A Patient With ADHD

FS was brought to the primary health care clinic by his mother at the age of 6 because of his motor restlessness, distractibility, and disruptive behavior in the classroom. According to his mother, FS had a reasonably good year in kindergarten but early in the first grade the teacher began to report disruptive behavior. On reflection, FSs mother recalled that kindergarten had been a half-day program in which there was more activity. By contrast, in the first grade, FS was expected to sit in his seat and pay attention for longer periods of time. FSs medical history was unremarkable. He was born by cesarean section after a long, unproductive labor to his then 19-year-old mother. The pregnancy was unplanned and it was his mothers first pregnancy. Although there were no complications during the pregnancy, the period was marked by significant marital discord, culminating in divorce before FSs first birthday. He was healthy at birth and grew normally, with no delays in his development. Despite genuine interest in other children, his intrusive style and inability to wait his turn resulted in frequent conflicts with other children. The family history was positive for substance abuse in his father. In addition, FSs mother reported that her former husband had been disruptive in school, had trouble concentrating, and was highly impulsive, which has continued into his adulthood. During the three evaluation sessions, FS was active although not uncooperative. His speech was fluent and normal in tone and tempo, but somewhat loud in volume. His discourse was coherent, but at times he made rather abrupt changes in conversation without warning his listeners. Psychological testing done at the school revealed average to above-average intelligence. Parent and teacher questionnaires concurred that FS was overactive, impulsive, inattentive, and quarrelsome, but not defiant. SETTING: PSYCHIATRIC HOME CARE AGENCY BASELINE ASSESSMENT: FS is a 6-year-old boy with prominent hyperactivity and disruptive behavior living with his single mother. These problems interfere with his interpersonal relationships and academic progress. FSs mother is discouraged and feels unable to manage his behavior. Associated Psychiatric Diagnosis Medications Axis I: Attention Deficit/Hyperactivity Disorder Methylphenidate 5 mg after breakfast to start, gradually increasing to 10 Axis II: None mg in AM and 5 mg at noon (approximately 0.6 mg/kg) Axis III: None Axis IV: Problems with primary support (mother is exhausted) Educational problems (failing in school) Economic problems (mother in entry-level job with no health insurance) Axis V: GAF 52 Nursing Diagnosis 1: Impaired Social Interactions Defining Characteristics Related Factors Inability to establish and maintain developmentally appropriate social Impulsive behavior relationships Overactive Interpersonal difficulties at school Inattentive Fails to complete tasks Risk-taking behavior (tried to climb out the window to get away from Not well accepted by his peers mother) Easily distracted Does not recognize impact of his behavior Butts in on others Unable to wait his turn in games Speaks out of turn in the classroom

Outcomes Initial Discharge 1. Decreased hyperactivity and disruptive behavior 4. Improved capacity to identify alternative responses in conflicts with 2. Improved attention and decreased distractibility peers 3. Decreased frequency of acting without forethought 5. Improved capacity to interpret behavior of age-mates Interventions Intervention Rationale Ongoing Assessment Educate mother and teach about ADHD and use Better understanding helps to ensure adherence; Determine extent to which parent or teacher of stimulant medication. also parents and teachers often miscast blames FS for his problems. children with ADHD as troublemakers. Uneven compliance may contribute to failed trial of medication. Parent and teacher questionnaires; inquire about Monitor adherence to medication schedule. behavior across entire day. Stimulants can affect appetite, sleep, and can Parent and teacher questionnaires; check height cause behavioral rebound (Scahill & and weight; ask about sleep and appetite. Ensure that medication is both effective and Lynch, 1994a). well tolerated. Evaluation Outcomes Revised Outcomes Interventions Decreased hyperactivity, decreased disruption Improve ability to identify disruptive classroom Initiate point system to reward appropriate in the classroom. behavior. behavior. Improved attention, decreased distractibility. Improve school performance. Move to front of classroom as an aid to Decreased impulsive behavior according to Increase capacity to recognize impact of his attention. mother and teacher. behavior on others. Encourage participation in structured activities. Identified alternative responses such as walking Increase frequency of acting on these alternative away until it is his turn. approaches. Inquire about social skills group at school, if Improved interpretation of motives and Improve acceptance by peers. needed. behaviors of others. Encourage participation in community activities. Nursing Diagnosis 2: Ineffective Individual Coping (Mother) Defining Characteristics Related Factors Verbalizes discouragement and inability to handle situation with FS Chronicity of ADHD Child-rearing problems Outcomes Initial Discharge 1. Verbalize frustration at trying to raise a child with ADHD alone. 3. Identify coping patterns that decrease the sense of frustration and 2. Identify positive methods of interacting and disciplining FS that will increase parental competence. support the parent-child relationship as well as meet FSs 4. Initiate a collaborative relationship with schoolteacher.

developmental needs.

5. Identify sources of support in the community and begin to access these resources. Interventions

Intervention Assess mothers discouragement and feelings about parenting. Identify specific problem areas. Refer mother to Community Mental Health Center for free parenting class. Refer mother to self-help organization. Make contact with school to enhance collaboration with mother.

Outcomes After two sessions she was able to express her frustrations, but was beginning to identify different ways of relating to FS and FSs developmental needs. Through attending the parenting class and joining a support group, she began to change her coping patterns, decreased her frustrations, and increased parental competence. She initiated a collaborative relationship with schoolteacher.

Rationale Helping the mother verbalize her feelings and identify problem areas helps in formulating problem-solving strategies. Parent training based on clear limits and rewards can be effective for decreasing impulsive and disruptive behavior. Parent groups such as Children and Adults With ADD (CHAAD) can be source of support and information. To assess effectiveness of medication and other interventions, need feedback from schoolteacher. Evaluation Revised Outcomes None.

Ongoing Assessment Assess the severity of the problems that she is living with. Monitor mothers level of confidence and perceived change in FSs behavior. Determine whether contact was made and whether it was helpful. Determine whether mother has been able to contact teacher.

Interventions None.

Complete parenting class; attend at least two support group meetings each month. Mutual development and implementation of behavior plans for home and school.

If necessary, refer for additional parent counseling. Have mother observe in the classroom; have mother visit highly structured classroom.