant medications that target norepinephrine are sometimes used to treat resistant ADHD, but these medications are not FDA-approved for this indication and are considered off label (CHADD, 2018).
Nursing care for the child with ADHD should include extensive patient education- both to the patient and their parent or guardian. The nurse should explain the nature of ADHD, expected signs and symptoms, and possible complications. The nurse should cover the entire treatment plan, including therapy and medication, expected effects and potential adverse effects. Direct the parent or guardian to reputable sources of additional information if desired, such as the NIMH, CDC, WHO and CHADD.
Lange et al. (2017) presented valuable information related to nutritional deficiencies in children with ADHD. Children with ADHD may have long-chain polyunsaturated fatty acids (LC-PUFAs) deficiencies, and this elicits the symptoms of ADHD. Additionally, the absence of minerals in the body can also play a role in the presentation of ADHD symptoms. The article suggests that more research is needed to validate the correlation between nutritional deficiencies and ADHD symptomatology. It is important to consider nutritional deficiencies as it relates to ADHD, as a healthy diet can improve the overall condition of the child who is experiencing ADHD and help achieve weight gain (Lange et al., 2017).
Heilskov Rytter et al. (2015), researched the dietary practices of children with ADHD. They have suggested two options for dietary changes: an elimination diet or a diet with an increased intake of specific nutrients. The elimination diet proposes that certain foods increase the symptoms of ADHD, and their removal will decrease them. For example, foods with artificial food coloring, sugar, and artificial sweeteners have all been proposed to cause an increase in hyperactivity. For the elimination diet to be successful, a detailed food diary must be recorded so that certain foods can be linked to specific behaviors. Another alternative is that vitamins and minerals be supplemented into the diet since children with ADHD may have certain mineral deficiencies. For example, deficiencies in zinc, essential fatty acids, and B vitamins have been seen in children with ADHD (Heilskov Rytter et al., 2015).
Barriers to Treatment
The AAP suggests that one of the barriers to treatment is limited access to mental health services, which causes primary care providers to diagnose and treat ADHD. The vast majority of children diagnosed with ADHD seek treatment with their primary healthcare provider and health insurance may not reimburse for additional provider evaluations such as mental health therapies. Because appropriate treatment is time-consuming, interacting with parents and the child, communicating with the school and the teachers, and ensuring continuity of care, the burden of care increases. Certain underrepresented ethnic groups are less likely to receive a diagnosis and subsequent treatment. African Americans and Latino children are less likely to be diagnosed. This demonstrates the need to ensure equity in the evaluation of all children for ADHD. (Wolraich et al., 2019).
Cortese (2016) established a need for further research in the area of eating patterns of children with ADHD. Nutrition and nutritional supplements should continue to be investigated as previous studies have shown a possible correlation between ADHD symptoms and dietary intake. Clinical trials continue to be an effective way to look at other avenues of care. For example, the National Human Genome Research Institute is looking at genetics as well as brain imaging for children with ADHD (NIMH, 2016a). Additional research opportunities include medication administration in the school setting, attendance to provider visits, medication adherence, and parental involvement (Chronis-Tuscano, Wang, Woods, Strickland, & Stein, 2017).
AAP suggests that future research be geared toward the correlation between ADHD and comorbidities. Comorbidities can complicate the treatment of ADHD and increase the symptomatology of the illness. Additional ideas for future research include a suitable screening tool for ADHD, assessment of ADHD diagnosis in the preschool years, evaluation methods used to determine ADHD treatment success, and the effects of medications on the physical and emotional development of children (Wolraich et al., 2019).
Childhood ADHD is a complex disorder impacting various segments of the child's life. Both the home and school environment are affected. Having a good understanding of the pathophysiology of ADHD, the risks for ADHD, and the treatment needed can help the child live a more productive life. Comorbidities can complicate the treatment plan if not recognized and managed early. Early identification is crucial as it can allow for earlier interventions, and symptoms of ADHD can be managed before the introduction of school. If diagnosed in the school-age child, the focus should be on medication and behavioral management for this population. Continued research and investigation of management plans will improve the ability for providers to diagnose, assess, and manage ADHD in the future. According to the CDC (2019), the care of the child should be the focus of treatment. Developing programs to address the condition in a manner that allows for an understanding of children and their complex needs can be helpful to foster a welcoming, therapeutic environment. Ensuring the family’s use of valid and evidence-based research will ensure the child is treated effectively (CDC, 2019). All of this together can improve the child’s quality of life.
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