Child with Attention Deficit Hyperactive Disorder - Essay Example

Child with Attention Deficit Hyperactive Disorder Introduction According to the Nursing and Midwifery Council of UK, nurses, midwives and other healthcare professionals are bound by the codes of conduct that aim at protecting patients’ rights and freedoms. A key constituent of the code of conduct speaks to the essence of confidentiality in the conduct of midwifery and nursing duties. As a school nurse, I am also bound by these codes of conduct. Part of my work description as a school nurse involves the provision of primary healthcare to the students and school fraternity. This is typically done through a medical home within the school compound where I conduct primary health care services. In addition, my duties also involve systematic screening and monitoring the immunization of students, which also provides a system for handling and managing medical situations within the school. In essence, my role as a school nurse is to provide a process for the recognition and resolution of the healthcare needs of students that may affect their academic performance. As earlier mentioned, the nursing and midwifery code of conduct requires utmost confidentiality with regard prognosis and treatment (Goodman and Scott 2005, p. 141). This means that nurses and midwives are required to respect patients’ rights to confidentiality, while at the same time ensuring that patients appreciate the need for sharing pertinent information with those providing their care. However, the code of conduct requires that the nurse or midwife discloses any information that could save the life of a patient in accordance with the UK Healthcare regulations. Essentially, the codes of conduct with regard to confidentiality imply that people have the explicit right to require that the information shared with a nurse or midwife is only used for the objective for which it was issued and it is not disclosed without prior permission. This typically encompasses situations where info is divulged directly to a nurse or midwife, as well as when information that nurses and midwives obtain from other persons. According to Schachar (1991, p. 82) attention deficit hyperactive disorder (ADHD) refers to a variety of paediatric behavioural disorders that include symptoms such as poor concentration, impulsivity and hyperactivity. Nearly 5% of UK children between the four and twelve years are diagnosed with ADHD. The prevalence of ADHD is thrice more in boys than girls. Treatment of ADHD consists of evaluation and treatment of a child’s craniosacral fascial system and the administration of methylphenidate. This paper will review the CAMHS assessment of a child with attention deficit hyperactive disorder (ADHD), examining the formulation and reflections of the nurse involved in assessment. Basic CAMHS Assessment CAMHS assessment is essentially a confidential service that must adhere to the confidentiality policy of the nursing and midwifery code of conduct. This means that all conversations and disclosures made by patients, especially during the initial CAMHS assessment should not be relayed to other persons other than family members and doctors. However, it is pertinent to note that it is sometimes critical that some information is shared with other CAMHS professionals to ensure a patient receives accurate and sufficient treatment for a disorder. Nonetheless, the patient must give informed consent for the information to be shared. A generic CAMHS assessment entails a series of information that is relevant not only to the identification of the disorder, but also its treatment. A standard CAMHS assessment entails important information with regard to the patient’s past medical history (Barkley 1998, p. 174). A CAMHS assessment typically contains the following elements: a) Developmental history b) Family history c) Attachment history d) Screening for ADHD symptoms e) Co morbidities f) Questionnaires g) Observation of the child (patient) The CAMHS assessment is typically conducted following a referral and involves a healthcare professional listening to the patient about the patient’s difficulties with regard to the aforementioned elements (Rutter and Taylor 2002, p. 79). The healthcare professional then decides on the appropriate line of action to adopt during the care plan, which may involve specialised consultation with other CAMHS professionals or prescription of medicine. At the end of the day, the essence of CAMHS assessment is to construct a fully detailed picture of all essential factors, both past and current, which have an undeniable effect on the child’s strengths and troubles. In addition, a CAMHS assessment entails the identification of the resources available to a patient to help with dealing with his/her problems, as well as the risks and resistances within the patient’s lives. The development of this comprehensive picture will result in the discovery of the difficulty and/or the recognition of a more documented mental disorder. Precision in the discovery and diagnosis is crucial in deciding which course of intervention is liable to give the best outcomes. A typical CAMHS assessment takes about four sessions, although this may vary depending on the situation at hand. For instance, a crisis intervention assessment can take a single session of an hour or two (Weeks, Laver, and Thompson 1999, p. 457). The assessment for non-crisis cases, on the other hand, involves numerous sessions, which include a session with the child alone, a sitting with the parent(s) alone and one involving the entire family. Gelder (2003, p. 11) asserts that viable assessment involves discussions and explorations of numerous topics such as the child’ present difficulties, development and family history, present relationships and circumstances of the family, as well as the parents’ own families. Within a CAMHS assessment, with the family’s consent, the CAMHS professional may seek additional information from other professionals such as teachers, paediatricians, GP, as well as other practitioners within the child services spectrum. Further specialised assessments like speech and language, occupational therapy assessments, psychometric testing and learning and cognitive assessments may be recommended. Under CAMHS assessment, proper diagnosis is done by investigating the child’s difficulties as identified, alongside additional information retrieved during assessment discussions. In the UK, the CAMHS Outcomes Research Consortium (CORC), a non-profit making organisation, is mandated with the institution of a standard model of routine analysis and evaluation of outcomes. In this scenario, the professional mandated with the provision of a basic assessment is done by the family therapist. The GP is the best provider of essential information for CAMHS as the professional is the initial point of contact between the child and the CAMHS health providers. GPs and paediatricians have specialised knowledge to deal with mental disorders, but when additional care is required, the GP and paediatrician may refer to the child to a community psychiatric nurse (CPN) (Barkley 1998, p. 97). Case Study An eight year old second grade child is brought to my station by his teacher. The teacher testifies that she is worried about her student’s behaviour, especially because the child does not listen to her. According to the teacher, the child’s mother had also complained that the child did not listen to her either. Child’s History The child has been under the care of his physician since birth. His mother did not encounter any complications during pregnancy and had a full birth with no birth complications. Furthermore, the child’s mother did not use any illicit drugs or drink alcohol while pregnant, but smoked cigarettes. The child’s development was rather normal as he attained developmental milestones at suitable ages and times. He was only treated for occasional accidents and other minor infections. However, the child required stitches at one time after leaping off furniture, severely grazing his chin on the table. In other visits to his physician, it was discovered that the child was extremely active, often attempting to disassemble a wall-mounted otoscope in the physician’s office. According to the child’s mother, the child has always been a handful, noting that he was expelled from his first preschool at the age of four years as he was disruptive and would not sit motionless during class circle time. Furthermore, the child often hit other students and his teachers whenever he did not get what he wanted. For this reason, his mother had to delay the child’s starting of kindergarten till he was 6 to allow him enough time to mature. Moreover, last year, his first grade teacher noted that the child was unable to follow instructions effectively and had a relatively shorter attention span and was more active than other students his age. According to the child’s mother, the patient is unable to focus on anything or activity for more than 10 minutes, except of course for his games in which he is often loud and destructive while playing. The family history has a prior history of depression, which was noted in the child’s maternal grandmother. In addition, according to the mother, the patient’s father was a wild boy when he was younger, but never received any treatment for any mental disorder. The child is currently not on any prescription medication. Physical Examination Upon conducting a physical examination, I realised that the child is well developed and has numerous bruises on his shins, arms and face. The child is in the 55th percentile in terms of heaviness and height. However, the child was uncooperative during the otoscope examination. For the remainder of the physical examination, this included neurologic examination turned out unremarkable, with vital signs showing normal limits. With regard to the mental status examination, the child is a cheerful boy who spent almost the entire examination duration climbing on and off the examination table and examining items across the room. Despite the mother’s attempts to have the child sit still on her lap and read a book, the child roamed throughout the room sifting through books and items rather briefly. The child’s speech is relatively loud and fast. His mood can be described as good, although when his mother tried to force him to sit still he became agitated. Furthermore, the child’s affect seems happy though when scolded by his mother for playing with the sink the child becomes labile. A number of mental disorders are linked to behavioural problems in young children and ADHD is the most common. While there are disorders have symptoms that mimic those of ADHD, it is paramount to note that the other disorders have other symptoms that are distinctive to their specific disorder (Baker 2002 p. 12). For instance, children who are defiant and refuse to follow adult instructions may be mistakenly diagnosed with ADHD while in fact they are suffering from oppositional defiant disorder (ODD). Furthermore, severe aggression, as well as inability to abide by societal rules may also present in other disorder just like in ADHD. Children suffering from bipolar disorder also present with inability to pay attention and hyperactivity-impulsivity. In addition, children who are either miserable or apprehensive and unable to pay attention may be mistaken as suffering from inattentive ADHD. It is pertinent to note that poor attention and unusual behaviour may be brought by problems such as seizures, impaired hearing and vision, poor nutrition and inadequate sleep among other causes. ADHD symptoms can also be present in children suffering from learning disorders, mental retardation and borderline intellectual functioning (Taylor, Sergeant, et al, 2004, p. 54). It is vital to realize that all these diverse problems can be rather difficult to identify in young children and it is critical to take into consideration that children with behavioural problems may merely have difficult temperament or activity levels that are typically above normal. In order to ascertain that a child has ADHD and not other behavioural problems, the CAMHS practitioner must examine the symptoms critically. In order to confirm the diagnosis, a number of systematic measures have to be employed. The diagnosis of ADHD is done on the basis of the formulation of a comprehensive history of symptoms that cause impairment in a number of settings. The DSM-IV-TR criterion for ADHD entails at least six symptoms of lack of concentration or at least symptoms of hyperactivity-impulsivity. Here, in order for symptoms to be valid for entry, they must have persisted for a minimum of six months and must be contrary to the child’ development level and maladaptive. For instance, a first or second grader incapable of remaining immobile and listen to a lecture for at least 30 minutes can be deemed developmentally inappropriate. Assessment Assessment of ADHD in a school child requires that a careful interview with the child’s family is conducted to record the prevalence of various symptoms of inattention, as well as hyperactivity-impulsivity. In order to do this, a direct interview was conducted with the mother where she was required to complete a rating scale meant specifically for ADHD. The child’s teachers also play an integral role in uncovering the child’s impairment level in the class environment. Therefore, it is pertinent that the teacher completes an ADHD-specific behaviour checklist and obtains narrative information from the teacher with regard to the child’s learning pattern, classroom behaviour and level of functional impairment (Lidz 2003, p. 57). This is primarily done because classroom interventions are essential in children suffering from ADHD (Barkley 1998, p. 219). Assessment involves questioning the patient’s mother with regard to the child’s behaviour. The following is the series of questions and responses obtained from the child’s mother: Doctor: What activities are especially difficult for your son? Mother: He is unable to stick with things he considers hard. He plays with is blocks for five minutes then move to his cars for a short while. However, whenever I play with him, he usually completes a brick project before demolishing it. Doctor: How do you manage his behaviour at home? Mother: I watch him steadily. Whenever I do not watch him, something or someone always gets hurt or damaged. This means I always have to take extra caution around busy street or parking lots. He has on several occasions darted into traffic. Doctor: Have these behaviours made family life hard? Mother: Totally. We cannot go to sit-down cafés because he cannot wait for his food. He usually goes under the table to play with our feet or talks too loud. Doctor: Does he often refuse to do what you ask him to do? Mother: Yes. Most times when I ask him to clean his room, he just goes to play with his toys. When I remind him to clean the room he starts to but soon gets distracted. Doctor: Is the child aggressive at home? Mother: Not really. However, he sometimes hits his sister when he wants a toy, but just as often she aggravates him and he hits back. Further Assessment As the physician, I require the child’s mother and teacher to fill out symptoms checklists. However, before talking to the teacher, I receive permission from the child’s mother, which she gives through written consent. Furthermore, I meet with the child who acknowledges to having problems both at school and home, but apparently does not know his role in the problems. In order to further assess the child, I run the Child Behavioural Checklist (CBCL) which generates a number of symptom subscales from different informants such as parents, teachers and other carers. However, by itself, the CBCL is not a viable measure of ADHD symptoms and would not be feasible in repeated administration with the aim of monitoring treatment. Follow-up Continued talks with the teacher show that the child is still more disruptive during class than his peers and is unable to sit still for more than 10 minutes. According to the teacher, the child’s hyperactivity makes it impossible for him to acquire sufficient reading skills. However, the nationwide tests show that the child’s performance is at par with that of any other second grader. When the patient’s mother returned in two weeks’ time with the filled out rating scales, there were no distinct indicators of any symptoms of defiance or moodiness. The teacher’s scale, on the other hand, shows an astounding 7 out of 9 inattentive symptoms and 8 out of 9 hyperactivity symptoms. Furthermore, the scale showed substantial academic impairment, especially with regard to maintaining focus in class. The parent’s rating scale also showed proof of multiple inattentiveness and hyperactivity symptoms and impairment of social functioning. The descriptions given by the parent and teacher are consistent with the symptoms of childhood ADHD. According to ICD-10, the child clearly suffers from ADHD and requires relevant treatment protocols (WHO, 1992). Formulation According to Crowe, Carlyle and Farmar (2008, p. 803), formulation refers to the process of attempting to add up the information received during an assessment and using that information to develop a productive system of helping the patient counter the effects of the disease or disorder. For most people, comprehending and appreciating the difficulties they or their loved ones experience is the key to ensuring they institute positive changes in their lives. In cases of psychological difficulties, formulation simply means the replacement of diagnosis as the principal framework for making sense of the experiences of patients. The aim of formulation is to equip people with necessary tools to cope with change and development. This is contrary to diagnosis, which leaves the patient and family members feeling dependent on the healthcare professionals to resolve their problems. According to the case at hand, the child is undeniably suffering from ADHD. Managing and treating the disease involves key steps that include educating the family, as well as formulating a viable treatment regimen. Education for families where a member suffers from the disease involves broad explanations of the disease’s symptoms, its impact on learning, social skills, behaviour and family function. It is pertinent that the family realises that ADHD lowers self esteem in children affected by it, especially as a result of poor academic performance and regular negative interactions with their peers, as well as adults, caused by the child’s impulsive and hyperactive behaviours. The etiology of the disease, which involves other issues such hereditability, should also be discussed (Carr 2006, p. 89). Furthermore, there it is crucial to review the various available treatment options that include administration of medication, as well as principles of behaviour management. It is pertinent to furnish families with information with regard to what the prognosis and expected course of the disorder. In order to conduct the formulation exercise effectively, it is paramount to give families information on how to advocate for the affected child within the school environment, work with teachers and the affected child’s legal rights in the school and society. Furthermore, because families may have misconceptions regarding ADHD, so it is essential to dispel these misconceptions. Some of the common misconceptions about ADHD is that it stops puberty and that its medication stop working during puberty, stimulant medication cause drug abuse and they work paradoxically. In addition, most parents erroneously believe that sugar causes hyperactivity in children (Cooper, Hooper and Thompson 2009, p. 114). Studies conducted on the effects of sugar on children’s activity show no evidence of effects in hyperactivity. After the patient and his family have a better understanding of ADHD, it is of paramount importance to identify areas that require improvement; these are especially areas of dysfunction. A treatment and management plan is established to improve different areas of the disorder. After the discovery of problem areas, a comprehensive treatment plan is then developed in coordination with the family. Medication involves the administration of stimulants to treat disruptive behaviour. Stimulants are typically the best first-line treatment agents for ADHS. Studies show that stimulants are quite effective in countering the symptoms of ADHD. Some of the most effective stimulants are methyphenidate-based and dextroamphetamine-based. Antidepressants can also be administered, especially when stimulants are not tolerated by the patient. Antidepressants are effective in relieving the symptoms of ADHD as a second-line agent. Furthermore, antidepressants can also be used in coordination with stimulants to improve response. Behaviour treatment is also effective as it resolves problematic responses and altering the child’s social and physical behaviours. There are numerous behavioural treatment interventions that can be implemented by training parents and teachers on techniques to enhance children’s behaviour (Crowe, Carlyle and Farmar 2008, p. 805). Parent and teacher training on behavioural therapy is a formidable regiment for improving behaviour in children with ADHD. Here, four distinct techniques are used to improve behaviour. These are positive reinforcement where privileges and rewards are provided to a child for improving performance. Time-out involves the removal of right to use a positive reinforcement depending on a child’s exhibition of unwanted behaviour. Response cost engrosses the withdrawal of rewards pursuant to performance of behavioural problems. A token economy, on the other hand, involves the combination of response costs and positive reinforcement. In behavioural management, a child learns to earn rewards by performing desirable behaviours and losses the rewards if he displays any undesirable behaviour. Reflections The patient was prescribed a long-acting stimulant medication at a relatively low dose, which was administered once a day. Over several visits that occurred on a monthly basis, with follow-up parent and teacher rating scales that were completed on alternating months, the child’s dose was increased. The child received a dose that was below the maximum dose after four months. After the patient reached the optimal dose, both teachers and parents described the child’s condition as having improved tremendously. This was especially with regard to the child’s hyperactivity, which went down dramatically, as well as the patient’s attention span that improved pursuant to the treatment module. However, after a few months of follow-ups it was noted that the child gained weight and height as expected on his growth curve. Earlier during treatment, the patient’s mother had reported that the child suffered appetite suppression, but it eased up in several months without any need for intervention. Because of the training received, the family was able to encourage the school to adopt educational interventions and place the child on an individualised education plan. After a few months of treatment and occasional increases in the dosage, the family and teachers realised that the patient’s aggression towards friends and his refusal to comply with parent’s instructions drastically went down. Conclusion ADHD is a widespread childhood psychiatric disorder, which usually perseveres to adulthood. ADHD does not only affect a child’s academic performance but their functioning within their families and the greater society. Treatment of ADHD can be conducted in the course of primary care in a clinician’s office, usually with the help of teachers and parents. When effectively diagnosed, administration of medication and behavioural treatment offer substantial improvements to a child’s ability to function normally (Carr 1999, p. 48). Because of the capacity of ADHD to adversely affect the academic performance of children, it is pertinent that teachers and clinicians and teachers collaborate in order to enhance a child’s academic performance. It is paramount that children with ADHD acquire individualised education suited to their capabilities and difficulties. These plans discover areas of functional impairment linked to ADHD and establish relevant interventions that offer accommodation and remediation of the problems. Parent counselling is also important as it allows for the establishment of reinforcement principles to enhance the performance of children both academically and socially (Barkley 1998, p. 246). Accordingly, training programs on social skills are essential as they teach on the different contingencies used in behavioural management such as reward systems, time-out, response cost, which all promote desirable behaviour. Considering the wide varieties of services and agencies involved in the administration and distribution of care and support to children with ADHD and their families, it is paramount that efforts are synchronised to offer the best service to both the patient and family (Carr 2002, p. 14). References Baker, P, 2002, Basic Child Psychiatry. New York: Oxford Publishers.  Barkley, RA, 1998, Attention-deficit hyperactivity disorder: A handbood for diagnosis and treatment (2nd ed.). New York: Guilford Press. Carr, A, 1999, Handbook of Clinical Child Psychology. A Contentual Approach. London: McGraw Hill. Carr,A, 2006, The Handbook of Child and Adolescence Clinical Psychology. A Contextual approach . 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