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You can learn many things from children. How much patience you have, for instance” Franklin P. Jones

This quotation certainly speaks of staying on the line despite frequent punch from one’s limitations. Parents with children diagnosed with ADHD or Attention Deficit Hyperactivity Disorder can absolutely relate to the notable quote above. Their patience is measured all the time, not by their children; but by their own conscience.

      Attention Deficit Hyperactivity Disorder (ADHD) is the most common behavioural disorder that happens six to nine times more on boys than girls (Huelskoetter, 1991) and occurs 3% to 7% on pre pubertal elementary students (Shives, 2008). It is said to be affecting children of average or above average general intelligence, characterized by inattention and/ or hyperactivity – impulsivity.

This disorder should be diagnosed carefully by an expert practitioner since it can be disguised as other conditions, such as learning disability, conduct disorder, oppositional defiant disorder, depression or anxiety disorder, bipolar disorder, and Tourette syndrome (National Institute on Mental Health, January 2012).  Sad to say, there is no single definitive test that could readily diagnose a child or in some cases, an adult to be having ADHD. Diagnosing an individual with it needs several types of tests in order to rule out other overlapping conditions.

According to Shives (2008) and Huelskoetter (1991), ADHD can be manifested by a child before he reaches the age of 7 years, though symptoms can already be observed as early as 3 years old. Attention deficit hyperactive disorder can hinder a child’s learning ability, the more common of which is reading ability, could affect his health (low calorie intake plus easy fatigability due to hyperactivity), loosen his connections with other people (due to his labile mood or mood swings) and could even influence his sense of esteem. On the contrary, this condition can possibly be brought by that individual in his adulthood if not well dealt with – leading to a life- long dysfunction.

But due to sensible efforts of many researches, this condition has been accepting more support and care despite its issues before. The American Psychiatric Association has developed criteria to be used by health care professionals in diagnosing ADHD.

(Adopted from Diagnostic and Statistical Manual of Mental Disorders IV- Text Revision or DSM IV – TR)

Diagnostic Criteria:

I. 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 behavior or failure to understand instructions).
  5. Often has a trouble organizing activity.
  6. Often avoids, dislikes, or doesn’t 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.

B. 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:
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.

Impulsivity

  1. Often blurts out answers before questions have been finished.
  2. Often has trouble waiting one’s turn.
  3. Often interrupts or intrudes on others.

II. 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 Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).

According to the criteria given above ADHD can be identified and classified into three types:

IA. ADHD, Combined Type:  if both criteria IA and IB are met for the past 6 months

IB. ADHD, Predominantly Inattentive Type: if criterion IA is met but criterion IB is not met for the past 6 months

IC. ADHD, Predominantly Hyperactive- Impulsive Type: if criterion IB is met but criterion IA is not met for the past 6 months

Nevertheless, the nursing profession has never been reluctant and impatient in dealing with these clients. There are still many things that a healthcare professional and a parent can do for them. Though it may be requiring a lot of hard work, clients has been increasingly adaptive to this management and it pays a lot more for seeing smiles in their faces.

   Nursing management for attention deficit hyperactivity disorder (ADHD) is balanced with a detailed history taking, either structured or unstructured (play therapy) routines, proper approach and appraisal methods, assisting with their basic needs, drug therapy, and adequate client and family education.

Assessment

Assessment does not only deal with how the child react or respond to a certain test, but as well involve the family’s observation of the child. If the child is already going to school, his teacher’s observation and appraisal is also considered.

In order to avoid overlaps associated with ADHD, the child may undergo several test like ophthalmologic and hearing evaluation, laboratory tests, some IQ tests and visual motor tests (Huelskoetter, 1991). In addition, other symptoms can also be observed in them which should be put into consideration, i.e. stubbornness, mood swings, temper tantrums, aggressiveness, inability to tolerate frustration, deficit in judgement, poor self- image, and obstinacy (Shives, 2008).

Common Nursing Diagnoses

– Risk for injury
– Sleep pattern disturbance
– Interrupted family processes
– Impaired verbal communication
– Noncompliance to rules
– Ineffective individual coping
– Compromised family coping
– Social isolation
– Disturbance in self- concept 

Planning/ Implementation

  • Accept the child or individual as what he is. Consider his condition and communicate with him as an equal.
  • Approach the child at his current level of functioning. Do not use baby talk nor direct him as to his chronological age. Encourage him to express his thoughts or emotions and respond to him therapeutically.
  •  Use simple and direct instructions. You may repeat your instructions more than once and at times, you may utilize visual aids or pictures in order for him to relate well. In educating the child, the lessons should only be brief in duration due to his short attention span.
  • Provide few easy rules to be followed.  Obedience from the child is always the “thing” that matters. Simplify what he needs to do for a specific time of the day without reiterating too much because the child may become over distracted if given with many tasks.
  • Implement scheduled routine every day. Make his routine predictable and something like ritualistic so that it will only be easy for him to grasp for his independent functioning.
  • Avoid stimulating or distracting settings. Ensure to involve the child in his daily activities in a quiet and non-stimulating area to prevent him from becoming easily distracted and hyperactive.
  • Involve the child in Play Therapy. Play therapy is used in children in order for them to express their emotions, gain control, manage their anxieties, and provides a medium for their creativity.
  •  Keep away harmful objects where he executes his activities. The child may have some decrease in impulse control or may become hyperactive, so it is better to hide sharp and fragile objects away.
  • Clocks and timers may be effective, too. According to Smith & Segal (May 2012), using timers in ensuring that the child finishes the task you opted him to do is helpful. By telling him firm instructions to finish a certain task prevents him from jumping from one task to another.
  • Give positive reinforcements. Every good deed done should be rewarded even with a simple smile, nod or a star. Praise him for achieving his goals for the day or a task that was finished. It is also advisable to provide immediate reinforcement since they sometimes have decrease tolerance to frustration.
  • Assist him with his needs. For food, finger foods are suggested. It should be adequate for his age and activity. But if able to, assist him with his daily intake and implement firm rules in eating.
  • Encourage physical activity. You may encourage him to join a physical activity that he likes as this may also help him make friends with other children. Allow him to exert his energy productively but do not let him get over fatigued, too. Physical activity helps in getting good sleep but over fatigue might as well make him uneasy and irritable.
  •  Administer medications as ordered. Stimulants are given to extend their attention span while tranquilizers are used to improve his behaviour (hyperactivity).
  • Provide Individual educational plans (IEPs).  A structured educational session with the child and the family is always helpful. Both the child and the family need emotional support. Siblings may as well be affected, thus it works much with their help, too.

An innocent child with ADHD needs an accepting and supportive environment. It does not only need a mother’s tender love or a father’s open arms, but also his siblings who could become his role models when he grew up. Love is not measured by what people do but by what they put on it.

References:

  •  ADAM Medical Encyclopedia (March 2012). Attention Deficit Hyperactive Disorder (ADHD). Retrieved last August 22, 2012 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/ American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. (2000).
  • Washington, DC, American Psychiatric Association. Retrieved last August 23, 2012 from http://www.cdc.gov/ncbddd/adhd/diagnosis.html Huelskoetter & Murray. (1991). Psychiatric Mental Health Nursing: Giving emotional care. C & E Publishing Co. National Institute on Mental Health. (January 2012).
  • What is attention deficit hyperactive disorder? Retrieved last August 23, 2012 from http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-index.shtml Smith & Segal (May 2012).
  • ADD/ADHD Parenting Tips. Retrieved last August 22, 2012 from http://www.helpguide.org/mental/adhd_add_parenting_strategies.htm Shives, L. R. (2008). Basic Concepts of Psychiatric- Mental Health Nursing 7th Edition. Lippincott Williams & Wilkins.
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A dedicated registered nurse who loves to view life as a revolving conundrum with spectacles of light and an aspiring writer who wants to share her expertise and experience in the nursing profession. She had pursued continuing education specializing in Psychiatric Nursing but had her practice on MNCHN.