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Attention deficit and hyperactivity disorder (ADHD) can lead to negative outcomes for children, their families, and communities if left untreated. Untreated ADHD in children has the potential to lead to long-term academic underachievement (14). It is vital for nurses and healthcare providers to recognize the signs and symptoms of ADHD in children, so they are able to reach their full potential.  

Introduction 

Symptoms of Attention Deficit Hyperactivity Disorder (ADHD) in children are characterized by impulsivity, hyperactivity, and inattention (1). ADHD affects approximately 6.1 million children in the United States. Males are diagnosed with ADHD more frequently than females. This may be attributed to females being underdiagnosed. Boys are diagnosed at 13% compared to girls at 6% (2)  

Nurses, school nurses, and primary care providers are often the first healthcare providers alerted to possible symptoms of ADHD in children. However, the current shortage of specialty providers, including child psychiatrists and developmental pediatricians, can impact the overall care of children with ADHD (1,16). Providers must utilize evidence-based practice protocols from the American Academy of Pediatrics (AAP) Clinical Practice Guidelines (CPG) to treat ADHD in children.

The AAP guidelines recommend specific diagnostic criteria and assessment of coexisting conditions, including emotional or behavioral, developmental, physical, parent and teacher symptom rating scales, medication, treatment, and behavior therapy (16). Efforts must be made to improve concordance with the AAP ADHD CPGs (4). Healthcare providers need to recognize the symptoms of ADHD in children and get them the care they need to reduce the adverse outcomes of untreated ADHD.  ​

Epidemiology 

The symptoms of ADHD in children will present during young childhood and, in most cases, will continue to contribute well into adulthood (17). The median age of diagnosis of ADHD is seven, and half of children were diagnosed by their primary care provider (12). Boys have a two times higher prevalence of ADHD than girls (2).  

Children with ADHD can have impacted social skills, often seeming to behave younger than their actual age. Additionally, they have difficulties forming friendships and struggle with long-term social problems (15). Children with ADHD can be rejected by their peers because of impulsive or hyperactive behaviors (9).

If untreated, ADHD in children can result in poor listening skills and is easy to anger, leading to potential impairments in family relationships (8). Additionally, mental health issues in adulthood are more likely to present if ADHD is not treated during childhood (8,10). For example, parents with untreated ADHD can develop negative relationships with their children and frustrate them quickly (8).  

There is a strong association between untreated ADHD in children and substance abuse, as well as increased risk for difficulty with law enforcement and higher rates of motor vehicle accidents (5).   ​

Diagnosing and Treating ADHD in Children 

Diagnosing ADHD  

Diagnosing ADHD in children is a lengthy process that can sometimes be frustrating for families. ADHD has two main categories of symptoms, including the hyperactivity/impulsivity subset and the inattention subset (1). For a diagnosis, the symptoms must be present in multiple locations (e.g., school and home or home and after-school activities). Symptoms must occur often, persist for more than six months, have an onset before age 12, and be disproportionate to the child’s developmental level (12).  

Parents, teachers, coaches, and other caregivers often report symptoms. Our job, as pediatric care providers, is to gather this information and help make the diagnosis. The AAP recommends using the Vanderbilt Assessment Scales for assistance with diagnosis and tracking of ADHD symptoms over time (13, 17). 

The evaluation for ADHD in children must be comprehensive so that a diagnosis can be confirmed and other diagnoses can be excluded. Providers must review the family, social, and patient’s medical histories (12). It is also essential to review the family history of ADHD and other mental health diagnoses.

Providers must also review and confirm that these symptoms occur in multiple environments (17). One way to do this is for teachers to complete the Vanderbilt Assessment Scales, which have both teacher and parent versions to aid in diagnosing ADHD (13, 17). The diagnostic process can and often takes more than one visit (17).  

The physical exam for children undergoing an evaluation for ADHD is essential. Vital signs must be obtained along with height, weight, and head circumference (11). Providers must complete a full neurologic exam and asses for dysmorphic features (e.g., key features that may be present in Fragile X). Providers must pay close attention to the child’s behavior in the office- is the child up and down on the exam table? How are they communicating with you? With the caregiver? 

Treatment for ADHD 

Treatment for ADHD is multimodal and involves medication, school-based, family, and behavioral interventions (3). Providers and families should base decisions about treatment on the risks and benefits of the treatment (11). They should also use shared decision-making to set SMART (specific, measurable, attainable, realistic, and time-sensitive) goals regarding treatment. 

Behavior Interventions/Therapy

Behavior interventions are a central part of treatment for ADHD in children (17). The goal of behavior interventions includes changing the social and physical environment of the child with ADHD using rewards and not punishment to change their behavior (17). The principles of behavior therapy include identifying the signals of the behavior families would like to target and changing the consequences of that behavior (6,12). There are many programs for guardians to sign up for to learn the principles of behavior therapy (e.g., Triple P Parenting Program). Key components that can help improve the behavior of children with ADHD include (6).  

• Maintaining a daily schedule. 
• Reducing distractions. 
• Having the child help set small and attainable goals. 
• Use charts or checklists to help the child stay on target. 
• Limiting choices. 
• Rewarding positive behavior. 
• Identifying and stopping unintentional reinforcement of negative behavior. 
• Using calm discipline methods (time out or distraction)   

Medications

There are hundreds of different ADHD medications available. Finding the right one for a child with ADHD sometimes feels more like an art than a science. Some key considerations when choosing an agent include how long you want the medication to work, whether the child can swallow pills or if the tablets can be crushed, whether the family wants to avoid administering medication at school, the possible side effects of the drug, and the expense to the family (6,7,11).   

Stimulant medications used to treat ADHD in children have common side effects that must be monitored and addressed. Some side effects can be managed with the child and families, and sometimes, medications must be stopped or changed due to the side effects. Decreased appetite is a common side effect of stimulants and can be managed by ensuring children eat before or at the time of their ADHD medication (11).

They should also be encouraged to eat small snacks when they are not hungry and are rich in nutrients and calories (e.g., peanut butter and apple, yogurt with pretzels). Some children can experience poor growth while on stimulant medications. If a child has a slowdown in their growth, providers and families should consider a drug holiday.

A drug holiday is when a child goes off the medication at certain times to promote growth (e.g., on the weekends or during school breaks) (11). Some children can experience trouble falling asleep due to their stimulant use. Suppose a child is having difficulty falling asleep. In that case, assessing the time of day the medication is being administered is necessary, or seeing if a short-acting preparation can be used instead of a long-acting (11).   

Complications 

Treating ADHD is extremely important. Untreated ADHD can result in severe problems. These can be long-term complications and include (14).  

• Substance abuse 
• Lack of self-esteem 
• Eating disorders 
• Impulsive behavior 
• Frequent vehicle accidents 
• Injuries 
• Relationship difficulties 
• Financial and employment instability 
• Depression 
• Anxiety 

Case Study of ADHD in Children

Tyler is a seven-year-old first-grader who lives with his mother, brother, and great-grandmother. He frequently gets in trouble, cannot sit still, does poorly in school, and is always punished. His teacher calls home a lot, and the reports are adverse. His great-grandmother, Mimi, “cannot handle him” anymore, and Tyler’s mom is concerned that she will stop watching the boys for her when she goes to work. Tyler’s mother calls the nurse triage line to talk to someone at their primary care office and see if this is “boys will be boys” behavior or if something else could happen with Tyler. Her older son does not act like this, so she is concerned that his behavior is something more. 

• What screening forms do you think Tyler’s PNP will recommend?  
• Based on your phone call with his mom, what hyperactivity/impulsivity and inattention criteria does Tyler already meet?  
• What will be necessary for Tyler’s PNP to address during the telehealth visit?
  

Tyler and his mother log into their telehealth visit, and his mom reports to Dr. Miller, DNP, CPNP, RN, that Tyler has been struggling with behavior problems for “a while now.” But it has gotten much worse in first grade. His teacher calls home to report that Tyler cannot sit still; he’s constantly climbing up and down and yelling out the answers to all the questions before she can even get through them.

At school, he has even run out of the classroom several times when he sees his brother walk by, making things unsafe for him. At home, Tyler is “all over the place,” he is constantly losing stuff (i.e., his homework), he never stops talking, and he and his brother fight constantly over the Nintendo Switch because Tyler just “can’t wait for his turn.” Tyler’s mom reports that he acts so much younger than kids his age and even than his brother at the same age.  

During the visit, Dr. Miller notices Tyler climbing behind his mom. He blurts out the answers to her questions before his mom can, and at one point, he comes over and starts pounding on the screen and keyboard. He notices a photograph of Dr. Miller’s dog in the background of her office, and despite being redirected multiple times by Dr. Miller, he continually asks to see her dog, who is not at the office. 

• What additional hyperactivity/impulsivity criteria do you note that Tyler meets? 
• What additional inattention criteria do you note that Tyler meets? 
• Have you ever encountered a pediatric patient like Tyler in your practice? Were they diagnosed with ADHD? 
• What would be some additional questions that would be important for Dr. Miller to ask regarding Tyler? 
• How can Dr. Miller confirm that Tyler has these symptoms in multiple environments (e.g., home and school)? 
  

Dr. Miller assures Tyler’s mother that she can help with Tyler’s behavior. However, she needs additional information from Tyler’s mother, Mimi, and his teachers.

Dr. Miller asks that everyone complete the Vanderbilt Assessment Scales and that Tyler’s mother return them to the patient email system through the electronic medical record provider. They set up a face-to-face appointment for the following week to review the results of the forms, check in on Tyler’s health status, and do a physical exam. 

• What are some important parameters for Dr. Miller and her team to look for in a physical exam?  
• Why does Mimi need to complete a Vanderbilt Assessment Scale?
  

Tyler’s mother returned all the forms to Dr. Miller, and she then scored them. The forms show that Tyler has inattentive and hyperactive behaviors at home (for Mimi and mom) and school. Tyler comes in for his face-to-face appointment, and his height, weight, and head circumference are all in the 60th percentile.

His neurologic exam is standard, and he has no dysmorphic features. During the exam, he is very active. He constantly climbs on the exam table, asks for snacks and juice frequently from the clinic staff, and raids the “treasure chest” even though he didn’t get a shot today. He disrupts the nursing staff several times while attempting to complete his hearing and vision screening.

The nursing staff could not complete the hearing screening because Tyler could not focus enough to follow directions. When the visit was complete, he left his hand-held video game in the room, and Dr. Miller had to chase the family out with it so he didn’t forget it. Dr. Miller noted that his mom reminded him six times to put his hand-held video game in his backpack before leaving.  

• Does the face-to-face visit help Dr. Miller with any further information about Tyler? 
• Why would a hearing screening be important for Tyler to get?  
• What additional criteria did Tyler meet during this face-to-face visit for ADHD? 
• Do you think that Tyler could have something else going on? What additional conditions are you concerned about for Tyler?
  

Dr. Miller diagnoses Tyler with ADHD and is coming up with a treatment plan for him and his family. She had a conversation with Tyler’s mom during the visit, and they decided that medication and behavior therapy would be a good option for him. His mom is wondering what behavior therapy is and how she will get all of this done. She’s also worried about the side effects of ADHD medication because her nephew is on ADHD medication and has had a lot of side effects. 

• What behavior therapy would you recommend for Tyler’s mom?  
• Are there other people in Tyler’s life that should be included in his behavior therapy plan? 
• What SMART goals could Tyler, his mom, and Dr. Miller set for his two-week return visit regarding his behavior therapy? 
  

Dr. Miller and Tyler’s mom discuss the Triple P Parenting program because their state offers it online, and it is free. Tyler’s mom wants to complete the program with Mimi because she helps care for the boys. Mimi uses a lot of “old school” punishment and shaming for Tyler’s behavior.

• What questions should you ask Mom and Tyler before making a medication recommendation?
  

Tyler is not comfortable swallowing pills. He has his essential classes in the morning at school and his “specials,” such as PE and art, after lunch. Dr. Miller and Tyler’s mom discuss trialing short-acting methylphenidate for Tyler to see how he does and if he gets too many side effects. Tyler’s mom says she will discuss this plan with his school and teachers.  

• What side effects should Dr. Miller discuss with Tyler’s mom regarding the short-acting methylphenidate?  
• Is Tyler’s growth a concern currently? 
• If you have a patient already on the low end of the growth curve, would your recommendations for treatment change? What about recommendations for follow-up? 
  

 Tyler has been doing exceptionally well since his diagnosis and treatment. Dr. Miller has had to make a few medication changes along the way as he has grown and his needs have changed (e.g. more homework, sports practices). He has experienced some side effects over the years, mainly appetite suppression. He has grown into a beautiful, intelligent, sweet, and sensitive middle schooler. His grades average between A’s and B’s. He loves nature and math. Mimi loves spending time with Tyler and enjoys playing card games together.   

Conclusion 

ADHD is a common chronic disorder in children. It is essential to recognize the signs and symptoms of ADHD in children, including hyperactivity and impulsivity symptoms along with inattention symptoms. The care of children with ADHD is multimodal and requires the whole family and community to assist with behavioral interventions. For children who are on ADHD medication, it is essential to monitor closely for side effects and growth. Primary care providers and families can manage ADHD well. Children with ADHD can succeed if provided with the right tools.  

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