Attention deficit hyperactivity disorder (ADHD) is currently one of the most prevalent neurodevelopmental psychiatric diagnoses for children and young people in the UK. An NHS series of surveys completed by Forbes et al (2018) found a ‘hyperactivity disorder’ diagnosis rate of 1.6% for children aged between 5 and 19 years. This is much lower than the estimated worldwide diagnostic rate of 5–7% in children and adolescents and did not capture the 47.4% persistence rate into adulthood, or the 2.8% adult diagnostic rate (Polanczyk et al, 2014).
With such a relatively common disorder, it is likely that all nurses will at some point in their careers care for a patient with a diagnosis of ADHD, regardless of clinical environment. Furthermore, individuals with ADHD are more likely to be overweight and have less healthy diets than other adults, leading to increased contact with health services because they are likely to need care for other conditions (Barkley, 2010).
Diagnosis
ADHD has had a long history of reclassification and debate. Until very recently the diagnosis of ADHD was not included within the international classification of diseases (ICD-10) (World Health Organization (WHO), 1992).
The ICD utilised a diagnostic label of hyperkinetic disorder which, although synonymous with the diagnosis ADHD, had minor differences regarding age of onset (symptoms present before 6 years of age) and significant differences regarding classification. Within the ICD-10, hyperkinetic disorder was classified as a ‘behavioural and emotional disorder with onset in childhood and adolescence’ (WHO, 1992). This conflicted with the US Diagnostic and Statistical Manual of Mental Disorders' (DSM) long history of framing ADHD as a neurodevelopmental disorder (American Psychiatric Association (APA), 2013). This discrepancy led to ADHD being incorrectly framed as a disorder of behaviour in previous decades (Doernberg and Hollander, 2016).
As understanding of ADHD pathology has improved, so too has its classification. With the most recent iteration of the ICD series (ICD-11) (WHO, 2019), ADHD has been reclassified as a neurodevelopmental disorder, allowing medical practitioners and the general public to conceptualise the disorder as one of neurology, and not behaviour.
Once considered to be a disorder of childhood, ADHD is now recognised as a potentially lifelong condition. The National Institute for Health and Care Excellence (NICE) (2018) guidelines state that the disorder should be considered ‘in all age groups’. This is an important addition because up to two thirds of young people with ADHD remain impaired by symptoms into adulthood (Hall et al, 2013).
For a diagnosis of ADHD to be made, an individual should present with difficulties within three main areas (APA, 2013):
Although it may be correct to state that all members of the public may experience increased levels of these three core symptoms at some point in their lives, it is important to note that the symptoms must be of significant ‘persistence’ and severity that they interfere with the person's overall functioning or development (APA, 2013). Individuals with a diagnosis of ADHD must have evidence that their symptoms interfere with their social, academic or occupational functioning in multiple settings.
Manifestation of symptoms
The three core groups of symptoms for ADHD—hyperactivity, impulsivity and inattention—are outlined in Box 1. It is important to understand these symptoms and how they can manifest, and it is vital that nurses are aware of the nuances of these difficulties, which can at times easily be overlooked. Despite the fact that there has been limited empirical research exploring the impact of ADHD symptoms within a general nursing setting, improving general nursing knowledge and understanding of how ADHD may present in individuals can ensure that nurses deliver more effective care.
Hyperactivity
The symptoms of hyperactivity associated with ADHD can be both overt and subtle within the clinical environment. Greater awareness by nurses of the presentation and impact of these symptoms on the individual will reduce the potential for misdiagnosis, as well as help improve the therapeutic relationship within the assessment process. The symptoms of an individual with a diagnosis of ADHD are outlined in Box 1.
Supporting hyperactivity
Nurses should be mindful of the distress and embarrassment that a patient exhibiting symptoms of hyperactivity may be experiencing. A non-judgemental, understanding and empathic approach may help service users feel more comfortable. Individuals with a diagnosis of ADHD may benefit from having opportunities to stand or move around during the assessment process, because sitting for long periods of time may cause frustration or agitation.
Impulsivity
The effects of the symptoms of impulsivity are often exhibited through what can be called lifestyle ‘choices’, such as illicit drug use, risk-taking behaviours and making decisions without taking full consideration of the consequences.
It is well documented that individuals diagnosed with ADHD have an increased risk of illicit substance use (Lee et al, 2011), substance abuse disorder and other negative lifetime health outcomes (Nicholson, 2018). In addition, symptoms of impulsivity associated with ADHD may also manifest on a smaller scale. Possible symptoms of impulsivity are presented in Box 1:
Supporting impulsivity
Nurses caring for an individual displaying impulsive symptoms of ADHD may find that completing a clinical assessment is challenging due to disruptions with the flow and structure of the process. Nurses should be aware of their own emotions and frustrations when working with impulsive individuals, and should endeavour to maintain a non-judgemental attitude, if interrupted.
Some of the difficulties associated with service user impulsivity may be reduced by giving clear and accurate information about expected waiting times for appointments, or by allowing additional time for the individual to express their concerns.
Inattention
Symptoms of inattention can be misinterpreted as evidence of patient boredom or lack of engagement with services. It is therefore vital for clinicians to differentiate between patients exhibiting inattentive symptoms and those displaying a lack of engagement. This however can be challenging. Some of the ways in which an individual with a diagnosis of ADHD may typically display symptoms of inattention are outlined in Box 1.
Supporting inattention
Nurses caring for individuals who have difficulties associated with inattentive symptoms of ADHD may find it beneficial to break larger tasks down into a series of smaller activities. They should also ensure that they deliver this information in a concise and uncomplicated manner, free of jargon.
Providing information in different formats could also benefit service users with ADHD: for example, details of treatment regimens should be provided both verbally and in writing to support adherence.
Where possible, nurses may find it helpful to send additional reminders to service users with ADHD who frequently lose items or forget their appointment cards. These can take the form of additional automated text reminders or individual reminders by staff, when possible. It may also be helpful to advise patients who struggle with inattentive symptoms to use daily prompts when starting new treatments, ie taking medication with a morning coffee or completing exercises while a meal is cooking.
Sensory needs
In addition to having symptoms in the three core groups associated with the disorder, service users with ADHD have an increased likelihood of atypical sensory sensitivities (Bijlenga et al, 2017). An individual's sensory experience can be categorised as being within the normal range, hypersensitive (having increased sensitivity) or hyposensitive (having decreased sensitivity). Children and adults diagnosed with ADHD have been found to exhibit increased hyper- and hyposensory sensitivity compared with control subjects (Bijlenga et al, 2017), alongside increased sensory responsiveness and greater problems modulating sensory input (Panagiotidi et al, 2017).
Hypo- and hypersensory sensitivities can occur in any of the eight documented senses: visual, auditory, olfactory, gustatory, tactile, vestibular, proprioceptive, and interoceptive systems. Difficulties associated with the three lesser known senses—vestibular (sense of balance), interoception (sensations related to internal sensations of the body such as hunger and elimination), and proprioception (the sense of muscles and joints: to ‘know’ where our limbs are in space and time)—can often be evidence of comorbid issues such as autism spectrum disorder and sensory processing difficulties.
The National Autistic Society (2017) provides effective and helpful advice on how to make a clinical environment more accessible for individuals with sensory needs:
Conclusion
Today, ADHD is recognised as a potentially lifelong disorder, with up to 60% of individuals diagnosed as children remaining symptomatic into adulthood.
If an adult presents with symptoms of ADHD within primary care, clinicians should consider referral for assessment by a mental health specialist (NICE, 2018). However, when working with individuals who have any difficulties associated with ADHD, knowledge of the potential challenges described above, alongside the strategies outlined, should help nurses support individuals with this complex and often misunderstood disorder.