Psych ADHD
Incidence of ADHD
-ADHD is the most commonly diagnosed disorder in school-aged children. (dx very young) -Although prevalence estimates vary depending on the diagnostic criteria used, the sources of data, and the sampling procedure, ADHD in school-aged children is about 6% with a range of 2% to 14% (Kessler et al., 2010; Syed, Masaud, Nkire, Iro, & Garland, 2010). -As of 2007, 9.5% of 4- to 17-year-olds were reportedly diagnosed with ADHD. That's 5.4 million kids -- an almost 22% increase from just four years earlier. -New findings make it possible for doctors to make a diagnosis as early as 4, according to American Academy of Pediatrics guidelines. Before 2011, the youngest age a child could be diagnosed was 6. Getting an early diagnosis may help kids start therapies that can improve their odds of success at school.More than twice as many boys aged 4 to 17 are diagnosed with ADHD -- 13.2% of boys compared to 5.6% of girls. -Girls, though, are more likely to have the predominantly inattentive type of ADHD. Girls' ADHD may be overlooked because their lack of attention is often mistaken for daydreaming and not recognized until they get older. Girls also tend to be less disruptive and less likely to have a learning disability, the red flags teachers often watch for. -It's not clear whether more kids are developing ADHD, or if more are being diagnosed because of better ways to identify it. can still dx past age 12
ADHD DSM-5
-There are actually three sub-classes of ADHD: --Attention-Deficit/Hyperactivity Disorder (Predominantly Inattentive, Predominantly Hyperactive/Impulsive, and Combined) --Other Specified Attention-Deficit/Hyperactivity Disorder (used if we think they have ADHD but not sure) --Unspecified Attention-Deficit/Hyperactivity Disorder (usually after age 12)
ADHD Symptoms -Inattentive
1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/ occupational activities. Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. Careless mistakes/poor attention to details Often has difficulty sustaining attention in tasks or play activities Poor listening skills (mind wanders, distracted) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace. Often has difficulty organizing tasks and activities (keeping materials organized, poor time management, etc.)Staying away from tasks that require sustained mental effort Often loses things necessary for tasks or activities (school materials, wallets, keys, paperwork, eyeglasses, telephones). Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). Being forgetful in daily activities (errands, calls, appointments, etc.) -make sure they dont have learning disability -cant block stimuli--attention to lots of things and cant block things that may be unimportant EX: cant block out lights/humming
ADHD Symptoms - Hyperactive and Impulsive
2. Hyperactivity and impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities: Note: The symptoms are not solely a manifestation of oppositional behavior, defiance, hostility, or a failure to understand tasks or instructions. For older adolescents and adults (age 17 and older), at least five symptoms are required. 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 situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.) Often unable to play or engage in leisure activities quietly. Talks excessively Interrupting or intruding on others Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with). --ex: can you stay in line at the grocery store Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation). Has difficulty waiting his or her turn (e.g., while waiting in line). -look at home life, school, sleep, career -24 hour assessment
Collaborative Information
A diagnosis is made based on school behavior, parents' reports, and direct observation of inattention and hyperactivity impulsivity that are inconsistent with developmental level (APA, 2000). Parents and teachers describe children with ADHD as restless, always on the go, highly distractible, unable to wait their turn, heedless, and frequently disruptive. Indeed, it is often disruptive behavior that brings these children into treatment.
Diagnosing ADHD DSM-5
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2): B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years. C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at home, school, or work; with friends or relatives; in other activities). D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning. E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal). -ADHD is 24 hours a day, other disorders cycle
ADHD Across the Lifespan
ADHD is a disorder usually diagnosed in childhood and was traditionally viewed as a problem of children. We now understand that ADHD persists into adulthood, and it is sometimes first diagnosed later than childhood. In adults, symptoms of hyperactivity and impulsivity tend to decline with age and deficit of attention persist and become more varied (Kessler et al., 2010). However, the majority of the adults with ADHD are undiagnosed and untreated (Waite & Ramsay, 2010). Many of the adults with ADHD become the parents of children with the same disorder.
Co-Morbidity
About two-thirds of children with ADHD also have other conditions or illnesses, such as: learning disability anxiety depression bipolar mood disorder oppositional defiant disorder conduct disorder delays in learning or language development These other conditions can make it more difficult to diagnose ADHD.
Psychosocial Theories
Although genetic endowment clearly plays a fundamental role in the role in the etiology of ADHD, psychosocial factors are also important risk factors, particularly related to inattention Family stress, marital discord, and parental substance use are associated with ADHD (Palcic, Jurbergs, & Kelley, 2009). Other psychosocial factors include poverty, crowded living, conditions and family dysfunction.
Nursing Diagnoses for the Psychological Domain
Assessment should generate numerous diagnoses including: Anxiety Defensive Coping Self-Esteem Disturbance
Atomoxetine Pharmacologic Intervention (cont.)
Atomoxetine (Strattera), a noradrenergic reuptake inhibitor, is not classified as a stimulant and is effective in the treatment of ADHD, especially when it is used in combination with the psychostimulants. Because it has little abuse or misuse, it is often used for those who comorbid substance abuse issue. It is also helpful in treating comorbid anxiety and inattention. This is generally well tolerated in children and adults. Common adverse events include headache, abdominal pain, decreased appetite, vomiting, somnolence, and nausea (Garnock-Jones & Keating, 2010). In some children and teens, Strattera increases the risk of suicidal thoughts or actions. Results from Strattera clinical studies with over 2200 child or teenage ADHD patients suggest that some children and teenagers may have a higher chance of having suicidal thoughts or actions. Although no suicides occurred in these studies, 4 out of every 1000 patients developed suicidal thoughts. Families should be instructed to call the doctor right away if their child or teenager has thoughts of suicide or sudden changes in mood or behavior, especially at the beginning of treatment or after a change in dose. Strattera is not approved for major depressive disorder.Need to know if the child/teenager has (or if there is a family history of) bipolar illness (manic-depressive illness) or suicidal thoughts or actions before starting Strattera. Need to notify immediately if child/teenager develops new psychological symptoms such as; abnormal thoughts/behaviors and/or extreme elevated or irritable moods while taking Strattera. Strattera can cause liver injury in some patients. Observe for itching, right upper belly pain, dark urine, yellow skin or eyes, or unexplained flu-like symptomsPatients taking Strattera have experienced problems passing urine, including trouble starting or keeping a urine stream, and not being able to fully empty the bladder. Erections that won't go away (priapism) have occurred rarely during treatment with Strattera. If the child/teenager has an erection that lasts more than 4 hours, seek medical help right away. Talk to your healthcare provider if your child experiences slowing of growth (height and weight). Children should have height and weight checked often while taking Strattera, and your healthcare provider may stop Strattera treatment if a problem is found during these checkups
Interventions for the Psychological Domain
Behavioral programs based on rewards for positive behavior, such as waiting turns and following directions, can foster new social skills. Interventions may also include specific cognitive behavioral techniques in which the child learn to "stop, look, and listen" before doing. These approaches have been refined and several useful treatment manuals are available. In general, these manuals emphasize problem solving and development of prosocial behavior. Interactions with children can be guided by the following: Set clear limits with clear consequences. Use few words and simplify instructions. Establish and maintain a predictable environment with clear rules and regular routines for eating, sleeping, and playing. Promote attention by maintaining a calm environment with few stimuli. These children cannot filter extraneous stimuli and react to all stimuli equally. Establish eye contact before giving directions, ask the child to repeat what was heard. Encourage the child to do homework in a quiet place outside of a traffic pattern. Assist the child to work on one assignment at a time (reward with a break after each completion).
Other Medications for ADHD
Bupropion (Wellbutrin) has both noradrenrgic and dopaminergic actions. TCAs: desipramine (dangerous with amphetamines as increases brain concentrations of amphetamine. May also increase cardiovascular events) , imipramine, amitriptyline, and clomipramine Tenex and Clonidine
Interdisciplinary Treatment and Recovery
Children with ADHD and their families benefit from symptom management, education, and support from a variety of disciplines in order to have a quality life. Early recognition and treatment Structured interactions Develop meaningful discipline strategies Modify physical environment Medications Behavioral approaches
Psychological Domain
Discipline is frequently an issue because parents may have difficulty controlling their child's behavior which can be disruptive and occasionally destructive. These children are at risk for depression and suicidal ideation, especially in adolescence. Girls and those with mothers who experience depression when the child is 4 to 6 years of age are more likely to attempt suicide 5 to 13 years later Children with ADHD are more likely to have problems with their cognitive process with changing demands of teachers and parents. Consequently, they may have more difficulty in school with decision making.
Diversion of a Prescription Stimulant
Diversion occurs when someone other than the person whose name is on the prescription uses it. Examples are giving your medication to a friend or taking medication from a sibling.
Social Domain Assessment
Dysfunctional interactions can develop within the family. Reviewing the problem behaviors and the situations in which they occur is a way to identify negative interaction patterns. These children are often behind in their work at school because of poor organization, off-task behavior, and impulsive responses. They can exhaust their parents, aggravate teachers, and annoy siblings and peers with their intrusive and disruptive behavior. It is important to review the family situation, including parenting style, ability of household membership, consistency of rules and routines, and life events (e.g., divorce; moves, deaths, job loss). Identification of these factors can be useful in shaping a care plan that builds on potential strengths and mitigates the effects of environmental factors that perpetuate the child's disruptive behavior. Data regarding school performance, behavior at home, and comorbid psychiatric disorders are essential for developing school interventions and behavior plans and establishing the baseline severity for medication.
Interventions for the Social Domain
Family treatment is nearly always a component of cognitive behavioral treatment approaches with the child. This may involve parent training that focuses on principles of behavior management; such as appropriate limit setting and the use of award systems. Revise expectations about the child's behavior. School programming often involves increasing structure in the child's school day to offset the child's tendency to act without forethought and to be easily distracted by extraneous stimuli. Specific remediation is required for the child with comorbid deficits in learning or language. Some children may require being pulled out of class to take exams in a quiet area. Some children may require small, self-contained classrooms.
Guanfacine ER Pharmacologic Intervention (cont.)
Guanfacine ER (Intuniv) is a nonstimulant prescription medicine used to treat ADHD in patients ages 6 to 17. In clinical studies, INTUNIV was shown to improve the symptoms of ADHD, both alone and when added to a stimulant. Adding nonstimulant INTUNIV is another option to treat ADHD. In a clinical study, doctors saw about 30% improvement in ADHD symptoms when INTUNIV was added to a stimulant compared with a sugar pill added to a stimulant. The most common side effects of INTUNIV include sleepiness, tiredness, trouble sleeping, low blood pressure, nausea, stomach pain, and dizziness. INTUNIV may cause serious side effects including low blood pressure, low heart rate, fainting, and sleepiness. Patients should drink plenty of water and not get overheated while taking INTUNIV. INTUNIV should be swallowed whole without crushing, chewing, or breaking the tablet. INTUNIV should not be taken with a high-fat meal. The medical provider will regularly check your child's blood pressure and heart rate. Do not take with Tenex (Guanfacine)
Nursing Diagnoses for the Social Domain Assessment
Impaired Social Interaction Ineffective Performance Compromised Family Coping, Short term outcomes, such as decreasing the number of class room ejections within a 2-week period, may be useful for one child, but reducing the frequency and amplitude of angry outbursts at home may be relevant to another child
ADHD Models
In ADHD, the person finds it difficult to attend to one task at a time and is easily distracted. For some, the lack of attention is related to being unable to filter incoming information, which leads to being unable to screen and select the important information. That is, all incoming stimuli are treated the same (e.g., directions from a teacher elicits the same importance as noise in the hall way). For others, the distractibility may be related to stimuli-seeking behavior. Given the heterogeneity of ADHD, either of these models explains problems of attention for subgroups of affected children.
assessment
In the school setting, the primary focus of the assessment is the impact of ADHD on classroom behavior and school performance. In the hospital, the nurse tries to determine the contribution of ADHD to the acute psychiatric problem. In both cases, the nurse collects assessment data through direct interview, observation of the child and parent, and teacher ratings. Because children with ADHD may have difficulty sitting through long sessions, interviews are typically brief. Parents and teachers are extremely important sources for assessment data. To this end, the nurse can make use of several standardized instruments (Conners Questionnaires, ADHD Rating Scale, Child Behavior Checklist). The nursing assessment of children with ADHD begins with identification and exploration of the presenting problem. Review of the child's developmental course, the onset and pattern of the current symptoms, factors that have worsened or improved the child's problems, and prior treatment or self-initiated efforts to remedy the situation. Medical history is also essential, consisting of perinatal course, childhood illnesses, hospital admissions, injuries, seizures, tics, physical growth, general health status, and timing of the child's last physical examination.
Misuse of a Prescription Stimulant
Misuse of a prescription stimulant happens any time the medicine is used in a way that is different from the doctor's instructions. Misuse could be: Taking an extra pill of your own prescription stimulant to concentrate while studying Taking a friend's prescription stimulant because you think you have ADHD
Evaluation and Treatment Outcomes
Observe for improvement in attention, impulsivity, and hyperactivity. Communicate with parents and teachers for their feedback. Assess child's perspective of how he/she is doing. Assess academic changes. Reevaluate status utilizing scales for comparisons.
Nursing Management
Planning of nursing interventions must be done in the context of the family, treatment setting, and school environment. With the parents, clinical team members, and school personnel, the nurse participates in designing a plan of care that fits the child's and family's needs. In Montana schools, this may be an IEP or a 504 with "accomadations". Persons with ADHD and their families will benefit from nursing care at many different times in the course of their disorder. Most treatment will occur outside the mental health system. School nurses often provide most of the nursing care and family education.
Psychostimulants Pharmacologic Intervention (cont.)
Psychostimulants are by far the most commonly used medications for the treatment of ADHD. Increases norepinepherine and especially dopamine actions by blocking reuptake and facilitating their release. The etiology and neurobiology of ADHD remain unclear, but psychostimulants produce a paradoxic calming of the increased motor activity characteristic of ADHD. Studies show that medication decreases disruptive activity during school hours, reduces noise and verbal activity, improves attention span and short-term memory, improves ability to follow directions, and decreases distractibility and impulsivity. Although these improvements have been well documented in the literature, the diagnosis of ADHD and subsequent use of psychostimulants with children remain matters of controversy. Amphetamine (D); Dexedrine, Dexedrine Spansules, Dextro Stat FDA approved for ADHD ages 3-16. Also FDA approved for Narcolepsy Amphetamine (D, L); Adderall, Adderall XR. Adderall FDA approved for ADHD in children ages 3-12. Adderall XR FDA approved for ADHD in children ages 6-17 and in adults. Lisdexamfetamine; Vyvanse FDA approved for ADHD in ages 6-12, 13-17, and adults. Methylphenidate (D); Focalin, Focalin XR FDA approved for ADHD in children ages 6-17. Focalin XR approved for ADHD in adults. Methylphenidate (D,L); Concerta, Metadate CD, Ritalin, Ritalin LA, Daytrana (transdermal patch) FDA approved for ADHD, ages vary based on formulation. Loss of appetite, weight loss, dry mouth, stomach upset/pain, nausea/vomiting, dizziness, headache, diarrhea, fever, nervousness, and trouble sleeping may occur. Serious side effects: mental/mood/behavior changes (e.g., agitation, aggression, mood swings, depression, abnormal thoughts), OCD, uncontrolled movements, continuous chewing movements/teeth grinding, outbursts of words/sounds (Tics), change in sexual ability/desire.Should not use if: heart/blood vessel disease (e.g., irregular heart beat, coronary artery disease, angina, heart failure, cardiomyopathy), problems with heart structure (e.g., valve problems), history of heart attack or stroke, moderate or severe high blood pressure (hypertension), over-active thyroid (hyperthyroidism), glaucoma, personal or family history of regular use/abuse of drugs/alcohol. Do not take if pregnant or breastfeeding.Death is rare from overdose or toxicity of the psychostimulants, but a 1O day supply may be lethal, especially in children. Symptoms of overdose include agitation, chest pain, hallucinations, paranoia, confusion, and dysphoria. Seizures may develop, along with fever, tremor, hypertension or hypotension, aggression, headache, palpations, rashes, difficulty breathing, leg pain, and abdominal pain. Toxic doses of dextroamphetamine are above 20 mg, with potential death resulting from a 400 mg dose. Parents should be warned regarding the potential lethality of these medications and take preventive measures by keeping the medication in a safe place. Prescription stimulants should never be used without a prescription. No matter what term you use to describe it, using a prescription medication in a way that does not follow the prescription or that is not yours can be dangerous and it's against the law. Stimulant medications aren't safer than street drugs just because they are prescribed. Terms used to describe improper stimulant use include misuse, abuse, and diversion.
Unspecified Attention-Deficit/Hyperactivity Disorder (314.01)
Same as 314.01 above but no reason specified or insufficient information is available to provide one,
Nursing Diagnoses for the Biologic Domain
Self-Care Deficit Risk for Imbalanced Nutrition Risk for Injury Disturbed Sleep Pattern
Epidemiology and Risk Factors
Sex (boys are twice as likely as girls) A familial history of ADHD, bipolar disorder, or substance use (Kessler et al., 2010) Early exposure to pesticides (Kuehn, 2011) Prenatal tobacco exposure and high lead concentrations (Froehlich, 2009)
Promoting Sleep
Sleep can be a problem for children with ADHD for many reasons. The over activity of the disorder itself and the side effects of the medications contribute to sleep problems. A sleep history should be taken before medications are prescribed (baseline). If sleep problems arise while taking medications, sleep diaries should be kept. Sleep hygiene and behavior therapy techniques should be implemented. May consider using sleep agent such as Melatonin or full spectrum lights to shift sleep.
ADHD Symptoms -Inattentive (cont.)
Staying away from tasks that require sustained mental effort Often loses things necessary for tasks or activities (school materials, wallets, keys, paperwork, eyeglasses, telephones). Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts). Being forgetful in daily activities (errands, calls, appointments, etc.)
Other Specified Attention-Deficit/Hyperactivity Disorder (314.01)
Symptoms of ADHD are present and cause significant impairment in important functional areas. Do not meet full criteria Reason for failing the criteria is specified -can see problems reading
Risk for Imbalanced Nutrition
The Restricted Elimination Diet has been shown to improve behavior in some children and can be used as an instrument to determine whether ADHD behaviors are induced by food. In this diet, all-natural, chemical free foods are eaten and most of the foods that are regularly eaten are removed. Fruits, vegetables, nuts, nut butters, beans, seeds, gluten-free grains such as rice and quinoa, fish, lamb, wild game meats, organic turkey, and large amounts of water are consumed. This, diet is very restricted and consequently difficult to follow. The Mediterranean diet is a good choice, but only because it promotes the kind of foods that are healthiest for ALL kids. There's no proof that ADHD can be caused by a poor diet or cured by a special diet. Health experts agree every child does better in general by eating a balanced diet like the Mediterranean diet. With this diet, eat mostly fruits, vegetables, whole grains, lean proteins, and omega-3 fats (found in foods like salmon and walnuts). Avoid saturated fats, sugar, and additives or processed foods.
assessment
The behavior of these children is characteristically very active and can often be observed in the office. They cannot sit still. They fidget. Even in sleep, they may be more active than normal children. A careful assessment of eating, sleeping, and activity patterns is essential. Assessing daily food intake, typical diet, and frequency of eating will help identify any nutrition problems. Caffeinated products can contribute to hyperactivity. Sleep is often disturbed for children with ADHD and consequently the family. A detailed sleep assessment can provide points for interventions and help the interpretation of drug effects.
Pharmacologic Intervention
The first-line recommended medications for ADHD symptoms are the psychostimulants and atomoxetine (Strattera). It is not unusual for two psychostimulants or a psychostimulant and atomoxetine to be prescribed together for maximum response. Second-line medications include bupropion (Wellbutrin) and other antidepressants (tricyclic antidepressants [TCAs]). If symptoms are not improved, alpha agonists (guanfacine or clonidine) are usually used (Pliszka et al., 2006).
Etiology
There is no one explanation for the occurrence of ADHD but instead, this disorder is viewed as having multiple causes. Genetic factors are implicated in the etiology of ADHD and they clearly play a fundamental role in the manifestation of the ADHD behavior. The heritability of ADHD is substantial. In some children, ADHD may have developed because of having hypersensitivity to environmental stimuli such as foods.
Biologic Theories
There is pervasive evidence of neurobiological dysfunction. Several lines of research have shown that the frontal lobe connections are impacted with specific subcortical structures are also dysregulated. One clearly dysfunctional area is the dorsolateral prefrontal cortex, the center of directed attention and the ability to manage emotions or delay emotional reactions. Several neurotransmitters (e.g., dopamine, serotonin) are dysregulated. The hyperactive-impulsive behavior characteristic of ADHD has been predominantly related to biological factors, not psychosocial.
Continuum of Care
Treatment is usually done outpatient and multimodal Individual treatment for the child Family treatment School accommodations Medications
Abuse of a Prescription Stimulant
Using a prescription medicine to get high or taking a prescription stimulant to see how it makes you feel is considered abuse. Stimulants have a high potential for abuse, and should be used only as directed.
ADHD
umbrella disorder