ADHD

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ADD/ADHD

• Tammy Marie Baker RN
• Pediatric Series 2012
• Pedi

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what is ADD/ADHDAttention DEFICIT DISORDER with
or with out hyperactivity

• ADHD is a commons disorder often diagnosed early
  in child
• It affects 3-5 of school aged children
• More common in boys than Girls
• Often seen in more than one child in the family
  and even Parents of child

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• DSM-IV Criteria for ADHD
• I. Either A or B
• 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
• Often does not give close attention to details or
  makes careless mistakes in schoolwork, work, or
  other activities.
• Often has trouble keeping attention on tasks or
  play activities.
• Often does not seem to listen when spoken to
  directly.
• 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).
• Often has trouble organizing activities.
• 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).
• Often loses things needed for tasks and
  activities (e.g. toys, school assignments,
  pencils, books, or tools).
• Is often easily distracted.
• Is often forgetful in daily activities.
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DSM-IV Criteria for ADHD

• 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
• Often fidgets with hands or feet or squirms in
  seat when sitting still is expected.
• Often gets up from seat when remaining in seat is
  expected.
• Often excessively runs about or climbs when and
  where it is not appropriate (adolescents or
  adults may feel very restless).
• Often has trouble playing or doing leisure
  activities quietly.
• Is often "on the go" or often acts as if "driven
  by a motor".
• Often talks excessively.
• Impulsivity
• Often blurts out answers before questions have
  been finished.
• Often has trouble waiting one's turn.
• Often interrupts or intrudes on others (e.g.,
  butts into conversations or games).
•  

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DSM CRITERIA CONTINUED
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 are not better
Psychotic Disorder. The symptoms for by another
mental disorder (e.g. Mood Disorder, Anxiety
Disorder,Dissociative Disorder, or a Personality
Disorder). 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
months IB. ADHD, Predominantly Inattentive Type
if criterion IA is met but criterion IB is not
met for the past six months  IC. 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.
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ADHD

• Inattentiveness
• Fails to give close attention to details or makes
  careless mistakes in schoolwork
• Has difficulty keeping attention during tasks or
  play
• Does not seem to listen when spoken to directly
• Does not follow through on instructions and fails
  to finish schoolwork, chores, or duties in the
  workplace
• Has difficulty organizing tasks and activities
• Avoids or dislikes tasks that require sustained
  mental effort (such as schoolwork)
• Often loses toys, assignments, pencils, books, or
  tools needed for tasks or activities
• Is easily distracted
• Is often forgetful in daily activities

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hyperactivity

• Hyperactivity symptoms
• Fidgets with hands or feet or squirms in seat
• Can not stay seated when asked to
• Mobilizes self , Runs around or climbs in
  inappropriate situations
• FInds Quiet Play Difficult
• Excessively verbal and always "on the go," acts
  as if "driven by a motor,"

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Impulsivity syptoms

• Blurts out answers before questions have been
  completed
• Has difficulty awaiting turn
• Interrupts or intrudes on others
• 4.Butts into conversations or games

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WHat does ADHd Look like?
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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

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Testing for ADHDMultidisciplinary approach

• Team involves Physician, Teachers, family
  Psychologist, psychiatrist, Physical and
  occupational therapist
• psychological evaluation of child/family
• psychological testing of child
• Behavioral Questionnaire Burke or Connors
• developmental/ physical exam
• Nutritional evaluation

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Treatment options

• Behavioral therapy
• Social Skills classes or therapy
• Environmental structure
• Medications
• IEP for school

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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 children's with ADHD do not
  tolerate change well
• Communicate regularly with the child's teachers,
  caregivers, therapist
• Minimize child's 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

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Medications
(Psychostimulants also known as Stimulants)

• Medications used for ADHD are stimulants
• Children respond to medications in a variety of
  ways. Each child should be evaluated and
  monitored closely while on stimulant
  medications as they may have adverse reactions or
  medications interactions if combined.
• Medications are kept out of reach of children and
  administered by the PCG/SN or school nurse
• Blood levels are checked to monitor toxicity,
  liver function and abnormalities
• Notify the MD if medications reactions are
  suspected or adverse reactions noted such as
  suicidal ideations, hallucinations, worsened
  behavior, insomnia, appetite loss or sever
  increase
• Do not discontinue meds abruptly, change dose or
  stop meds on weekends with out consulting a
  physician first. Drop in medication levels can
  cause abrupt behavioral changes

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TERMinology

• BIP Behavioral intervention Plan
• FBA Functional Behavioral Assessment
• IEP Individual Education Plan
• MDM Manifestation Determination Meeting

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MEDICATIONS commonly used

• Methylphenidate (Ritalin,Concerta,Metadate,daytran
  a)
• Atomoxetine Strettara ( non stimulant)
• Amphetamine-Dextroamphetamine (Addarel)
• Dexmethylphenidate (Focalin)
• Dextroamphetamine ( Dexidrin, Dextrostat
• LIsdexamfetamine (Vyvanse)

Combinations of Medications may also be
seen Caution and Observation should always be
used when these types of medications are combined
administered to children.Nursing observation
and Assessment of childs tolerance and behavior
is essential
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Nursing care of children with ADD/ADHD

• Safety measures includephysical safety of the
  child secondary to impulsivity, medication safety
• Medication Administration and Education of family
  
• Behavioral observations and recording in nursing
  notes reporting to the physician any sudden
  changes in affect or behavior
• IEP (Individual Educational Plan) advocacy and
  support to the child and Family.The nurse should
  be familiar with the child's IEP. Nurses are
  often included in the IEP meetings.
• Behavioral intervention Plan Adhere to the
  behavioral guidelines set in the plan and assist
  the family in implementation and adhering to the
  guidelines of the plan.
• The nurse should not judge the family nor the
  child. Behaviors are a function of the child's
  disability Provide support and understanding to
  the family.

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conclusion
Children with ADHD are a challenge and a
Gift Nurses who care for them make a difference..