Journal of Pediatric Nursing
Volume 21, Issue 3 , Pages 171-174, May 2006

Attention Deficit Hyperactivity Disorder: Nurses are Important Members of the Team

Journal of Pediatric Nursing, USC Center for Excellence in Developmental Disabilities, Children's Hospital Los Angeles, CA

Article Outline

 

ATTENTION DEFICIT HYPERACTIVITY disorder (ADHD) affects nearly 13% of school-age children, primarily male children, making it the most prevalent behavior problem of childhood (Connor et al., 2003, Garland et al., 2001, National Institutes of Health Consensus Development Conference, 2000). Children with ADHD exhibit a characteristic triad of behaviors of increased activity, impulsivity, and inattention. The increase in the number of children diagnosed with ADHD has been striking; it has quintupled from 1990 to 1998 from 1 million to nearly 5 million. This dramatic growth has been accompanied by a significant increase in stimulant use in children with ADHD amounting to as much as 48% (Kube, Peterson, & Palmer, 2002).

Nurses who provide care to children and their families in the hospital, school, juvenile justice, and community are important members of the teams that provide diagnostic, treatment, and support services. Nurses provide care not only to children and youth with ADHD who are hospitalized for other diagnostic reasons such as having a special health care need or disability but also to those in the community setting, where children and youth with ADHD live, play, and work. Interestingly, the role of nursing is often overlooked in discussions of the care of children and youth with ADHD, yet nurses are typically the primary and frontline professionals providing health care services who can readily observe the behaviors and treatment responses of children and youth with ADHD (Vlam, 2006).

Children with ADHD manifest a number of problems in school and social situations. These problems include school failures, increase in the number of youth who drop out of high school, juvenile delinquency, and social isolation (Riggs et al., 1999, Sullivan & Rudnik-Levin, 2001). Children and adolescents with ADHD may also have other diagnoses, such as learning disabilities, anxiety disorders, substance and alcohol use disorders, major depression, and other mental health problems, that contribute to school and social problems (Biederman et al., 1998, Biederman et al., 1998, Ercan et al., 2003, Hoagwood et al., 2000, Kelly et al., 2004, Kube et al., 2002, Leibson et al., 2001, Milberger et al., 1995, Murphy et al., 2002). The reported comorbidities of psychiatric problems in children and youth with ADHD are associated with the ADHD levels of severity; that is, children and youth with more severe manifestations of ADHD are more likely to have a psychiatric comorbidity (Connor et al., 2003).

Researchers have reported the following percentages of comorbidity in children and adolescents with ADHD: depression, 56%; bipolar disorder, 56%; generalized anxiety disorder, 75%; and conduct disorder, 30%–50%) (Milberger et al., 1995, Riggs et al., 1999). One study found that 40% of the children treated for ADHD presented with a comorbid diagnosis such as depression, autism, and disruptive behaviors. Children and adolescents diagnosed with both ADHD and comorbid psychopathology have more serious long-term problems associated with daily living and the management of their diagnoses (Connor et al., 2003). Untreated children with ADHD are at a higher risk for a number of untoward outcomes as adults, including antisocial behavior, drug abuse, violent crime, unintentional injuries, and lower academic achievement (NIH Consensus Development Conference, 2000).

Studies on health utilization involving children and adults with ADHD found that they had a greater need for medical, mental health, social, and special education services as compared with children and adults without ADHD (Bussing et al., 1998, Cornelius et al., 2001, Guevara et al., 2001, Leibson et al., 2001). For example, a study on children with (5.2% of 2,992 children) and those without ADHD enrolled in a health maintenance organization found significant differences. Children with ADHD had 9.9 visits to mental health professionals, 1.6 more visits to primary care providers, and 3.4 more medication prescriptions filled as compared with children who did not have ADHD. The cost of care was more than double for children with ADHD as compared with children without ADHD (Guevara et al., 2001).

Another study examining hospital, outpatient, and emergency department admissions of adolescents with and those without ADHD found similar results. Youth with ADHD had higher rates of admissions for the three types of health services as compared with youth without ADHD. In addition, medical services costs for adolescents with ADHD were more than double those for adolescents without ADHD (Leibson et al., 2001). Primary care physicians reported that they treated more children with ADHD than any other group of children with a chronic condition (Kube et al., 2002).

Pediatric nurses, whether in hospital or community settings, have numerous opportunities not only to provide direct services to children and youth with ADHD but also to educate children and youth themselves, their parents, and community-based colleagues about the continuum of care that these children and youth need. These needs include assessment and diagnosis as well as monitoring the children's response to the behavioral management program and medication for comorbid symptoms and early signs of at-risk behaviors. It is a concern that children and youth with ADHD demonstrate an increased need for services and treatment from medical, mental health, and educational providers. It would appear that children and youth with ADHD would benefit from care coordination, as do other populations of children with special health care needs and disabilities, to improve what their reported outcomes of care are.

In addition, nurses have a voice in ensuring that children and youth diagnosed with ADHD are treated according to the evidence-based standards of care. Best practice standards emphasize the importance of conducting a thorough assessment incorporating input from both home and school settings about a child's behavior before any stimulant is prescribed. Advocating that approaches to care in practice settings—whether it be a physician's office, a community or mental health clinic, or school—and instructing parents about what is considered to be the best practices would contribute to reducing the overidentification of male children as having ADHD and the proliferation of prescriptions for stimulants for children and youth as discussed in last month's editorial (Betz, 2006). The same approach is needed in pediatric hospitals and other institutions providing long-term care to children and youth (American Academy of Pediatrics, 2000, American Academy of Pediatrics, 2001, American Psychiatric Association, 2000).

The long-term outcomes of children with ADHD are discouraging. Research findings have reported that adolescents with ADHD have triple the alcohol use and dependence as compared with adolescents without ADHD (Burke et al., 2001, Kupperman et al., 2001). To date, the research evidence suggest that male patients with ADHD are at an increased risk for substance use disorder (SUD); however, findings from some studies suggest that ADHD treatment can result in significant reduction of SUD risk—as much as 50% (Biederman et al., 1998, Biederman et al., 1998, Biederman et al., 1995, Milberger et al., 1997, Moss & Lynch, 2001, Wilens et al., 2003). Alcohol-dependent adults with childhood ADHD became alcohol dependent 6.5 years earlier than those without ADHD (Ercan et al., 2003). Other negative outcomes reported in adults with childhood ADHD as compared with adults without ADHD are higher rates of job loss, criminality, legal problems, drug abuse, and treatment and recovery relapse (Biederman et al., 1998, Ercan et al., 2003, Milberger et al., 1998, Rassmussen & Gillberg, 2000).

As demonstrated by the problematic long-term outcomes of adults with ADHD, evidence-based approaches are needed to ameliorate the negative consequences of living with ADHD. Certainly, the research conducted with other samples of adults with childhood-acquired chronic or life-threatening illnesses have revealed findings that dealing with a chronic lifelong disease or disability requires ongoing home and community management. Likewise, the quality of long-term care provided to children, youth, and young adults with ADHD is dependent on the availability of services and supports as well as the clinical expertise of health care professionals providing services.

It is telling that there are limited data to provide a clear understanding of the role, function, knowledge, and clinical acumen of pediatric nurses in providing services to children, youth, and young adults with ADHD (Vlam, 2006, Wasserman et al., 1999). A recent study that examined the assessment methods of advanced practice registered nurses (APRNs) reported that approximately half of the APRNs had received advanced training pertaining to diagnostic practices (Vlam, 2006). Sixty-six percent of APRNs reported that additional training on diagnostic practices was needed for those who provided primary care services to this population of children, youth, and young adults with ADHD. Obviously, this professional issue of practice and training remains unanswered in terms of the extent of the learning needs of nurses and the use of evidence-based approaches by nurses in varied settings in providing care to children, youth, and young adults with ADHD. Given the tremendous number of children and youth with ADHD who currently receive services in health care settings and the expected continued increases of this population of children, there is an urgent need for pediatric nurses to address these important professional practice and training issues as well as a need to generate the evidence to support nursing practice.

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Acknowledgments 

I wish to thank Wendy Nehring, PhD, RN, FAAN, FAAMR for her scholarly insights that assisted me in writing this editorial.

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PII: S0882-5963(06)00204-1

doi:10.1016/j.pedn.2006.03.001

Journal of Pediatric Nursing
Volume 21, Issue 3 , Pages 171-174, May 2006

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