Counseling Points - Psychiatric Nurse 11/08 - (Page 11)

• “What I’m hearing you say is Am I getting that right?” • “I want to be sure I’m saying this clearly. Can you tell me what you understood me to say?” • “This is the dosage schedule. Can we go over that again with you stating it this time?” • “Here is a booklet for the family to read—or would a film or website be more useful to your family?” • “Here is a checklist of helpful hints.” • “Here is a graph or chart.” Finally, when ADHD is identified as a probable diagnosis, although adults and their families may first feel disbelief, disappointment, or grief, in the long run, the diagnosis can come as a huge relief. Adults with ADHD and Psychiatric Co-morbidity Few clinical trials have examined patterns of co-morbidity in adults with ADHD. Among those that have, high rates of co-morbid mood, anxiety, and conduct disorders have been noted in adults with ADHD that are similar to those seen in child and adolescent studies. 12,13,34 For instance, the prevalence of comorbid depression ranges from 26% to 45%, just as in children.23 Overall, lifetime prevalence rates of psychiatric co-morbidities have been estimated to be as high as 89% in adults with ADHD.12,35 The DSM IV-TR criteria are still used officially to diagnose ADHD in adults. 5 However, clinicians are increasingly dissatisfied with it, as it was designed for use with children, and some adult features manifest differently. ODD and CD of childhood can later appear as the difficult adult behavior of people with various personality disorders. Early childhood behavioral evidence (before age 7) may be unavailable. Hyperactivity may have turned into “relaxation avoidance” or been channeled into working too many jobs for too many hours, compromising family relationships. 36 Adults may appear under- or hyperfocused, or both, with decreased facility in “switching” focus. ADHD appears co-morbidly with and must be differentiated from anxiety disorders, depression, bipolar disorder, OCD, neurological insult, substance abuse, hormonal dysfunctions, and specific learning disorders. Psychopharmacological treatment of individuals with ADHD and co-morbid psychiatric disorders is quite challenging. Co-morbid psychiatric disorders associated with ADHD may lead to poor treatment response and subsequent functional impairment. When a co-morbid psychiatric disorder accompanies ADHD, it is critical to first treat the more severe disorder (i.e., psychosis, depression, anxiety, and then ADHD).8 If ADHD is treated first, it may exacerbate symptoms such as psychosis, mania, and anxiety. The initial medication utilized in patients with ADHD should be an agent that is approved by the Food and Drug Administration. It is important to start low and titrate slowly with medications, as well as allow an adequate trial of a medication before determining that it is or is not effective. If a patient does not respond to a number of medications, the clinician should re-examine the diagnosis and consider use of other medications or psychotherapy. Combined pharmacotherapy is usually required with co-morbid psychiatric disorders. 8 Care must be taken to avoid the potential for drug-drug interactions and to monitor for treatment-emergent side effects. It is also important to periodically reassess the individual’s need for treatment and determine if symptoms have remitted. Treatment of ADHD symptoms should continue as long as symptoms remain present and cause significant functional impairment.8 Conclusion ADHD is now recognized as a condition that can persist into adulthood and, if unrecognized, can take a heavy toll in social, educational, and vocational functioning throughout life. No treatment has been found to cure ADHD, but there are a number of psychotherapeutic, environmental structuring, coaching, and medication interventions that can manage symptoms and improve an individual’s quality of life and ability to function in school, work, and social situations. Some argue that ADHD is an exaggerated normal human variation. All of us, sometimes, have trouble with focusing, moodiness and impulsivity. These challenges may be more debilitating for individuals with ADHD. Some can meet these challenges by themselves. Many more require psychosocial and/or pharmacological assistance. ADHDers can develop strateg ies to “work around” their limitations and pursue very successful lives while enjoying their “gifts” for spontaneity, creativity, and exuberance. Join Pediatric Healthcare Professionals & Work Together to Achieve Common Goals The National Association of Pediatric Nurse Practitioners (NAPNAP) is the professional home for pediatric nurse practitioners (PNPs) and other advanced practice nurses who care for children. NAPNAP is the only national organization dedicated to improving the quality of health care for infants, children, and adolescents and to advancing the PNP’s role in providing that care. Visit www.napnap.org for more information about membership and to apply online. 11 NOVEMBER 2008 http://www.napnap.org

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