ADD/ADHDTammy Marie Baker RN Pediatric Series 2012
what is ADD/ADHDAttention DEFICIT DISORDER with or with out hyperactivityADHD is a commons disorder often diagnosedearly in child It affects 3-5 % of school aged childrenMore common in boys than GirlsOften seen in more than one child in the familyand even Parents of child
DSM-IV Criteria for ADHDI. Either A or B: A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level: Inattention 1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. 2. Often has trouble keeping attention on tasks or play activities. 3. Often does not seem to listen when spoken to directly. 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behav or failure to understand instructions). 5. Often has trouble organizing activities. 6. Often avoids, dislikes, or doesnt want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework 7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools). 8. Is often easily distracted. 9. Is often forgetful in daily activities.
DSM-IV Criteria for ADHD A. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level: B. Hyperactivity 1. Often fidgets with hands or feet or squirms in seat when sitting still is expected. 2. Often gets up from seat when remaining in seat is expected. 3. Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). 4. Often has trouble playing or doing leisure activities quietly. 5. Is often "on the go" or often acts as if "driven by a motor". 6. Often talks excessively. 3. Impulsivity 1. Often blurts out answers before questions have been finished. 2. Often has trouble waiting ones turn. 3. Often interrupts or intrudes on others (e.g., butts into conversations or games).
DSM CRITERIA CONTINUEDII. Some symptoms that cause impairment were present before age 7 years.III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).IV. There must be clear evidence of clinically significant impairment in social, school, or work functioning.V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other are not betterPsychotic Disorder. The symptoms for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder,Dissociative Disorder, or a PersonalityDisorder).Based on these criteria, three types of ADHD are identified:IA. ADHD, Combined Type: if both criteria IA and IB are met for the past 6 monthsIB. ADHD, Predominantly Inattentive Type: if criterion IA is met but criterion IB is not met for the past six monthsIC. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion IB is met but Criterion IA is not met for the past six months.American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC,American Psychiatric Association, 2000.
ADHD Inattentiveness1. Fails to give close attention to details or makes careless mistakes in schoolwork2. Has difﬁculty keeping attention during tasks or play3. Does not seem to listen when spoken to directly4. Does not follow through on instructions and fails to ﬁnish schoolwork, chores, or duties in the workplace5. Has difﬁculty organizing tasks and activities6. Avoids or dislikes tasks that require sustained mental effort (such as schoolwork)7. Often loses toys, assignments, pencils, books, or tools needed for tasks or activities8. Is easily distracted9. Is often forgetful in daily activities
hyperactivityHyperactivity symptoms:1.Fidgets with hands or feet or squirms in seat2.Can not stay seated when asked to3.Mobilizes self , Runs around or climbs in inappropriate situations4.FInds Quiet Play Difﬁcult5.Excessively verbal and always "on the go," acts as if "driven by a motor,"
Impulsivity syptoms1.Blurts out answers before questions have been completed2.Has difﬁculty awaiting turn3.Interrupts or intrudes on others4.Butts into conversations or games
DIAgnosis The diagnosis is based on very specific symptoms, which must be present in more than one setting. 6 attention or 6 hyperactivity symptoms present prior to age 7 Symptoms present in more than one environmental setting ( home, school, church, peer relationships) Symptoms are sever enough to cause disruption in the environmental settings•
Testing for ADHD Multidisciplinary approachTeam involves Physician, Teachers, family Psychologist, psychiatrist, Physical andoccupational therapistpsychological evaluation of child/familypsychological testing of childBehavioral Questionnaire Burke or Connorsdevelopmental/ physical examNutritional evaluation
Treatment optionsBehavioral therapySocial Skills classes or therapyEnvironmental structureMedicationsIEP for school
working with ADHD children Maintain set schedules for school , home work, meals and activities• Avoid abrupt changes in schedules, plan changes ahead of time as childrens with ADHD do not tolerate change well• Communicate regularly with the childs teachers, caregivers, therapist• Minimize childs environmental distractions• Healthy Nutritional Choices should include , nutritional variety ,plenty of fiber and basic nutrients.• Establish good sleep patterns with consistency in amount of sleep• Acknowledge good behavior with Praise and positive reinforcement• Provide clear and consistent rules for the child. teach and instruct PCG/Teachers and Nurses
Medications (Psychostimulants also known as Stimulants)Medications used for ADHD are stimulantsChildren respond to medications in a variety of ways. Each child should be evaluated and monitored closelywhile on “stimulant” medications as they may have adverse reactions or medications interactions ifcombined.Medications are kept out of reach of children and administered by the PCG/SN or school nurseBlood levels are checked to monitor toxicity, liver function and abnormalitiesNotify the MD if medications reactions are suspected or adverse reactions noted such as suicidal ideations,hallucinations, worsened behavior, insomnia, appetite loss or sever increaseDo not discontinue meds abruptly, change dose or stop meds on weekends with out consulting a physicianﬁrst. Drop in medication levels can cause abrupt behavioral changes
MEDICATIONS commonly used Methylphenidate (Ritalin,Concerta,Metadate,daytrana) Atomoxetine : Strettara ( non stimulant) Amphetamine-Dextroamphetamine: (Addarel) Dexmethylphenidate (Focalin) Dextroamphetamine ( Dexidrin, Dextrostat LIsdexamfetamine (Vyvanse) Combinations of Medications may also be seenCaution and Observation should always be used when these types of medications arecombined & administered to children.Nursing observation and Assessment of childs tolerance and behavior is essential
Nursing care of children with ADD/ADHDSafety measures include:physical safety of the child secondary to impulsivity,medication safetyMedication Administration and Education of familyBehavioral observations and recording in nursing notes; reporting to the physicianany sudden changes in affect or behaviorIEP (Individual Educational Plan) advocacy and support to the child andFamily.The nurse should be familiar with the childs IEP. Nurses are oftenincluded in the IEP meetings.Behavioral intervention Plan: Adhere to the behavioral guidelines set in the planand assist the family in implementation and adhering to the guidelines of theplan.The nurse should not judge the family nor the child. Behaviors are a function ofthe childs disability Provide support and understanding to the family.
conclusionChildren with ADHD are a challenge and a Gift Nurse’s who care for them make a difference..