Care of the Patient with ADHD

Attention deficit hyperactivity disorder (ADHD) was once considered only a childhood disorder. However, it is now known that the disorder covers the lifespan. ADHD was first described in 18th-century by Sir Alexander Crichton when he described mental restlessness (Barkley & Peters, 2012). Years later in the mid-1800s, a German physician Heinrich Hoffman, wrote a case study entitled fidgety Phil describing symptoms of what we now call ADHD (Barkley & Peters, 2012). Later in the early 1900s, George Still presented another picture of lack of moral control in children and described an abnormal relationship to the environment (Barkely, 2014). As research continued, the symptoms and impacts of inattentiveness and excess energy became clearer.

Continued studies on symptoms in children have given us a greater understanding of what ADHD is and that it can continue into adulthood. Once called Hyperkinesis or brain dysfunction, it is the most common disorder of childhood. Several studies estimate the prevalence of ADHD in children and adolescents at about 5% (American Psychiatric Association, 2013; Center for Disease Control and Preventions, 2010, Wilcutt, 2012; Viser, et. Al. 2014) although other have estimated that ADHD affects closer to 8% (Kessler, et al. 2006) of those under 18. Studies also show that about 65% of children diagnosed with ADHD will continue to have symptoms into adulthood. Adult ADHD studies suggest that about 2.5%-4.4% of the population suffer from ADHD symptoms (Kessler ,et al., 2006; Fayyad et al, 2007; Simon et al, 2009; Matte et. al., 2015). Another study suggests that adults with ADHD are thought to number at about 9-11 million (Kessler,2006; Umansky 2010; CDC,2010). Although the numbers may differ slightly, the studies all agree that the numbers are growing even with the changes in the new DSM-V. Studies also report that ADHD affects more males than females. Therefore, it is important for healthcare providers to understand ADHD throughout the lifespan.

Symptoms of ADHD are different in children than in adults. However, hyperactivity-impulsive behavior, wandering thoughts, and inattentiveness are hallmarks of the disorder. Children and adolescents have difficulties in school and at home not only with grades and but also with relationships. Adults report difficulties with family and peers and occupational problems (National Resource Center on ADHD, 2016).

Although the exact cause of ADHD is unknown, studies suggest several possible reasons (Tapar, Cooper, Eyre & Langley, 2013). Some scientists have researched the role of glucose, a source of energy for the brain, in both impulse control and attention. Studies reveal that those with ADHD have a lower level of glucose or do not use glucose efficiently (Hedlund, 2013). Other studies suggest that brain development is disrupted during pregnancy possibly due to toxins or genetics (Tapar, Cooper, Eyre & Langley, 2013). Cigarette smoking, alcohol and other drugs appear to have damaging effects on nerve cells in the brain of the fetus. Additional studies show possible links to toxins in the environment, such as lead, that may also lead to ADHD (Taper, Cooper, Eyre, & Langley, 2013). The strongest link found so far is that children with ADHD usually have at least one close relative with ADHD as well, showing a genetic link. Genetic studies are also showing that twins have the same symptoms and traits, again, showing a genetic link (Taper, Cooper, Eyre, & Langley, 2013).

The majority of research does agree that ADHD is linked to certain neurotransmitters in the brain. Remember that neurotransmitters are the brains chemicals that help send messages throughout parts of the brain to cause reactions or emotions. In ADHD, dopamine and norepinephrine are thought to be out of balance (Stahl & Muntner, 2013).

ADHD is not caused by too much TV, allergies to food or substances, too much sugar, bad schools, or a poor home life (National Resource Center on ADHD, 2016). More recently, new techniques for studying the brain such as a positron emission tomography, or PET scan, can show the brain working. This allows scientists to see what part of the brain is more active or less active with ADHD.

ADHD is identified through behaviors and testing. Common behaviors fall into three categories they are inattention, hyperactivity, and impulsivity.

Inattentive children or adults have a hard time keeping their mind centered on one thing (American Psychiatric Association, 2013). They tend to get bored and jump from task to task. Asking them to give their attention to one thing is very difficult. For example, asking the adults to pick out clothing for the day may be a difficult task because they cannot focus long enough to pick out all articles of clothing. A child, on the other hand, may find it difficult to focus on schoolwork or someone talking for a long period of time. Other examples of inattentiveness include being easily distracted, not able to complete tasks, or making careless mistakes.

Impulsivity occurs when the person or child is very impatient and has immediate reactions to situations or events (American Psychiatric Association, 2013). They may appear to be bouncing off the walls, moving from one activity to the next very quickly, or even have racing thoughts. The result is usually inappropriate actions or comments. For example, an adult in a hurry to get their work done overlooks details. A child, on the other hand, may forget schoolbooks or shoes.

Hyperactivity is being in constant excessive movement. For example, the child who cannot seem to sit still or squirms. The adults may talk quickly or constantly and may also be fidgety. Examples of hyperactivity and impulsivity are feeling restless, leaving their seat, blurting out answers, interrupting, does not seem to listen when spoken to, or has difficulty waiting their turn. Furthermore, an adult with ADHD may have problems with friendships or relationships, not able to pay attention, or has difficulty holding a job. The symptoms can cause significant impairment in daily life for the child as well as for the adults.

Additionally, other disorders can co-occur with ADHD making it difficult to diagnose and to work with them. Although essential features are inattention, hyperactivity or impulsivity, the caregiver may also see learning disabilities, speech disorders, oppositional defiant disorder, posttraumatic stress disorder, anxiety, depression, and other mood disorders (American Psychiatric Association, 2013). It is important to observe all symptoms and be ready to report them to the nurse.

Interventions should include a structured environment and a routine providing consistent, clear rules and organization strategies (Hockenberry & Wilson, 2014; Jaska, 2010). For children who are more hyperactive, make sure the area they are in is free from sharp objects or items that they can get hurt on. Be sure to monitor food and fluid intake. Offering finger foods and even sippy cups can help keep them hydrated and fed. For both children and adults, developing routines for tasks can be helpful to keep them focused. Keeping directions and routines simple is also helpful. Break up tasks into smaller parts to help keep attention (Jaska, 2010). Helping the adult or the parent to set limits such as how much T.V. to watch or establishing a wake-up and go to school or work schedule can help to channel energy and keep the focus on a task. A reward system is also helpful as studies show that those with ADHD are more responsive to immediate rewards (Barkely, 2014). A structured system can address motivational problems as well as help the child or adult focus on getting a task done to get the reward (Haenlein & Caul, 1987; Barkely, 2014).

It is important to understand that other conditions can co-occur with ADHD. In a child a comorbidity may be oppositional defiant disorder, conduct disorder, anxiety, depression or learning disabilities (American Academy of Pediatrics, 2000). Being aware of any additional diagnosis or symptoms will help in the care of the patient. For example, does the patient not listen, constantly in motion, has any mood changes, or cries easily, may signal that there is a mood disorder such as bipolar or anxiety in addition to ADHD. Another co morbid disorder is substance abuse. If working with a teenager or adult, observe for signs of intoxication or withdrawal.

Most likely the child or the adult will be on medication for ADHD. The most common type of medication is a stimulant. Be aware of any signs of abuse such as constantly asking for refills before they are due, euphoria, increase blood pressure, increase energy or alertness, rapid breathing, dilated pupils, no appetite or staying up for longer periods (“What are the possible consequences of stimulant use and abuse?” 2014). These signs should be immediately reported to the nurse.

Along with a normal report, be sure to immediately report any changes in the patient’s mood or behavior. Changes that need to be reported immediately may include (Sorrentino & Remmert, 2013):

• Sudden anger or crying
• Becoming demanding or aggressive
• Withdrawing from others or groups
• Inappropriate behaviors such as touching or undressing
• Confusion
• Nonverbal signs such as a clenched fist, pacing or rapid movements
• Physical signs of a possible medication reaction such as hives, vomiting or diarrhea
• Decreased or increased appetite or fluid intake
• Safety issues
• New injuries
• Changes in mobility
• Abnormal vital signs
• Difficulty swallowing
• Difficulty with daily activities

Susan is a 30-year-old female who is has a diagnosis of anxiety. This is her first hospitalization. The nurse tells you she has been able to manage her anxiety until just recently. The nurse is suspicious that Susan has something else going on. You enter Susan’s room and notice that she is looking for something and is very upset. You approach her asking if you can help. Susan tells you she lost her hair brush. She also tells you that she looses everything or forgets where she puts her things. You help her find her brush and when she is dressed you escort her first to breakfast and then a group to follow. In the group, you notice that Susan seems to “tune out.” She seems not to be able to keep up with the conversation, and when asked to complete a questionnaire in the group, Susan was not able to finish and what she did complete had several mistakes such as missing her name, and not answering questions completely. You decide to tell the nurse about your findings. What do you report?

Today you are taking care of a 12-year-old boy, John, who is believed to be suffering from ADHD. When you enter the home, you notice that John is running through the house like he is driven by a motor. He is yelling at the top of his lungs and being very disruptive while you try to talk to his parents. The parents tell you that they don’t understand what is happening. They have been giving John his medication daily, but he seems worse. You ask the parents to describe what happens each day while keeping an eye on John. They tell you he is more irritable and moody all day. The teacher reports he is acting out more and won’t stay in his seat. Although he did this before the medication, it is much worse now. They also tell you John is not sleeping for more than two hours a night but does not appear tired at all. He is not eating well and just can’t stop moving. You notice all this and that John has a red splotch on his arm. You approach John and ask if you can look at his arm. You talk to John, asking him what he has been doing today. John is talking so fast he is starting to stutter. You can see that he has several red spots on his arm and with the help of his mother, you see more on his back. What do you do?

In both cases, you need to report your findings to the nurse.

In Susan’s case, you will need to report what you have been observing. Susan is forgetful, looses items easily, cannot stay focused in the group and seems to tune out often. She was not able to complete the questionnaire, and you saw that she made careless mistakes on the form. Once you have reported this to the nurse. She tells you that she suspects Susan also suffers from ADHD. She calls the provider to see what can be done to help Susan.

In John’s case, you call the nurse as soon as you notice the red marks or hives. He is having an allergic reaction that is most likely from the medication. You also report that John is not responding to the medication as he should be. You relay what the parents told you as well as your own observations. John has more energy and is starting to act out. He is not able to sit still and is talking rapidly, not eating well and not sleeping more than two hours. You also report that you took his vital signs and his respirations, heart rate and blood pressure is increased. The nurse asks that you stay with the patient and the parents while she calls the provider. While you wait, you talk to the parents about the routine that is set up for John in the morning and when he comes home from school. You discover that John could benefit from a more structured routine and begin to discuss this with the parents. Together, you set up a structured routine for John.

Attention Deficit Disorder, or ADHD, is a disorder that impacts children as well as adults in various settings. Symptoms range from inattentiveness such as tuning out or making careless mistakes, to hyperactivity and impulsivity such as talking too fast, not being able to sit still, or not being able to finish tasks. ADHD can also co occur with other disorders such as anxiety, depression or Conduct Disorder. It is important for the care giver to be able to recognize any signs of excessive energy or inattentiveness. The care giver can help by setting up routines and offering strategies for the patient to stay focus depending on the patient’s age and capabilities. With medication, routines and strategies to help with focus, patients with ADHD can be successful. 

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