Teaching – Learning Process
(Parents with school aged diagnosed with ADHD)
James C. Whear
Metropolitan State University
Instructor: Deborah Matthias-Anderson

NURS 407-01 Family Health Nursing
December 7, 2012

Objectives
Attention-deficit/hyperactivity disorder (ADHD) is a syndrome of inattention, hyperactivity, and impulsivity. The 3 types of ADHD are predominantly inattentive, predominantly hyperactive-impulsive, and combined. Diagnosis is made by clinical criteria. Treatment usually includes drug therapy with stimulant drugs, behavioral therapy, and educational interventions.
According to the Diagnostic and Statistical Manual of Mental Disorders ADHD has been classified as a developmental disorder, although increasingly it is considered a disruptive behavior disorder. ADHD affects an estimated 5 to 15% of school-aged children. However, many experts think ADHD is over diagnosed, largely because criteria are applied inaccurately.
According to Center for Disease Control (CDC) 2012 “The predominantly hyperactive-impulsive type occurs 2 to 9 times more frequently in boys; the predominantly inattentive type occurs with about equal frequency in both sexes. ADHD tends to run in families.” ADHD has no known single specific cause. CDC (2012) indicates that potential causes include: genetic, biochemical, sensorimotor, physiologic, and behavioral factors. Some risk factors include birth weight < 1000 g, head trauma, and lead exposure, as well as prenatal exposures to alcohol, tobacco, and cocaine. Fewer than 5% of children with ADHD have other symptoms and signs of neurologic damage. Increasing evidence implicates abnormalities in dopaminergic and noradrenergic systems with decreased activity or stimulation in upper brain stem and frontal-midbrain tracts.
Symptoms and Signs:
Onset often occurs before age 4 and invariably before age 7. The peak age for diagnosis is between age 8 and 10; however, patients with the predominantly inattentive type may not be diagnosed until after adolescence. Core symptoms and signs of ADHD include: Inattention, Hyperactivity, and Impulsivity.
Inattention tends to appear when a child is involved in tasks that require vigilance, rapid reaction time, visual and perceptual search, and systematic and sustained listening. Inattention and impulsivity impede development of academic skills and thinking and reasoning strategies, motivation for school, and adjustment to social demands. Children who have predominantly inattentive ADHD tend to be hands-on learners who have difficulty in passive learning situations that require continuous performance and task completion. Overall, about 20 to 60% of children with ADHD have learning disabilities, but some school dysfunction occurs in most children with ADHD.
Behavioral history can reveal low frustration tolerance, opposition, temper tantrums, aggressiveness, poor social skills and peer relationships, sleep disturbances, anxiety, dysphoria, depression, and mood swings. Although there are no specific physical examination or laboratory findings associated with ADHD, signs can include: Motor incoordination or clumsiness, Non-localized “soft” neurologic findings, Perceptual-motor dysfunctions
Assessment:
* Medical assessment focuses on identifying potentially treatable conditions that may contribute to or worsen symptoms and signs. * Developmental assessment focuses on determining the onset and course of symptoms and signs. * Educational assessment focuses on documenting core symptoms and signs; it may involve reviewing educational records and using rating scales or checklists. However, rating scales and checklists alone often cannot distinguish ADHD from other developmental disorders or from behavioral disorders.

DSM-IV-TR symptom Criteria for ADHD
Inattention: Does not pay attention to details, Has difficulty sustaining attention at school, Does not seem to listen when spoken to, Does not follow through on instructions or finish tasks, Has difficulty organizing tasks and activities, Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort, Often loses things, Is easily distracted and child is forgetful
Hyperactivity: Often fidgets with hands or feet or squirms, Often leaves seat in classroom or elsewhere, Often runs about or climbs excessively, Has difficulty playing quietly, Often on the go, acting as if driven by a motor, Often talks excessively.
Impulsivity: Often blurts out answers before questions are completed, Often has difficulty awaiting turn, Often interrupts or intrudes on others.
Diagnosis by DSM-IV criteria requires that symptom criteria must be present in at least 2 situations and present before age 7. Diagnosis also requires the following:
≥ 6 of the 9 possible symptoms of inattention for the predominantly inattentive type
≥ 6 of the 9 possible symptoms of hyperactivity and impulsivity for the hyperactive-impulsive type
≥ 6 symptoms each of inattention and hyperactivity-impulsivity for the combined type

BEHAVIORAL MANAGEMENT / PLAN INTERVENTIONS: * Counseling, including cognitive-behavioral therapy, which includes: goal-setting, self-monitoring, modeling, role-playing are often effective and helps children understand ADHD. Structure and routines are essential. * Classroom behavior is often improved by environmental control of noise and visual stimulation, appropriate task length, novelty, coaching, and teacher proximity. * When difficulties persist at home, parents should be encouraged to seek additional professional assistance and training in behavioral management techniques. Adding incentives and token rewards reinforces behavioral management and is often effective. Children with ADHD in whom hyperactivity and poor impulse control predominate are often helped at home when structure, consistent parenting techniques, and well-defined limits are established. * Treatment involve both Behavioral therapy and Drug therapy, typically with stimulants such as methylphenidate or dextroamphetamine
According to the Merck manuals (2009) stated “randomized, controlled studies show behavioral therapy alone is less effective than therapy with stimulant drugs alone; combination therapy has mixed results.” Although correction of the underlying neurophysiologic differences of patients with ADHD does not occur with drug therapy, drugs are effective in alleviating ADHD symptoms, and they permit participation in activities previously inaccessible because of poor attention and impulsivity. Drugs often interrupt the cycle of inappropriate behavior, enhancing behavioral and academic interventions, motivation, and self-esteem.
References:

Diagnostic and Statistical Manual of Mental Disorders (2000), Fourth Edition
Text Revision (DSM-IV-TR)
Centers for Disease Control and Prevention (2012) Retrieved from: http://www.cdc.gov/ncbddd/adhd/facts.html
The Merck Manual Home Health handbook: (2011) for patients and caregivers. Merck sharp && Dohme Corp., Whitehouse Station, N.J