Application of the Nursing Process: Attention Deficit Hyperactivity Disorder

APPLICATION OF THE NURSING PROCESS: ATTENTION DEFICIT HYPERACTIVITY DISORDER

Assessment

During assessment, the nurse gathers information through direct observation and from the child’s parents, day care providers (if any), and teachers. Assessing the child in a group of peers is likely to yield useful information because the child’s behavior may be subdued or different in a focused one-to-one interaction with the nurse. It is often helpful to use a checklist when talking with parents to help focus their input on the target symptoms or behaviors their child exhibits.

History

Parents may report that the child was fussy and had prob-lems as an infant, or they may not have noticed the hyper-active behavior until the child was a toddler or entered day care or school. The child probably has difficulties in all major life areas such as school or play, and he or she likely displays overactive or even dangerous behavior at home. Often, parents say the child is “out of control,” and they feel unable to deal with the behavior. Parents may report many largely unsuccessful attempts to discipline the child or to change the behavior.

General Appearance and Motor Behavior

The child cannot sit still in a chair and squirms and wiggles while trying to do so. He or she may dart around the room with little or no apparent purpose. Speech is unimpaired, but the child cannot carry on a conversation: he or she inter-rupts, blurts out answers before the question is finished, and fails to pay attention to what has been said. Conversation topics may jump abruptly. The child may appear immature or lag behind in developmental milestones.

Mood and Affect

Mood may be labile, even to the point of verbal outbursts or temper tantrums. Anxiety, frustration, and agitation are common. The child appears to be driven to keep moving or talking and appears to have little control over movement or speech. Attempts to focus the child’s attention or redirect the child to a topic may evoke resistance and anger.

Thought Process and Content

There are generally no impairments in this area, although assessment can be difficult depending on the child’s activ-ity level and age or developmental stage.

Sensorium and Intellectual Processes 

The child is alert and oriented with no sensory or percep-tual alterations such as hallucinations. Ability to pay atten-tion or to concentrate is markedly impaired. The child’s attention span may be as little as 2 or 3 seconds with severe ADHD or 2 or 3 minutes in milder forms of the disorder. Assessing the child’s memory may be difficult; he or she frequently answers, “I don’t know,” because he or she can-not pay attention to the question or stop the mind from racing. The child with ADHD is very distractible and rarely able to complete tasks.

Judgment and Insight

Children with ADHD usually exhibit poor judgment and often do not think before acting. They may fail to perceive harm or danger and engage in impulsive acts such as run-ning into the street or jumping off high objects. Although assessing judgment and insight in young children is diffi-cult, children with ADHD display more lack of judgment when compared with others of the same age. Most young children with ADHD are totally unaware that their behav-ior is different from that of others and cannot perceive how it harms others. Older children might report, “No one at school likes me,” but they cannot relate the lack of friends to their own behavior.

Self-Concept

Again, this may be difficult to assess in a very young child, but generally the self-esteem of children with ADHD is low. Because they are not successful at school, may not develop many friends, and have trouble getting along at home, they generally feel out of place and bad about themselves. The negative reactions their behavior evokes from others often cause them to see themselves as bad or stupid.

Roles and Relationships

The child is usually unsuccessful academically and socially at school. He or she frequently is disruptive and intrusive at home, which causes friction with siblings and parents. Until the child is diagnosed and treated, parents often believe that the child is willful, stubborn, and purposefully misbehaving. Generally, measures to discipline have lim-ited success; in some cases, the child becomes physically out of control, even hitting parents or destroying family possessions. Parents find themselves chronically exhausted mentally and physically. Teachers often feel the same frus-tration as parents, and day care providers or baby-sitters may refuse to care for the child with ADHD, which adds to the child’s rejection.

Physiologic and Self-Care Considerations

Children with ADHD may be thin if they do not take time to eat properly or cannot sit through meals. Trouble settling down and difficulty sleeping are problems as well. If the child engages in reckless or risk-taking behaviors, there also may be a history of physical injuries.

Data Analysis and Planning

Nursing diagnoses commonly used when working with children with ADHD include the following:

·    Risk for Injury

·    Ineffective Role Performance

·    Impaired Social Interaction

·    Compromised Family Coping

Outcome Identification

Treatment outcomes for clients with ADHD may include the following:

·    The client will be free of injury.

·    The client will not violate the boundaries of others.

·    The client will demonstrate age-appropriate social skills.

·    The client will complete tasks.

·    The client will follow directions.

Intervention

Interventions described in this section can be adapted to various settings and used by nurses and other health pro-fessionals, teachers, and parents or caregivers.

Ensuring Safety

Safety of the child and others is always a priority. If the child is engaged in a potentially dangerous activity, the first step is to stop the behavior. This may require physical intervention if the child is running into the street or attempting to jump from a high place. Attempting to talk to or reason with a child engaged in a dangerous activity is unlikely to succeed because his or her ability to pay atten-tion and to listen is limited. When the incident is over and the child is safe, the adult should talk to the child directly about the expectations for safe behavior. Close supervi-sion may be required for a time to ensure compliance and to avoid injury.

Explanations should be short and clear, and the adult should not use a punitive or belittling tone of voice. The adult should not assume that the child knows acceptable behavior but instead should state expectations clearly. For example, if the child was jumping down a flight of stairs, the adult might say,

“It is unsafe to jump down stairs. From now on, you are to walk down the stairs, one at a time.”

If the child crowded ahead of others, the adult would walk the child back to the proper place in line and say,

“It is not okay to crowd ahead of others. Take your place at the end of the line.”

To prevent physically intrusive behavior, it also may be necessary to supervise the child closely while he or she is playing. Again, it is often necessary to act first to stop the harmful behavior by separating the child from the friend such as stepping between them or physically removing the child. Afterward, the adult should clearly explain expected and unacceptable behaviors. For example, the adult might say,

“It is not okay to grab other people. When you are playing with others, you must ask for the toy.” 

Improving Role Performance

It is extremely important to give the child specific positive feedback when he or she meets stated expectations. Doing so reinforces desired behaviors and gives the child a sense of accomplishment. For example, the adult might say,

“You walked down the stairs safely” or “You did a good job of asking to play with the guitar and waited until it was your turn.” 

Managing the environment helps the child to improve his or her ability to listen, pay attention, and complete tasks. A quiet place with minimal noise and distraction is desir-able. At school, this may be a seat directly facing the teacher at the front of the room and away from the distraction of a window or door. At home, the child should have a quiet area for homework away from the television or radio.

Simplifying Instructions

Before beginning any task, adults must gain the child’s full attention. It is helpful to face the child on his or her level and use good eye contact. The adult should tell the child what needs to be done and break the task into smaller steps if nec-essary. For example, if the child has 25 math problems, it may help to give him or her 5 problems at a time, then 5 more when those are completed, and so on. This approach prevents overwhelming the child and provides the opportunity for feedback about each set of problems he or she completes. With sedentary tasks, it is also important to allow the child to have breaks or opportunities to move around.

Adults can use the same approach for tasks such as cleaning or picking up toys. Initially, the child needs the supervision or at least the presence of the adult. The adult can direct the child to do one portion of the task at a time; when the child shows progress, the adult can give only occasional reminders and then allow the child to complete the task independently. It helps to provide specific, step-by-step directions rather than give a general direction such as “Please clean your room.” The adult could say,

“Put your dirty clothes in the hamper.”

After this step is completed, the adult gives another direction:

“Now make the bed.”

The adult assigns specific tasks until the child has com-pleted the overall chore.

Promoting a Structured Daily Routine

A structured daily routine is helpful. The child will accom-plish getting up, dressing, doing homework, playing, going to bed, and so forth much more readily if there is a routine time for these daily activities. Children with ADHD do not adjust to changes readily and are less likely to meet expec-tations if times for activities are arbitrary or differ from day to day.

Providing Client and Family Education and Support

Including parents in planning and providing care for the child with ADHD is important. The nurse can teach par-ents the approaches described previously for use at home. Parents feel empowered and relieved to have specific strat-egies that can help both them and their child be more successful.

The nurse must listen to parents’ feelings. They may feel frustrated, angry, or guilty and blame themselves or the school system for their child’s problems. Parents need to hear that neither they nor their child are at fault and that techniques and school programs are available to help. Children with ADHD qualify for special school services under the Individuals With Disabilities Education Act.

Because raising a child with ADHD can be frustrating and exhausting, it often helps parents to attend support groups that can provide information and encouragement from other parents with the same problems. Parents must learn strategies to help their child improve his or her social and academic abilities, but they also must understand how to help rebuild their child’s self-esteem. Most of these children have low self-esteem because they have been labeled as having behavior problems and have been cor-rected continually by parents and teachers for not listen-ing, not paying attention, and misbehaving. Parents should give positive comments as much as possible to encourage the child and acknowledge his or her strengths. One tech-nique to help parents to achieve a good balance is to ask them to count the number of times they praise or criticize their child each day or for several days.

Although medication can help reduce hyperactivity and inattention and allow the child to focus during school, it is by no means a cure-all. The child needs strategies and practice to improve social skills and academic perfor-mance. Because these children are often not diagnosed until the second or third grade, they may have missed much basic learning for reading and math. Parents should know that it takes time for them to catch up with other children of the same age.

Evaluation

Parents and teachers are likely to notice positive outcomes of treatment before the child does. Medications are often effective in decreasing hyperactivity and impulsivity and improving attention relatively quickly, if the child responds to them. Improved sociability, peer relationships, and aca-demic achievement happen more slowly and gradually but are possible with effective treatment.