attention-deficit/hyperactivity disorder in clinical...

Running head: ATTENTION-DEFiCIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE 1

Attention-Deficit/Hyperactivity Disorder in Clinical Practice

Cheryl S. Davis-Triplett

Methodist University

Research for Professional Nursing Practice, Professor Barry

ATTENTION-DEFiCIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE 2

Attention-Deficit/Hyperactivity Disorder in Clinical Practice

Attention-Deficit/Hyperactivity Disorder or ADHD is a chronic mental health condition

characterized by inattention, hyperactivity, and impulsivity. This condition can affect children as

well as adults and is often misdiagnosed, prematurely diagnosed, or altogether misinterpreted in

the clinical setting. These inconsistencies in care may be due to the fact that the signs and

symptoms of this condition are usually manifested in the academic setting. This is an expected

finding as the child or adolescent spends the majority of their time in school. In this paper, this

author is going to discuss recommended clinical guidelines in the assessment, diagnosis, and

treatment and/or management of ADHD in the child and adolescent population from age 4 to 18.

Definition of Terms

The following terms may appear throughout this author’s literature reviews. Behavior

therapy is a form of psychotherapy that uses basic learning techniques to modify maladaptive

behavior patterns by substituting new responses to given stimuli for undesirable ones. Treatment

modality are methods used to treat a patient for a particular condition (Baily & Simpson, 2008).

School truancy is defined as a child who made an attempt to go to school but strayed

elsewhere. Oppositional defiant disorder (ODD) is defined by the Diagnostic and Statistical

Manual of Mental Disorders, fourth edition (DSM-IV), as a recurring pattern of negative, hostile,

disobedient, and defiant behavior in a child or adolescent, lasting for at least six months without

serious violation of the basic rights of others. (LaMuhammad et al, 2011).

Risk-taking behavior includes alcohol and drug use, delinquency, acts of aggression,

sexual activity, and so on. Delinquency refers to the participation in any of a number of antisocial

acts such as truancy, vandalism, sexual promiscuity, shoplifting, homicide; delinquency most

often occurs during adolescence. Comorbidities refer to two or more coexisting medical


conditions or disease processes that are additional to an initial diagnosis. Learning Disabilities

(LD) are disorders in the basic cognitive and psychological processes involved in using language

or performing mathematical calculations, affecting persons of normal intelligence, and not the

result of emotional disturbance or impairment of sight or hearing (McNamara, Vervaeke, &

Willoughby, 2008).

Substance abuse refers to excessive use of a potentially addictive substance, especially

one that may modify body functions, such as alcohol and drugs. Prescription stimulant refers to a

substance that temporarily increases the physiologic activity of an organ or organ system (Nelson

& Galon, 2012).

Adverse drug reactions are un-intended and harmful effects of drug therapy, neither

intended nor expected in normal therapeutic use. Pharmacologic therapy any oral, parenteral, or

topical substance used to alleviate symptoms and treat or control a disease process or aid

recovery from an injury (Roma, 2010).

Problem, Intervention, Comparison, Outcomes (PICO)

The symptoms of Attention-Deficit/Hyperactivity Disorder can vary from patient to

patient which may require more than one treatment modality. In order to discover the best

current evidence regarding this mental health process, this author used the PICO model. The

patient/problem identified in this paper are children and adolescents with symptoms of ADHD.

The intervention of interest includes early diagnoses combined with evidence-based parent,

physician, and teacher therapy. This author did not have a comparison of interest regarding this

topic. The outcome of interest involves a decreased incidence of academic and behavioral

problems due to ADHD symptoms. Therefore the question generated is as follows: For a patient

with Attention-Deficit/Hyperactivity Disorder, will early diagnosis combined with evidence-


based parent, physician, and teacher administered therapy decrease the incidence of associated

academic and behavioral problems? In order to answer this question, this author reviewed and

analyzed the guideline titled ADHD: clinical practice guideline for the diagnosis, evaluation,

and treatment of attention-deficit/hyperactivity disorder in children and adolescents by the

subcommittee on attention-deficit/hyperactivity disorder, steering committee on quality

improvement management (ADHD, 2011).

Literature Review

The guideline reviewed proposes recommendations for the assessment, diagnosis, and

treatment of ADHD in children and adolescents age 4 – 18. The guideline lists recommendations

in the form of six action statements. The guideline strongly advocates early diagnosis in order to

ensure appropriate individualized treatment to prevent escalating symptoms of ADHD. This

author conducted a systematic search of relevant peer-reviewed articles to determine if the use of

this guideline in clinical practice will yield positive outcomes. The following articles provided

information addressed by the guideline.

Bailey & Simpson (2008) on the attitudes of health care professionals regarding ADHD it

was revealed that “in the discussions that took place in the interviews, participants expressed

doubts, cynicism, and a lack of acceptance of the existence of the condition” (p. 30, Appendix

A). The guideline reviewed addresses this issue in action statement number four which states

that “the primary care clinician should recognize ADHD as a chronic condition and, therefore,

consider children and adolescents with ADHD as children and youth with special health care

needs” (ADHD, 2011, p. 1014).

LaMuhammad, et al (2011) provided information on truancy and the associated

behavioral issues that may arise from the delayed diagnosis and treatment of ADHD. The case


report presented by this researcher describes a 14 year old adolescent who’s violent and

impulsive behaviors were first diagnosed as resulting from major depressive disorder rather than

the proper subsequent diagnosis of oppositional defiant disorder (ODD) combined with ADHD

(p. 250-251, Appendix I). This misdiagnosing issue is addressed in the guideline in action

statement 3 “in the evaluation of a child for ADHD, the primary care clinician should include

assessment for other conditions that might coexist with ADHD…” (ADHD, 2011, p. 1013).

McNamara, Vervaeke, & Willoughby (2008) also found a correlation between ADHD and risk

taking behaviors seen in individuals who have a comorbid condition of a learning disability (p.

561, Appendix A).

Action statements 5b and 5c of the guideline describe recommendations for medication

administration in children and adolescents. One researcher provides information on the efficacy

of stimulant versus non-stimulant pharmacologic therapy in the treatment of ADHD. This

researcher proposes

that non-stimulant drug therapy may be more beneficial in the ADHD population due to the

decreased potential for uncomfortable side effects compared to stimulant drugs (Roman, 2010, p.

548, Appendix A). The proper administration of these drugs in such a sensitive patient

population is addressed by Nelson & Galon (2012) in their research on the correlation between

the adolescent ADHD population and substance abuse in which they advocate for combined

behavioral therapy to decrease the risk of dependency to stimulants (p. 116, Appendix A). The

research reviewed in conjunction with the guideline analyzed has provided this author to

conclude that the recommendations put forth by the board members of the subcommittee on

attention-deficit/hyperactivity disorder is a valid and relevant tool to utilize in the clinical setting

to provide accurate and efficient assessment, diagnosis, and treatment of ADHD.


Action Plan

Physicians, parents, teachers, and the ADHD patient population have a direct influence

on the treatment related to this condition. All of these individuals must be educated in the signs,

symptoms, treatment, and outcome goals of ADHD. This can be achieved by using the plan, do

study, act (PDSA) evidence based practice model of measuring change (Appendix C). In order

to properly measure the recommendations outlined in the guideline, this author proposes using

behavioral assessment tools in the clinical and academic setting every two years for the ADHD

population beginning at age 4 and analyzing the occurrence of new diagnosis annually to see if a

correlation exists between early detection and truancy behaviors related to ADHD. This author

proposes that an increase in ADHD diagnosis will exist as well as a decrease in the behavioral

symptoms and academic issues related to this condition as a result of eliminated delayed

diagnosis.

Special Considerations

Complementary and alternative therapies for the treatment of ADHD such as increase in

physical activity and dietary changes such as implementing a gluten free diet were not

considered as having enough research to validate such claims.


APPENDIX A

Author & Year Bailey, S., & Simpson, A. (2008)

Title Attitudes towards attention deficit hyperactivity disorder in child and adolescent mental health services teams.

Question/Purpose

The study set out to explore the attitudes of child and adolescent mental health workers towards the identification, conceptualization, assessment and treatment of ADHD and the use of the NICE clinical guidelines in practice.

Design A semi-structured interview survey of multi-disciplinary members of three CAMHS teams was used.

Sample

Ten multidisciplinary staff members were purposively sampled to provide representatives from three different CAMHS teams, several different professions and to reflect the gender and age balance of the teams.

Data Collection

Responses from the interviews were transcribed and analyzed using interpretative phenomenological analysis. This method of analysis is used to identify specific themes in the acquired data systematically and objectively. The procedure involved selecting one interview and reading the transcript several times. Sub-themes that were similar were grouped together and those that were different were placed in a separate group. Clusters of themes were then formulated where similar topics or issues were identified and a master list of themes was produced, each containing a number of categories. These major themes captured most strongly the participants concerns on the topic.

Findings

In general there was a consensus of knowledge base in all the responses suggestive of participants' understanding of classifications and clinical presentations of ADHD. However, views concerning the etiology of ADHD varied. Medical staff were more likely to proffer biological explanations, whereas non-medical staff referred to factors such as social construction theory, family dynamics and psychoanalytic theories, which appeared to reflect professional background and training. The relationship between the role of participants and their professional background caused conflict for a number of non-medical participants. The findings demonstrated that ADHD was predominantly defined as a medical condition that needed diagnosis and treatment.

LimitationsStudy of only ten professionals across just three CAMHS teams, so caution is required when considering the wider relevance of the findings.

Level of Evidence

Level III, Quality B (Johns Hopkins Hospital Strength of Evidence located in Appendix B)


Author & Year La Muhammad, N., Ismail, W., Chai Eng, T., Jaffar, A., Sharip, S., & Omar, K. (2011)

Title Attention-deficit hyperactive disorder presenting with school truancy in an adolescent: a case report.

Question/PurposeTo increase public awareness of ADHD, especially among parents and teachers so that early intervention can be instituted in these children.

Case Study Case ReportSample A 14 year old adolescent male

Data Collection Physical, Mental, Psychosocial Examination. Family and Past Medical History

Findings

Age at presentation is an important point to consider. In pre-school-aged children, hyperactivity and inattentive symptoms are common. In adolescents, symptoms of hyperactivity are diminished, but there are more symptoms of inattention and impulsivity. In this case, the comorbid depressive features masked symptoms of ADHD and obscured the diagnosis of ADHD in the patient. In order for ADHD to be managed comprehensively at the primary care level, high levels of awareness and early detection are necessary. Adequate time should be allowed to make an accurate diagnosis. Once ADHD is diagnosed, physicians need to look for common comorbid conditions.

LimitationsCurrent DSM-IV-TR criteria reflect the clinical features of ADHD in children and do not focus on adolescents. This is a case study of one individual adolescent.

Level of Evidence

Level III, Quality C (Johns Hopkins Hospital Strength of Evidence located in Appendix B)


Author & Year Nelson, A., & Galon, P. (2012)

Title Exploring the relationship among ADHD, stimulants, and substance abuse.

Question/Purpose

This literature review explores the current state of prescriptive stimulant use for ADHD and the possible links to SA. Developmental, genetic, and neurochemical theories of the disorder that may contribute to SA as well as the burden of comorbidity are considered. The impact of gender, cultural, legal, and ethical influences on diagnostic and treatment recommendations is also included.

DesignA cross-sectional review was used to analyze previously written articles that examined the most commonly prescribed ADHD medications.

SampleOf the drug prescriptions analyzed, 33.3% were written for ages 10-14, 23% were for 5-9 year olds, 16% were for 15-19 year olds, and 2% were under the age of 5.

Data Collection

U.S. and other English language articles were identified through PubMed and the Cumulated Index of Nursing and Allied Health Literature. These sources were used to determine the current practice of stimulant prescription and the prevalence of SA as a comorbidity to other child psychiatric disorders including ADHD.

Findings

The authors conclude that the use of stimulants is appropriate for children and adolescents with ADHD when opportunities for screening, family and child education, and counseling concerning SA are consistently integrated into the ongoing treatment regimen.

LimitationsThere is limited research information on the current incidence and prevalence of co-occurring ADHD and SUD in both adults and adolescents.

Level of Evidence



Author & Year Roman, M. (2010)

TitleNewly approved once-daily formulations of medications for the treatment of attention deficit (hyperactivity) disorder (ADHD) in children and adolescents.

Question/Purpose Advocate new formulations of ADHD medications that produce fewer adverse effects.

DesignReevaluation of statistics that review medication adherence rates versus adverse side effects reported between stimulant and non-stimulant treatments.

Sample Children and adolescent population

Data Collection

Efficacy and adherence rates reported by the National Health and Nutrition Examination Survey (NHANES) regarding the use of stimulant pharmacologic therapy for the treatment of ADHD.

Findings

The non-stimulant drug Guanfacine XR is the first alpha-2 agonist approved for the disorder, and appears to be more specific to the anatomic areas that fine tune attention and distractibility.

Limitations Costs and long-term effects are additional pertinent concerns that are not addressed here.

Level of Evidence



Appendix B


Appendix C

Aim: Decrease in the behavioral symptoms and academic problems associated with ADHD

Every goal will require multiple smaller tests of changeDescribe your first (or next) test of change: Person responsible When to be

doneWhere to be done

Assessment, Recognition, or Diagnosis of ADHD PhysicianParent/TeacherPatient

Screening every 2 yrs

ClinicSchool

PlanList the tasks needed to set up this test of change Person

responsibleWhen to be done

Where to be done

Connors Parents Rating Scale, the Child Attention Problem RatingScale, Strength and Weakness ADHD symptom and NormalBehavior Scale, Connors Teachers Rating Scale, and ChildBehavior Checklist

PhysicianParent/Teacher

Every 2 yrs.

Clinic School

Predict what will happen when the test is carried out Measures to determine if prediction succeeds

If the ADHD screening tools are used to screen children and adolescents every two years beginning at age 4 until age 18, treatment can be initiated appropriately and truancy behaviors can be eliminated.

Frequency of ADHD diagnosis being made yearlyPercentage of truant behaviors decreasedThese measurements must be made within a specific time frame to gauge level of change.

Do Describe what actually happened when you ran the test

Study Describe the measured results and how they compared to the predictions

Act Describe what modifications to the plan will be made for the next cycle from what you learned


References

ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-

Deficit/ Hyperactivity Disorder in Children and Adolescents. (2011). Pediatrics, 128(5),

1007-1022. doi:10.1542/peds.2011.2654.

Bailey, S., & Simpson, A. (2008). Attitudes towards attention deficit hyperactivity disorder in

child and adolescent mental health services teams. Mental Health Practice, 11(10), 26-31.

La Muhammad, N., Ismail, W., Chai Eng, T., Jaffar, A., Sharip, S., & Omar, K. (2011). Attention-

deficit hyperactive disorder presenting with school truancy in an adolescent: a case

report. Mental Health In Family Medicine, 8(4), 249-254.

McNamara, J., Vervaeke, S., & Willoughby, T. (2008). Learning disabilities and risk-taking

behavior in adolescents: A comparison of those with and without comorbid attention-

deficit/hyperactivity disorder. Journal of Learning Disabilities, 41(6), 561-574.

Nelson, A., & Galon, P. (2012). Exploring the relationship among ADHD, stimulants, and

substance abuse. Journal Of Child & Adolescent Psychiatric Nursing, 25(3), 113-118.

doi:10.1111/j.1744-6171.2012.00322.x.

Roman, M. (2010). Newly approved once-daily formulations of medications for the treatment of

attention deficit (hyperactivity) disorder (ADHD) in children and adolescents. Issues in

Mental Health Nursing, 31(8), 548-549. doi:10.3109/01612840.2010.497241.

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