Download Attention-Deficit/Hyperactivity Disorder in Clinical Practice

Running head: ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL
PRACTICE
Attention-Deficit/Hyperactivity Disorder in Clinical Practice
Cheryl S. Davis-Triplett
Methodist University
Research for Professional Nursing Practice, Professor Barry
1
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
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
3
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-
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
4
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
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
5
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.
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
6
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.
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
APPENDIX A
Author & Year
Bailey, S., & Simpson, A. (2008)
Attitudes towards attention deficit hyperactivity disorder in child
Title
and adolescent mental health services teams.
The study set out to explore the attitudes of child and adolescent
mental health workers towards the identification, conceptualization,
Question/Purpose
assessment and treatment of ADHD and the use of the NICE
clinical guidelines in practice.
A semi-structured interview survey of multi-disciplinary members
Design
of three CAMHS teams was used.
Ten multidisciplinary staff members were purposively sampled to
provide representatives from three different CAMHS teams, several
Sample
different professions and to reflect the gender and age balance of
the teams.
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
Data Collection 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.
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
Findings
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.
Study of only ten professionals across just three CAMHS teams, so
Limitations
caution is required when considering the wider relevance of the
findings.
Level of
Level III, Quality B (Johns Hopkins Hospital Strength of Evidence
Evidence
located in Appendix B)
7
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
La Muhammad, N., Ismail, W., Chai Eng, T., Jaffar, A.,
Sharip, S., & Omar, K. (2011)
Attention-deficit hyperactive disorder presenting with
Title
school truancy in an adolescent: a case report.
To increase public awareness of ADHD, especially among
Question/Purpose parents and teachers so that early intervention can be
instituted in these children.
Case Study
Case Report
Sample
A 14 year old adolescent male
Physical, Mental, Psychosocial Examination. Family and
Data Collection
Past Medical History
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
Findings
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.
Current DSM-IV-TR criteria reflect the clinical features
of ADHD in children and do not focus on
Limitations
adolescents. This is a case study of one individual
adolescent.
Level of
Level III, Quality C (Johns Hopkins Hospital Strength of
Evidence
Evidence located in Appendix B)
Author & Year
8
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
Author & Year
Nelson, A., & Galon, P. (2012)
Exploring the relationship among ADHD, stimulants, and
Title
substance abuse.
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
Question/Purpose
as the burden of comorbidity are considered. The impact
of gender, cultural, legal, and ethical influences on
diagnostic and treatment recommendations is also
included.
A cross-sectional review was used to analyze previously
Design
written articles that examined the most commonly
prescribed ADHD medications.
Of the drug prescriptions analyzed, 33.3% were written
Sample
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.
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
Data Collection
determine the current practice of stimulant prescription
and the prevalence of SA as a comorbidity to other child
psychiatric disorders including ADHD.
The authors conclude that the use of stimulants is
appropriate for children and adolescents with ADHD
Findings
when opportunities for screening, family and child
education, and counseling concerning SA are consistently
integrated into the ongoing treatment regimen.
There is limited research information on the current
Limitations
incidence and prevalence of co-occurring ADHD and
SUD in both adults and adolescents.
Level of
Level III, Quality C (Johns Hopkins Hospital Strength of
Evidence
Evidence located in Appendix B)
9
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
Author & Year
Nelson, A., & Galon, P. (2012)
Exploring the relationship among ADHD, stimulants, and
Title
substance abuse.
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
Question/Purpose
as the burden of comorbidity are considered. The impact
of gender, cultural, legal, and ethical influences on
diagnostic and treatment recommendations is also
included.
A cross-sectional review was used to analyze previously
Design
written articles that examined the most commonly
prescribed ADHD medications.
Of the drug prescriptions analyzed, 33.3% were written
Sample
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.
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
Data Collection
determine the current practice of stimulant prescription
and the prevalence of SA as a comorbidity to other child
psychiatric disorders including ADHD.
The authors conclude that the use of stimulants is
appropriate for children and adolescents with ADHD
Findings
when opportunities for screening, family and child
education, and counseling concerning SA are consistently
integrated into the ongoing treatment regimen.
There is limited research information on the current
Limitations
incidence and prevalence of co-occurring ADHD and
SUD in both adults and adolescents.
Level of
Level III, Quality C (Johns Hopkins Hospital Strength of
Evidence
Evidence located in Appendix B)
10
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
Author & Year
Roman, M. (2010)
Newly approved once-daily formulations of medications
Title
for the treatment of attention deficit (hyperactivity)
disorder (ADHD) in children and adolescents.
Advocate new formulations of ADHD medications that
Question/Purpose
produce fewer adverse effects.
Reevaluation of statistics that review medication
Design
adherence rates versus adverse side effects reported
between stimulant and non-stimulant treatments.
Sample
Children and adolescent population
Efficacy and adherence rates reported by the National
Health and Nutrition Examination Survey (NHANES)
Data Collection
regarding the use of stimulant pharmacologic therapy for
the treatment of ADHD.
The non-stimulant drug Guanfacine XR is the first alpha-2
agonist approved for the disorder, and appears to be more
Findings
specific to the anatomic areas that fine tune attention and
distractibility.
Costs and long-term effects are additional pertinent
Limitations
concerns that are not addressed here.
Level of
Level III, Quality C (Johns Hopkins Hospital Strength of
Evidence
Evidence located in Appendix B)
11
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
Appendix B
12
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
13
Appendix C
Aim: Decrease in the behavioral symptoms and academic problems associated with ADHD
Every goal will require multiple smaller tests of change
Describe your first (or next) test of change:
Person responsible
Assessment, Recognition, or Diagnosis of ADHD
Physician
Parent/Teacher
Patient
Plan
List the tasks needed to set up this test of change
Connors Parents Rating Scale, the Child Attention Problem Rating
Scale, Strength and Weakness ADHD symptom and Normal
Behavior Scale, Connors Teachers Rating Scale, and Child
Behavior Checklist
When to be
done
Screening
every 2 yrs
Person
responsible
Physician
Parent/Teache
r
When to
be done
Every 2
yrs.
Where to be
done
Clinic
School
Where to be
done
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 yearly
Percentage of truant behaviors decreased
These 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
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
14
References
ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of AttentionDeficit/ 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). Attentiondeficit 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 attentiondeficit/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.
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER IN CLINICAL PRACTICE
15