Disclaimer: I, in no way, make a stance against medicating children with severe cases of ADHD. I just feel as though parents are not fully educated on alternative treatments and I also believe that diagnosis ADHD is beyond a teachers scope of practice and should be done by a pediatric mental health provider.
Attention-deficit/hyperactivity disorder (ADHD) is the most common chronic childhood disorder. Children with ADHD may have difficulty controlling their behavior in school and social settings and often fail to achieve their full academic potential. The child may present with varying symptoms of hyperactivity, impulsivity, and/or inattention. He or she may be easily distracted, unable to follow directions, overactive, and/or have poor self-control (American Psychiatric Association, 2000). Current estimates indicate that 4.5 million children under age 18 have been diagnosed with ADHD (Centers for Disease Control and Prevention, 2010). These are staggering statistics. It is important that children are assessed properly, thoroughly, and by the appropriate criteria before implementing a treatment plan. Extensive research revealed that approximately 1 million children within the United States are misdiagnosed with ADHD, and most of these children are being medicated (Elder, 2010).
Stimulants are often the first intervention used when treating children with ADHD. Psychosocial interventions that involve both parents and teachers working together to shape the child’s behaviors have proven more effective than medication alone, but this treatment method is not often used. Even though there is evidence that would enable smaller amounts of medication to be used with fewer side effects, parents are not utilizing the resources available to them because of the vast knowledge deficit concerning treatment options (The National Institute of Mental Health, 2009). Using MRIs, EEGs, and SPECT imaging, scientists have proven that brain development does not stop until approximately age 25 (Chudler, 2008). The only longitudinal study done on the effects of stimulant usage on development has proven that these medications directly affect children’s growth pertaining to height and weight (NIMH, 2009). There have only been a few studies done on the long term effects of stimulants on brain development, but armed with the knowledge that brain development does not stop until 25 years of age and proof that ADHD medication has a direct effect on growth, some research has shown that changing chemical balances within the brain could potentially have an impact on the growth and chemical composition of the brain (Bobinchock, & Neves, 2004). As a parent and an adult with ADHD, I want to understand the depth of the disease process, the treatment options available, and why there are close to a million children not receiving proper treatment. I want to educate parents on how to properly get help for their child. The data used in this project was collected through a rigorous and systematic search of literature, relevant data, and health events pertaining to ADHD. The data was then compiled and analyzed to highlight the points in which education and intervention are necessary.
Of the 4.5 million children living with an ADHD diagnosis, roughly 2.5 million of them are regularly using prescription medication to treat their symptoms (CDC, 2010). In a recent study done by Michigan State University, a staggering 900,000 of these children with a diagnosis of ADHD have likely been misdiagnosed. An even more disturbing fact would be that approximately 20% of the 2.5 million children who use stimulants intended to treat ADHD have been misdiagnosed and are unnecessarily medicated (Elder, 2010). The percentage of children ages 4 to 17 diagnosed with ADHD rose from 7.8% to 9.5% between 2003 and 2007—a 22% increase (National Survey of Children's Health Data Resource, 2007). In 2000, the U.S. ADHD pharmaceutical market was valued at 1 billion dollars. In 2008, that same market was worth 4 billion dollars (Bobinchock, & Neves, 2004). The latest statistics provided by the CDC state that 9.9% of Tennessee’s children have been diagnosed with ADHD and 4.8% of them are medicated. From 1996 – 2001, the use of ADHD medications increased from 23 per 10,000 children to 45 per 10,000 in Tennessee (CDC, 2010).
As healthcare providers it is our responsibility to educate and increase awareness about this epidemic. To facilitate this process we must educate our patients to recognize the breakdown in communication amongst all care providers that can result in their children being needlessly medicated. Teachers have a critical part in the diagnosis of ADHD amongst their students. Though diagnosis is beyond their scope of practice, the requirement that ADHD symptoms must be present in at least two settings makes teachers’ opinions influential in assessment (NIMH, 2009). Rather than a mental health professional being consulted, most children are referred to their pediatrician and 56% of children are prescribed medication immediately after diagnosis (Edge Foundation, 2009). NIMH guidelines explicitly instruct doctors to judge whether the child displays attention deficits and hyperactivity in comparison to his or her peers (NIMH, 2009). These evaluations are deeply dependent on the teachers’ opinion of the child. As a result, the assessment that the teacher gives individual students highly correlates with whether the child is eventually diagnosed with ADHD (Hendrick, 2009). An estimated one-third of parents (32%) report that teachers do not complete questionnaires sent to school about their children for diagnosis (American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality, 2002). A shocking 44% of pediatricians spend no time interviewing teachers about their patients. In the cases where an interview might take place, no one other than the teacher observes the child in a classroom 53% of the time (National Survey of Children's Health Data Resource, 2007).
The diagnosis of ADHD hinges on comparison of one child to that of his or her peers (NIMH, 2009). Keeping in mind the dramatic changes in growth in development that occur during a child’s preschool and kindergarten years, it should not come as a surprise that the youngest kindergartners are 60% more likely to be diagnosed with ADHD than the oldest children in the same grade (Elder, 2010). These subjective “symptoms” children are displaying, which can be associated with the emotional and intellectual immaturity amongst the youngest children in class, aid in the potential misdiagnosis and subsequent unnecessary treatment of ADHD (Elder, 2010). To further prove that diagnosis is radically subjective, it should be noted that children born in August are more than twice as likely to use stimulants as those born in September (8.3 versus 3.5 percent). As equally shocking, in the fifth and eighth grades, the youngest students are more than twice as likely to be prescribed stimulants (Elder, 2010). Of the children who are suspect to have and are treated for ADHD, only 70% have had a physical examination and only 52% were given hearing tests (National Survey, 2007).
Studies show that stimulants put children at risk for a cardiac incident. Clinically relevant doses raise average pulse rates by 8.1 beats per minute and increase systolic blood pressure by 6.2 mmHg (NIMH, 2009). Also, children taking ADHD stimulant medication on average grow 0.76 inches less and weigh 8.36 pounds less than those who are not taking ADHD medication (NIMH, 2009). These same studies also showed that the growth effects are not reversible. For many of these 900,000 children misdiagnosed with ADHD, transient deficiencies in maturity were attributed to the long-lasting use of stimulants intended to treat the ADHD symptoms (Elder, 2010).
If knowledge is power, then as caregivers it is our responsibility to empower our patients to think critically when making decisions about long-term healthcare options. The goals of this teaching project are to facilitate education about ADHD and treatment options. This project will put a desire in parents to want to read about ADHD—what it is, how it is diagnosed, and how it is treated. Parents will make informed decisions on whether it is appropriate to get their child tested and understand that an evaluation should be tailored to the individual child’s needs. Parents will understand that medicating the child does not need to be the first choice. Following this project, healthcare management of an ADHD child will decrease from being medication alone and will instead require medical, educational, behavioral, and psychological interventions and treatments. The child will be treated holistically and without over-emphasis on just one area. Parents will be provided with the knowledge to ensure that their child truly has ADHD and is not simply being perceived differently than his/her peers because of age and maturity. The brochure is a written form of information that will help parents to see the facts about misdiagnosis and alternative methods of treatment. It is important to inform the American public about the vast number of children misdiagnosed with ADHD so that they can better understand how to assess their children. If this education is implemented correctly, there could be a 20% decrease in incidences of ADHD.
The long-term objectives and outcomes expected from implementation of this project include decreasing the occurrence of ADHD diagnoses within the United States or a decrease in the rates of medicated children, especially in Tennessee, by at least 10% in the next 10 years. In order to increase awareness of the potential effects medications can have on a growing mind and body, mandatory longitudinal studies will be funded by the government at the expense of pharmaceutical companies to ensure objectivity. Parental involvement is pivotal in the education and maturation of children, and healthcare providers will provide educational brochures about alternative treatments along with the information already provided on stimulants. A re-evaluation of the incidents of ADHD amongst American youth is imperative to increasing awareness. Rather than just talking about it, parents and healthcare providers will start to question why medication is the first line in treatment. The NIMH will look at the relationship between age and diagnosis of ADHD and re-evaluate whether it is appropriate to compare all children to their peers to determine a diagnosis. The Department of Health and Human Services will survey households diagnosed with ADHD about their environmental, nutritional, and pharmacological habits and evaluate correlation data.
For the implementation of this project, a brochure was made stating facts and statistics about the reality of ADHD. It was easy for me to spend extensive time and energy researching this material to be able to accurately state the facts and statistics about the problem because I am so interested in it. The brochure offered symptoms of ADHD and alternative treatment methods for children diagnosed with ADHD. Due to the lack of community and financial resources, I was unable to implement the education process to the extent I would have preferred, but the brochure and education classes should be available for PTO meetings, school nursing offices, and pediatricians’ offices. This would potentially increase public awareness of the escalating number of children being medicated and misdiagnosed with ADHD. If I were to implement this project again, I would contact local schools in an effort to find specific statistics for children in my local community.
Children with ADHD are a high-risk population. They are at an increased risk for impaired social interaction, ineffective coping, loneliness, disturbed thought process, and disproportionate growth and development related to the use of stimulants. Because ADHD is a disorder that affects the entire family, it leads to an interrupted family process and results in an increased risk for compromised family coping and caregiver role strain. As a community, parents have a knowledge deficit related to ADHD and are at a point in readiness for enhanced knowledge on this subject.
Broad scope education is a major form of community intervention. Ensuring the public has the objective facts so that they are able to make informed decisions is a key component. If a population has the knowledge to arm themselves then they are more easily protected against healthcare deficits. The main intervention in this specific population pertains to educating the parent on the channels in which ADHD assessment should properly be handled, specific interventions that can be done to facilitate change in the child and family, and providing support group information that allows for community outreach. The assessment data clearly defines the scope of the problems of misdiagnosis and over-medication, and the goals above would be evaluated by polling and measurable decreases in the incidence of ADHD and increase in alternative treatments. Implementation of community interventions is considerably more expensive and time consuming. There is an increased risk of noncompliance and it is much harder to evaluate results. When providing care on a tertiary level, however, the nurse can ensure that there is proper understanding for the patient, and they are able to spend the time ensuring that the therapeutic regimen is successful and the resources are available. While it is hard to find resources for the ADHD community, the assessment data clearly proves that resources should be made more readily available.
The impact that ADHD and pharmaceuticals have on our society is important to evaluate in all situations. Accountability should be a priority for physicians, teachers, and pharmaceutical companies in reference to the implications of misdiagnosis and over-medication of children. Most importantly, though, parents should be encouraged to take a more proactive approach in dealing with challenging children. Environmental, nutritional, behavioral, and cognitive changes must be implemented along with pharmacological changes when treating children (or adults) who struggle with ADHD. As a healthcare provider, it is the nurse’s responsibility to advocate for their patient and ensure that the community is aware of and educated about health issues such as ADHD.
References:
American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality. (2002). Does my child have adhd?. Retrieved from http://www.nichq.org/toolkits_publications/complete_adhd/15Does%20my%20Child%20Have%20ADHD.pdf
American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality. (2002). Evaluating your child for adhd – a team approach. Retrieved from http://www.nichq.org/toolkits_publications/complete_adhd/16Evaluating%20Your%20Child%20for%20AD.pdf
American Academy of Pediatrics and National Initiative for Children’s Healthcare Quality. (2002). Medication management information. Retrieved from http://www.nichq.org/toolkits_publications/complete_adhd/13Medication%20Manage.pdf
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders: dsm-iv-tr. Washington: American Psychiatric Association.
Bobinchock, A, & Neves, L. (2004). Early ritalin exposure may cause long-term effects on the brain. Manuscript submitted for publication, Mc Lean Hospital, Harvard Medical School, Belmont, MA. Retrieved from http://www.mclean.harvard.edu/news/press/current.php?id=65
Centers for Disease Control and Prevention. (2010). Attention-deficit / hyperactivity disorder (adhd) – data and statistics. Retrieved from http://www.cdc.gov/ncbddd/adhd/data.html
Chudler, E. (2008). Brain development. Retrieved from http://faculty.washington.edu/chudler/dev.html
Edge Foundation. (2009). Is adhd over medicated?. Retrieved from http://www.edgefoundation.org/blog/2010/03/11/is-adhd-overmedicated/
Elder, T. (2010). The importance of relative standards in adhd diagnoses: evidence based on exact birth dates. Manuscript submitted for publication, Economics, Michigan State University, East Lansing, MI. Retrieved from http://news.msu.edu/media/documents/2010/08/d686acc3-5efd-407e-a3ae-334f81b4593d.pdf
Hendrick, B. (2009). Diagnosing adhd: teacher input overlooked?. Retrieved from http://www.medicinenet.com/script/main/art.asp?articlekey=106852
Henion, A. (2010, August 17). Nearly 1 million children potentially misdiagnosed with adhd. Retrieved from http://news.msu.edu/story/8160/
Helpguide.org. (2010). Are adhd drugs right for you or your child?. Retrieved from http://www.helpguide.org/mental/adhd_medications.htm
National Initiative for Children’s Healthcare Quality. (2010). Caring for children with adhd: a resource toolkit for clinicians. Retrieved from http://www.nichq.org/adhd_tools.html#adhd_parent
National Survey of Children's Health Data Resource. (2007). National survey of children’s health (nsch), 2007. Retrieved from http://www.nschdata.org/Content/Guide2007.aspx
The National Institute of Mental Health. (2009). Short-term intensive treatment not likely to improve long-term outcomes for children with adhd. Retrieved from http://www.nimh.nih.gov/science-news/2009/short-term-intensive-treatment-not-likely-to-improve-long-term-outcomes-for-children-with-adhd.shtml
The National Institute of Mental Health. (2009). The multimodal treatment of attention deficit hyperactivity disorder study (mta): questions and answers . Retrieved from http://www.nimh.nih.gov/trials/practical/mta/the-multimodal-treatment-of-attention-deficit-hyperactivity-disorder-study-mta-questions-and-answers.shtml
Valera, E, & Seidman, L. (2006). Neurobiology of attention-deficit/hyperactivity disorder in preschoolers. Infants & Young Children, 19(2), 94-108.
