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Psychiatric-Mental Health Nursing

23.4 Attention-Deficit/Hyperactivity Disorder

Psychiatric-Mental Health Nursing23.4 Attention-Deficit/Hyperactivity Disorder

Learning Objectives

By the end of this section, you will be able to:

  • Outline diagnosis and presentation of attention-deficit hyperactivity disorder
  • Define the nurse’s role in creating a family plan for child with attention-deficit hyperactivity disorder
  • Identify resources for information and support

One of the most common neurodevelopmental disorders is attention-deficit hyperactivity disorder (ADHD), which involves difficulty paying attention, difficulty controlling impulsive behaviors, or excessive activity (CDC, 2023e). It is usually first diagnosed in childhood and often lasts into adulthood. Not everyone living with attention deficit shows hyperactivity; attention-deficit disorder (ADD) involves distractibility and difficulties with mental focus and working memory. ADHD can negatively affect a person's academics, social functioning, and relationships with peers. It can also have a negative effect on their family life. While ADHD and ADD have typically been associated with childhood, both can be diagnosed during adulthood; childhood ADHD and ADD can also persist into adulthood.

Diagnosis and Presentations of Attention-Deficit Hyperactivity Disorder

ADHD affects approximately 9.8 percent of American children aged thirteen to seventeen (CDC, 2022f). The global prevalence of ADHD in children and adolescents who are younger than nineteen is estimated to be 5 percent (Wüstner et al., 2019). It is normal for children to exhibit challenging behaviors and have trouble focusing at certain times. Children with ADHD, however, often have more severe symptoms that cause difficulties at school, at home, or with friends (CDC, 2021c), including:

  • daydreaming
  • forgetting or losing things
  • squirming or fidgeting
  • talking too much
  • making careless mistakes or taking unnecessary risks
  • difficulty resisting temptation
  • difficulty getting along with others

Diagnosing a child with ADHD is a process requiring several steps by a mental health professional or pediatrician. There is no single test to diagnose ADHD, and many other problems, such as anxiety, depression, sleep problems, and learning disorders can have similar symptoms as ADHD. The diagnostic process includes a medical exam; hearing and vision tests; and a checklist rating ADHD symptoms completed by parents, teachers, and the child (CDC, 2021c). ADHD lasts into adulthood for at least one-third of children with ADHD. Treatments for adults can include medication, psychotherapy, or a combination of treatments (CDC, 2021c). There are three types of ADHD, depending on which types of symptoms are strongest in the individual: inattentive, hyperactive-impulsive, and combined (CDC, 2021c).


A person who is inattentive finds it difficult for the individual to organize or finish a task, to pay attention to details, or to follow instructions or conversations. The person is easily distracted or forgets details of daily routines. The presentation of these symptoms can be missed or misinterpreted by others as “laziness” or “not paying attention.”

Life-Stage Context

ADHD Is Not Just for Kids

According to an article published by the Harvard Medical School (Collier, 2020), older adults who may not have ever been diagnosed with ADHD often seek the advice of their primary care provider when they begin to notice problems with their memory or completion of tasks. It is often not recognized until the older person realizes that other people in their family are being diagnosed with ADHD. This disease is one of the “most inherited disorders in medicine” (para. 4) so providers will look at family history when addressing memory concerns in older adults.

(Collier, 2020)


The person fidgets and talks a lot. It is hard for them to sit still for a length of time (such as during a meal or while doing homework). Young children may run, jump, or climb constantly. The individual feels restless and has trouble with impulsiveness. Someone who is impulsive may interrupt others, grab things from other people, or speak at inappropriate times. It is hard for the person to wait their turn or listen to directions. A person with impulsiveness may also have more accidents and injuries than others.

Combined Type

Mixed symptoms of the above two types are equally present in the person with the combined type. It is important to remember that a person’s symptoms of ADHD can change over time, and their predominant presentation may change.

Nurse’s Role in Supporting Families with Children with ADHD

A nurse can support parents of children with ADHD by educating them on some interventions they can use with their children. The CDC (2023) suggests that families:

  • Create a routine to help the child to stay focused.
  • Organize things like shoes, toys, school bags, and keep them in the same place.
  • Provide a quiet environment for completing homework. Limit distractions, such as background noise from TVs.
  • Do not give the child a lot of choices because that can be overwhelming for them. It is better to give them just two options to choose from when they need to make a choice.
  • Be clear with directions that you give your child. Be sure to include praise for when the child meets goals that have been set. The use of a sticker chart is a visual reminder of the work they are accomplishing.
  • Help the child try different things like sports or after-school activities to see which ones they really like and are good at because this helps to create positive experiences for them.
  • Provide healthy lifestyle options—good food, time for exercise, and plenty of sleep.

Nurses should be aware of the different community resources available and refer parents to those entities. Nurses also need to be aware of cultural beliefs, financial concerns, and support systems in place for the family/child and provide the nursing care accordingly. Patient-centered care is outlined in the QSEN Institute Competencies (2022).

Clinical Safety and Procedures (QSEN)

Client/Family-Centered Care for the Client with ADHD

When caring for a client with ADHD, nurse will:

  • Recognize the client’s inability to focus as a potential barrier to participation in the plan of care.
  • Promote and facilitate the client’s involvement in extracurricular activities as a means to promote healthy lifestyle, socialization and well-being.
  • Allow the client time to make decisions in order to show the nurse’s respect for the client’s unique abilities.

Promoting Overall Wellness

Many children with ADHD also have other disorders. These can include learning disabilities, conduct problems, anxiety, and depression, so it is important for nurses to screen children with ADHD for additional disorders (CDC, 2023e). The main symptoms of ADHD, being impulsive and inattentive, can cause these children to have a higher risk for injuries. They may ride a bicycle and not pay attention to traffic, be reckless when driving a car, act aggressively (in children who also have conduct disorder), and not remember to make healthy food choices or participate in regular physical activity. Parents and health-care providers can work together to remind children about safety and to monitor their well-being.


Nurses may play a role in medication management. Medication may help children aged six and older manage their ADHD symptoms and control behaviors that cause difficulties with family, with friends, and at school (CDC, 2021c). A comprehensive medical exam, including height, weight, blood pressure, heart rate, and cardiovascular history, should precede medication. Providers should establish a pretreatment baseline to measure common side effects, such as appetite and sleep changes, headaches, and abdominal pain. Adolescent clients should also be assessed for substance use (Krull, 2022).

The choice of medication by the prescriber depends on many factors, such as the following (Krull, 2022):

  • duration of coverage (e.g., desired coverage for school day plus completion of homework)
  • the desire to avoid medication administration at school
  • the ability of the child to swallow pills or capsules
  • coexisting emotional or behavioral conditions
  • history of substance misuse in the client or a household member (i.e., stimulants with less abuse potential are prescribed)
  • expense
  • preferences of the child and their caregivers

Stimulants, such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine), and dextroamphetamine-amphetamine (Adderall), are considered first-line treatment because of rapid onset of action and a long record of safety and efficacy. Stimulants are available in short-, intermediate-, and long-acting formulations. The exact mechanism of action of stimulants in ADHD is unknown, but they are known to affect the dopaminergic and noradrenergic systems, causing a release of catecholamines. Stimulants have been found to improve caregiver-child interactions, aggressive behavior, and academic productivity (Krull, 2022).

Stimulants are controlled substances and require a Schedule II prescription. There is a black box warning for CNS stimulants, including methylphenidate and amphetamine-like substances, because they have a high potential for abuse and dependence. In fact, up to 29 percent of school- and college-aged students with stimulant prescriptions have been asked to give, sell, or trade their medication (Krull, 2022). Assess the risk of abuse by the client or their family members before prescribing stimulants, and evaluate for signs of abuse and dependence while the client is receiving therapy (Food and Drug Administration, 2023).

Stimulants may cause minor side effects that resolve with lower dosage levels or a different prescription. The most common side effects include the following (National Institute of Mental Health, 2016; U.S. National Library of Medicine, n.d.): difficulty falling asleep or staying asleep, loss of appetite and weight loss, stomach pain, and/or headache. Less common side effects include motor or verbal tics (sudden, repetitive movements or sounds) or personality changes, such as appearing “flat” or without emotion (National Institute of Mental Health, 2016). Neurobiology and Pharmacological Standards provides more information on pharmacology.

SNRIs, such as atomoxetine (Strattera), are an alternative to stimulants for clients who experience side effects. They may also be helpful in treating concurrent depressive or anxiety disorders. SNRIs are not controlled substances, so they may be prescribed for adolescents (or their family members) with substance use disorders. The dosage depends on the child’s weight, and the duration of action is ten to twelve hours. Atomoxetine has a black box warning about increased risk of suicidal ideation in children and adolescents (Krull, 2022).

Alpha-2 adrenergic agonists, such as clonidine, may be utilized in combination with stimulants to reduce hyperactivity and sleep difficulties. These medications may also be used when children respond poorly to stimulants or SNRIs, have unacceptable side effects, or have significant coexisting conditions. Neuchat et al. (2023) assert that further research is indicated into the safe and effective long-term use of Alpha-2 agonists.

Clinical Judgment Measurement Model

Analyze Cues: The Use of Graphic Organizers to Develop Clinical Judgment Related to the Use of Medication to Treat ADHD

Nursing students today are being encouraged to use some type of graphic organizer to assist them with organizing the vast amount of information they are learning. Being able to analyze cues from assessment date is a priority nursing action. Concept maps are a tool that can be used to identify how data points are connected. To understand the side effects of certain medications, such as medications used to treat ADHD, a student could be asked to create a concept map. This would clearly connect certain side effects to certain medications and help the student to understand the importance of asking their clients if they are having any significant side effects since beginning a medication.

(Ignatavicius & Silvestri, 2023)

Behavioral Therapies

Behavioral therapies are aimed at helping the child with ADHD decrease their disruptive behaviors and increase their positive behaviors (CDC, 2023e). Parent training in managing their children’s behavior is the go-to first therapy for children younger than six years old. Training parents helps them be better equipped for their young children. For children older than six years, a combination of medication and behavior therapy is recommended, along with parent training and school involvement in which teachers educate children on the behavior that is expected within the classroom and help them to create focus plans. Behavioral therapies include parent training in “behavior management, behavior therapy with the child, and behavior management in the classroom” (CDC, 2023e, para. 6).

Community Services and Information Resources

Parents can be referred to the National Resource Center on ADHD, funded through the National Center on Birth Defects and Developmental Disabilities (NCBDDD) and the CDC (Children and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD], 2023). This program provides resources, an ADHD Helpline, digital media, weekly newsletters, education, and advocacy for those with ADHD and their families. Another great resource is the ADHD Resources Center on the American Academy of Child & Adolescent Psychiatry website. Parents can find educational resources, locate treatment resources, watch video clips, and learn about clinical resources. To find local resources, parents can speak with their child’s pediatrician, teacher, or go to the SAMHSA website to find a local provider.


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