Pediatric Primary Care (129 page)

D.  Etiology.

1.  Specific etiology unknown. Believed that abnormal dopamine transport and uptake at nerve synapse may account for symptoms displayed.

E.  Occurrence.

1.  The prevalence of ADHD is 5%.

2.  Two-thirds of children with ADHD continue to have symptoms in adolescence.

3.  More prevalent in males than females–approximate ratio of 4:1.

4.  Prevalence of comorbid conditions ranges from 9-50% depending on specific comorbid condition. Refer to
Table 34-1
.

F.  Clinical manifestations.

1.  Child displays and/or parents and teachers report inappropriate degrees of:

a.  Hyperactivity.

b.  Impulsivity.

c.  Inattentive behaviors.

2.  
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) diagnostic criteria delineate clinical manifestations of ADHD and clarify criteria utilized to make definitive diagnosis
(
Box 34-4
).

Table 34-1
Prevalence of Comorbid Conditions in Children with ADH

Source:
Adapted from Agency for Healthcare Policy and Research, U.S. Department of Health & Human Services.

Box 34-4
DSM-IV Diagnostic Criteria for ADHD

Content removed due to
copyright restrictions

Content removed due to
copyright restrictions

3.  Identifying at-risk child.

a.  Nurse practitioner plays integral role in identifying children at risk for ADHD by evaluating comprehensive medical history.

b.  Positive family history of one or more of hyperactivity disorder, conduct disorder, learning disorder, substance abuse, psychiatric disorder.

c.  Intrauterine exposure to smoking and drug/alcohol use, especially during first trimester.

d.  Parent, schoolteacher report that child displays impulsive and inattentive behaviors.

•  School-age children tend to steal, tell lies, deliberately destroy property.

•  Adolescents display behaviors associated with anger and mood lability: alcohol/substance abuse, smoking, sexually transmitted infections, early pregnancy, low self-esteem, involvement in motor vehicle accidents.

4.  Comprehensive medical history–include questions that elicit details concerning each of following parameters:

a.  Parental concerns.

•  Onset and duration of symptoms.

•  Parental approaches to displayed symptoms.

b.  Behavioral history.

•  Hyperactivity as described by parents, caregivers, teachers.

•  Behaviors that display impulsivity, inattentiveness to details.

•  Ability to focus on interactive video games.

•  Sleep patterns.

•  General behavior at home and in school settings.

•  Previous results of Denver Developmental Screening Tests and any formal psychological testing.

•  School performance.

•  Identification of any learning disabilities.

•  Behaviors displayed while playing with other children.

•  Parenting styles: what works, what does not work with the child.

c.  Significant past medical history.

•  Prenatal, birth, neonatal history.

•  Evaluation of growth charts.

•  Evaluation of previous diagnostic testing including complete blood count (CBC) results, lead levels, visual and hearing test results.

•  Seizures/seizure-like behaviors including staring episodes, tics, head trauma.

•  Medication history (prescribed, OTC, illicit).

d.  Developmental history.

•  Achievement of developmental milestones.

•  Speech and language development.

•  Gross motor and fine motor development.

•  Coordination.

e.  Educational history.

•  Type of educational program.

•  Early intervention.

•  Special education program.

•  Participation in mainstream programs.

•  One-on-one programs.

•  Success/failure in each educational program.

•  Mathematical ability.

f.  Behaviors at school.

•  Reports from teachers, counselors.

•  Relationships with children at home and school.

•  Relationships with teacher, school nurse, counselor.

g.  Family history.

•  Parents or siblings diagnosed with ADHD.

•  Substance abuse.

•  Mental illness.

•  Learning disabilities.

h.  Psychosocial history.

•  Family structure, function.

•  Head of family.

•  Parents' occupation, employment, level of education.

•  Substance abuse by parents/child.

•  Evaluate family-child interactions.

•  Family stress level due to child's behavior.

i.  Manifestations consistent with comorbid conditions:

•  Lack of motor control; clumsiness (developmental coordination disorder [dyspraxia]).

•  Preschooler with speech, language delay (learning disability).

•  Writes number in reverse order after age 7 (learning disability).

•  Poor school performance: unable to learn to read, write, or do mathematics (learning disability).

•  Insomnia.

•  Enuresis, encopresis.

•  Negative, hostile, defiant behaviors lasting at least 6 months (oppositional defiant disorder [ODD]).

•  Violation of home/school rules (conduct disorder).

•  Symptoms of depression.

•  Inappropriate levels of anxiety.

•  Low self-esteem.