Mental Health

Helping Parents Make Sense of ADHD Diagnosis and Treatment

The early months of the new school year are often marked by a familiar tale from parents: "The teacher says he can't come back to school until he sees a doctor and gets medication to help him calm down." Parent reactions to this demand by teachers vary from indignation to concern to a desire for a quick fix. Pediatric nurse practitioners (PNPs) are in a key position to help assure that the child suspected of having ADHD receives a thorough and appropriate evaluation and a comprehensive plan of care. Parent support and education through the processes of assessment, diagnosis, and development of an effective treatment plan are critical elements in achieving good outcomes for the child and family (Selekman & Snyder, 2000). Below are answers for questions parents ask frequently. From Journal of Pediatric Health Care

Helping Parents Make Sense of ADHD Diagnosis and Treatment
Posted 05/16/2003

Mary Margaret Gottesman, PhD, RN, CPNP
Who Gets ADHD?
ADD/ADHD is the most common psychiatric condition diagnosed in children, affecting about 5-10% of all children, or approximately 1.5 million children (Barkley, 1998). It is more frequent in boys (9.2%) than girls (2.9%) (Baren, 2002). Many people are unaware that it affects adults as well, as many as 6 million (Ingram, 1999). Attention deficit with hyperactivity and impulsiveness affects boys more often than girls, but girls are more likely to have the attention deficit disorder without hyperactivity variant (Gaub & Carlson, 1997). Hence, many girls are not diagnosed until middle school or later when learning tasks become more complex.

What Causes ADHD?
No one gene or structural abnormality of the brain accounts for the diversity of the ADHD spectrum (Castellanos, 1997). Rather it is believed to result from the complex interaction of genetic, biological, and environmental risk factors (Conners, 2003).

About 25% of children with ADHD have a first degree relative with ADHD (Hunt, Paguin, & Payton, 2001). Other genetic risks include the presence of parental mood and conduct disorders, learning disabilities, and antisocial behavior. Parental substance abuse and smoking may also be markers for risk since many adults attempt to improve their sense of well-being via the effects of alcohol, nicotine, and drugs (Beiderman, et al, 1997).

Biological risks also increase the likelihood of ADHD. Among the known associations are maternal smoking and alcohol use during pregnancy, especially during the first trimester (Biederman, et al., 1998). Preterm labor, impaired placental functioning with resultant impairments in fetal nutrition and growth, as well as impaired oxygenation leading to fetal distress and low birth weight, infections of the central nervous system, seizures, and serious head injury are also associated with a higher incidence of ADHD (Saigal, 2000). Preterm infants, especially those with intraventricular hemorrhages, are at greater risk, as well (Seubert, Stelzer, Wolfe, & Treadwell, 1999).

Exposure to heavy metal toxins such as lead and mercury, as well as exposure to carbon monoxide fumes, are known environmental risks for behavior disorders (Conners, 2003). Poor childhood diet, family stress, and living in poverty further increase the risk (Jakovitz & Sroufe, 1987). Newborn illness and stress from the care environment of the NICU also increase vulnerability to the disorder (Gunnar & Barr, 1998). In addition, children with the extremes of easy and difficult temperament appear to be at greater risk for ADHD and a variety of mood disorders (Conners, 2003).

While ADHD is the result of the complex interaction of a variety of risk factors, each individual’s outcome is difficult to predict because of the ability of protective factors to modify the negative effects of risk (Conners, 2003). Certainly, access to high quality health care, adequate family resources to access care, and parent investment in the child all ameliorate the negative impact of ADHD.

What Exactly is the Problem in ADHD?
Researchers characterize ADHD as a developmentally sensitive disorder characterized by a delay in maturation of the brain’s ability to achieve mastery of self-regulation (Hunt, et al., 2001). The three hallmark impairments of ADHD are inattentiveness/distractibility, hyperactivity, and impulsivity (American Psychiatric Association, 1994). Individual children vary in the degree to which each impairment presents.

The behaviors peers and adults perceive as troublesome are the result of actual physiologic differences in brain functions related to learning, particularly in regard to filtering stimuli and selecting relevant information to which to attend, shifting and sustaining attention, as well as linking new and old information, known as working memory (Castellanos, 1997). Not only do children with ADHD have difficulty inhibiting attending to any and every stimulus and controlling inappropriate motor behavior, they also have difficulty modulating their feelings (Hunt, et al., 2001). Hence, they are also vulnerable to mood disorders as well as the social and academic problems of ADHD (Pliszka, 1998). At the heart of the problematic behaviors are deficits in the quantity and function of neurotransmitters, substances produced in the final stage of neuronal development and differentiation (Gualtieri, 1991).

Neurotransmitters and the receptors with which they interact serve both to actively transmit information as well as to selectively repress transmission of information and motor behaviors that would hinder attention and learning (Castellanos, 1997). Children with ADHD appear to lack adequate norepinephrine with which to initiate arousal and to exhaust their dopamine supplies, which help to sustain attention and filter irrelevant stimuli for the current mental task (Hunt, et al., 2001).

Do Children Outgrow ADHD?
Researchers find that the behaviors associated with ADHD do change as the child grows older (Biederman, 1998). For example, dopamine levels that help drive the need for exploration peaks at two years of age in normal children, which is developmentally helpful since very young children lay a strong foundation for learning through active exploration (Castellanos, 1997). Dopamine levels decline thereafter, allowing the child to begin the equally important tasks of learning to attend for longer periods of time and to fit into social expectations by bringing their behavior under voluntary and inhibitory control (Biederman, 1998).

A similar process also occurs for children with ADHD, but with a two-year or more delay. Thus, hyperactivity decreases in as many as 50% of children with ADHD as they grow older. However, there is no developmental improvement in attention deficit noted for either boys or girls (Baren, 2002). About 80% of children continue to exhibit symptoms in adolescence, and 85% or more have functional impairments as adults (Barkley, Fisher, Edelrock, & Smallish, 1990).


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