For this assignment I have decided to look at the disorder known as ADHD (Attention Deficit-Hyperactivity Disorder), or its European description Hyperkinetic disorder. For the purposes of this assignment I will use the term ADHD. The reason I have chosen this particular subject is that there are many arguments surrounding the diagnosis, treatment and management of this potentially disabling developmental disorder.
It is a disorder, which is enduring; affecting the physical, social, psychological and spiritual life of the individual, it also presents with acute episodes, which may also require nursing intervention. I have worked with children and adults with ADHD and find it amazing that in some cases little is known by parents, carers and the individuals about the condition. Is this because resources are poor, or because opinion is divided on the condition itself?
Munden & Arcelus (1999) comment that many parents become despondent, because their attempts to find either an explanation for ADHD or a way of rectifying it have been unsuccessful. To begin a definition of ADHD will be given, this will be followed by an explanation of the diagnostic approach used in determining ADHD, showing differences in current thinking on the subject. As a future learning disability nurse, I aim to look at the link between ADHD and learning disabilities.
The assignment will then look at the enduring problems associated with ADHD not only for the individual but carers also. Acute problems faced by individuals and carers will then be highlighted. It is hoped that the role of the nurse can be explained in the assessment, treatment and management of ADHD. ADHD is not a newly recognised condition, in 1902 Frederic Still, described ‘abnormal psychical conditions and the deficit of moral control’ in children (Munden & Arcelus 1999). ADHD is one of the most common psychiatric disorders of children.
Historically, since medical science first documented the disorder in 1902, a number of terms have been used to describe the disorder presenting with symptoms of ADHD. These include Minimal Brain Dysfunction or Damage (MBD), Hyperkinetic Reaction, and Hyperkinesis (Munden & Arcelus 1999). During the 1970s and 1980s intensive research and the development of diagnostic criteria made ADHD the most written about childhood condition, and as a result ADHD is now recognised as a disorder with an underlying biological cause that can be successfully treated (American Psychiatric Association 1980).
ADHD is characterized by developmentally inappropriate degrees of inattention, impulsivity, and hyperactivity (American Psychiatric Association 1994). Prior to diagnosis, parents or teachers may complain that their child is not listening, not fitting in or not responding to discipline as other children do. The three main characteristics of ADHD illustrate how such a child might behave. Many experts consider impulsivity to be the hallmark of ADHD (Barkley 1998). This behaviour often pushes the limits of parents and teachers patience.
Impulsivity is exemplified by the careless errors the child may make. A child with ADHD has difficulty sustaining attention; especially during monotonous tasks, they are also highly distractible. Typically, a child with ADHD is described as restless, in constant motion and fidgety. They may also talk excessively (Ingersoll and Goldstein 1993). Children with ADHD are typically impulsive, forgetful, restless, prone to failure, unpredictable and moody. These characteristics appear in early childhood and are chronic in nature.
The persistence, pattern, and frequency of these behavioural characteristics sets children with ADHD apart from other children who may show these traits from time to time. Although its aetiology is unknown, there is evidence that the frontal lobe of the brain may play a role in ADHD; other studies have shown diminished levels of dopamine in the brain in these children compared to controls, and norepinephrine is thought to be released in insufficient quantities. While most cases of ADHD are idiopathic, there is a genetic correlation (U. S Department of Health and human Services 1999).
Studies by Biederman et al (1990) found about 25% of biological parents also have ADHD. In addition, pregnancy complications, exposure to prenatal toxins (including drugs and alcohol), brain trauma, and increased serum lead levels have been associated with a small number of ADHD cases (Barkley 1998). In very rare instances, particularly in very young children and in those with multiple allergies, hypersensitivity to certain food additives and dyes may cause adverse responses that include behavioural manifestations (Ingersoll and Goldstein 1993).
However, allergic reactions to food additives, dyes, and preservatives, as well as refined sugar, do not seem to be a primary cause of ADHD (Barkley 1998). Research has also linked stress, poor nutrition, central nervous infections, and drug addition (Mehl-Madrona 2001). So how common is ADHD? Figures for the U. K, according to Professor Taylor suggest that about 1. 7% of the British population has ADHD in its more severe form (Taylor et al 1991). Approximately 3-5% of children around the world have this disorder (Barkley 1998). About 50% have another psychiatric disorder with ADHD.
In the past, it has been thought that ADHD was only present in boys. However, it is now known that girls may have it too. The diagnosis of ADHD is very difficult as there is no concrete medical test, making the diagnosis very subjective. This brings about the first disputed topic surrounding ADHD. In the U. K. psychiatrists and other health professionals use the ICD-10 (International Classification of Diseases 10th ed) diagnostic criteria, while America and other parts of the world use the DSM-1V (Diagnostic Statistical Manual) criteria.
Although similar, there are significant differences in the number of symptoms required and the way in which behaviours are described (Munden and Arcelus 1999) (see appendix 1). ICD-10 has been shown to select a smaller group of children than those selected using DSM-1V. By insisting that ICD-10 criteria are met before treating for ADHD, clinicians in the U. K. are depriving a group of children with significant impairment (who fulfil DSM-1V criteria) proper treatment and intervention (Munden and Arcelus 1999). It is thought that only one in ten children with ADHD in Britain has been identified and is receiving help.
The undiagnosed children and their families are presumably experiencing unnecessary problems that are potentially treatable (Munden and Arcelus 1999). As nurses we are expected to utilise evidence-based practice, therefore it would make sense that as professionals we make use of research, particularly well designed, multi-centre studies on ADHD. The majority of this research is carried out on patients who fulfil DSM-1V criteria, therefore to utilise this evidence we as health care professionals should apply it to the same clinical population (i. e. that selected by DSM-1V diagnostic criteria). At present this is clearly not the case.
Another area of contention in ADHD is the issue of which form of treatment to use. Treatment consists of four components; medication therapy, home behaviour management, school interventions, and psychological services. No approach is effective in isolation; for maximum benefit, interventions need to be used together to treat the entire child and family unit. Many arguments can arise surrounding the treatment strategies for ADHD.
These arguments occur when there is a conflict of interest on behalf of the child, Cooper and Ideus (1995) state that “Political concerns can interfere with the management of ADHD, where competition between the educational and the medical professions has tended to discourage the use of combined therapies, and may even lead to a refusal to contemplate the possibility that there may be even a limited role for some forms of treatment”. Schools will try to use educational interventions such as behavioural reinforcement strategies, where as the medical profession will sometimes advocate the use of drug interventions.