Attention deficit hyperactivity disorder is associated with inattentive, impulsive, and hyperactive behavior that is maladaptive and inconsistent with developmental level. This behavior creates clinically significant impairment in social/academic functioning. Accurate diagnosis is difficult, as symptoms resemble depression, learning disabilities, or emotional problems. The diagnosis is made through extensive observation of the child’s behavior; however, contact with health professionals is limited and the child’s activity may be misleading during short office visits. Reports from parents and teachers are often used to make the diagnosis, and their observations may be distorted, as they assume a problem exists and often predetermine the diagnosis themselves.
314.00 ADHD predominantly inattentive type
314.01 ADHD predominantly hyperactive-impulsive type
314.01 ADHD combined type
314.9 ADHD NOS
The child with this disorder has impaired ego development. Ego development is retarded and manifested impulsive behavior represents unchecked id impulses, as in severe temper tantrums. Repeated performance failure, failure to attend to social cues, and limited impulse control reinforce low self-esteem. Some theories suggest that the child is fixed in the symbiotic phase of development and has not differentiated self from mother.
The disorder may be gender-linked as the incidence is higher in boys than in girls (3:1). ADHD is also more prevalent among children whose siblings have been diagnosed with the same disorder. Recent studies have established that the fathers of hyperactive children are more likely to be alcoholic or to have antisocial personality disorders. Affected children have shown the presence of subtle chromosomal changes and mild neurological deficits with irregular brain function including too little activity in the area that inhibits impulsiveness. Hyperactivity may result from fetal alcohol syndrome, congenital infections, and brain damage resulting from birth trauma or hypoxia. Cognitive distractibility and impulsivity are associated with other disorders involving brain damage or dysfunction, such as mental retardation, seizure disorder, and brain lesions.
Physiological conditions that can mimic the symptoms include constipation, hypoglycemia, lead toxicity, and thyroid and other metabolic diseases.
This theory suggests that disruptive behavior is learned as a means for a child to gain adult attention. It is likely that whether or not the impulsive irritability seen in individuals with ADHD was present from birth, some parental reactions tend to reinforce and thus maintain or increase its intensity. Anxiety generated by a dysfunctional family system, marital problems, and so forth, could also contribute to symptoms of this disorder. Parents become frustrated with the child’s poor response to limit-setting. Parents may become overly sensitive or may give up and provide no external structure.
1. Facilitate child’s achievement of more consistent behavioral self-control and improvement in selfesteem.
2. Promote parents’ development of effective means of coping with and interventions for their child’s behavioral symptoms.
3. Participate in the development of a comprehensive, ongoing treatment approach using family and community resources.
Nursing diagnosis for attention deficit hyperactivity disorder (ADHD): SOCIAL INTERACTION, impaired may be related to retarded ego development; low self-esteem; dysfunctional family system, negative role models; abuse/neglect; neurological impairment; mental retardation possibly evidenced by discomfort in social situations; Difficulty waiting turn in games or group situations; interrupts or intrudes on others; Does not seem to listen to what is being said; Difficulty playing quietly, maintaining attention to task or play activity; often shifts from one activity to another.
1. Identify feelings that lead to poor social interactions.
2. Participate appropriately in interactive play with another child or group of children.
3. Develop a mutual relationship with another child or adult.
Nursing intervention with rationale:
1. Develop trust relationship with child, show of child separate from unacceptable behavior.
Rationale: Acceptance and trust encourage feelings of self acceptance worth.
2. Encourage client to verbalize feelings of inadequacy and need for acceptance from others. Discuss how these feelings affect relationships by provoking defensive behaviors such as blaming and manipulating others.
Rationale: Recognition of problem is first step toward resolution.
3. Offer positive reinforcement for appropriate social interaction. Ignore ineffective methods of relating to others; teach competing behaviors.
Rationale: Behavior modification can be an effective method of reducing disruptive behaviors in children by encouraging repetition of desirable behaviors. Attention to unacceptable behavior may actually reinforce it.
4. Identify situations that provoke defensiveness and role-play more appropriate responses.
Rationale: Provides confidence to deal with difficult situations when they occur.
5. Provide opportunities for group interaction and encourage a positive and negative peer feedback system.
Rationale: Appropriate social behavior is often learned from age-mates.
6. Arrange staffings with other professionals (e.g., social workers, teachers). Include parents and child when possible.
Rationale: Cooperation and coordination among those working with these children enhance treatment program. Including child and parents provides them with understanding of the total problem and proposed treatment program.