Counseling Points - Family/Pediatric Nurse 11/08 - (Page 6)

These treatments can rapidly become cost-prohibitive for families and school districts required to provide numerous services. A child’s health insurance coverage frequently has limited behavioral/mental health benefits; thus, the costs of mental health counseling and behavioral training become the responsibility of the child’s school system and parents. School districts, although responsible for providing the majority of academic and behavioral interventions, have few, if any, options for seeking reimbursement for these services and must support them out of the general school budget. Many school districts are frankly unsympathetic to families of children with ADHD, and parents can find themselves in an adversarial position while advocating for their child.15 Because of the allencompassing nature of ADHD and the numerous issues faced by families, many parents of children with ADHD experience significant stress, as well as depression and marital discord.15,16 The societal burden is increased when children are not diagnosed in a timely manner and/or receive ineffective treatment. Such children are more likely to experience academic failure, difficulty in maintaining peer relationships, substance abuse, and mental health problems, all of which augur poorly for successful long-term interpersonal relationships and occupational success in adulthood.7,10,17,18 transmitter dysregulation in causing ADHD is supported by the fact that effective ADHD medications work on the dopaminergic and noradrenergic systems. Other research is attempting to identify structural anomalies in the brain, with an emphasis on the neurocircuitry of the prefrontal cortex, an area that is rich in dopamine receptors. Recent studies have demonstrated anatomic differences in individuals with ADHD compared with individuals who do not have ADHD. For instance, the right prefrontal cortex, caudate nucleus, and globus pallidus often are somewhat smaller and demonstrate less blood flow and decreased electrical activity.7,14 As these are key areas of the brain that help children process stimuli, control emotions, develop social awareness, and sustain attention while inhibiting untoward behaviors, these findings support the idea that neuroanatomic differences play a role in ADHD. Risk Factors Numerous risk factors for ADHD have been identified. Symptoms of ADHD can be seen in association with neurological impairment resulting from infection (e.g., meningitis, encephalitis), injury (e.g., closed head trauma, lead intoxication), hypoxia, or maternal substance abuse during pregnancy.14,15 ADHD is also more common in children who were very low birth weight infants. 7 Although ADHD can occur with other disabling conditions (e.g., sensory impairment, intellectual disability, and serious psychosocial and emotional disturbances) or in the presence of other extrinsic influences (e.g., dysfunctional parenting or a poor socioeconomic background), it is not a direct result of those conditions or influences.They may, however, exacerbate the symptomatology, and higher rates of ADHD have been noted in such populations.14,15 In addition, there is no proof that nutritional intake of free sugars or artificial additives causes ADHD.21,22 Pathophysiology ADHD is a highly heterogeneous, nonprogressive, neurological condition. The exact pathophysiological mechanisms are not confirmed, although genetic, neurological, and environmental influences all play a role. ADHD is considered to be highly inheritable, with estimates that range from 60%-90% across generations.7,14 Twin studies confirm a genetic link between monozygotic twins.7 Because of these strong familial patterns, ADHD is thought to be a polygenic disorder that interferes with the encoding of the function of neurotransmitters and their receptors.8,15,19 Current investigations center around identifying affected genes and the resultant mechanisms responsible for the dysregulation of neurotransmitters—primarily the catecholamines dopamine and norepinephrine, their receptors, and their transporters.20 These neurotransmitters influence attention, arousal, impulsivity, and mood. Defects in the neurotransmission process result in insufficient amounts of catecholamines being available to modulate the behaviors they influence.7,20 The role of neuroCOUNSELING POINTS™ 6 ADHD Signs and Symptoms Signs and symptoms of ADHD are determined, in part, by the age of the child and the form of ADHD that the child has. For ADHD-H/I and ADHD-I, at least six of the nine characteristics in each of the diagnostic categories specified in Table 1 must be present.5 For ADHDC, at least six symptoms from both diagnostic categories are required.5 The individual who does not have documented symptoms of ADHD before the age of 7 years but who meets the criteria at the time of diagnosis is usually classified as ADHD—Not Otherwise Specified.5 The

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Counseling Points - Family/Pediatric Nurse 11/08

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