The saying “a rose by any other name would smell as sweet” applies very well to attention-deficit/hyperactivity disorder (ADHD). ADHD appeared, although not by that name, as Fidgety Phil, in a book of German fairy tales in the late 1800s (Hoffman, 2007). Hoffman also stated that in 1798 Alexander Crichton, a physician, used the term mental restlessness to describe what later appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as ADHD. Hallowell and Ratey (1994), not referring to the book of German fairy tales, reported that “The Story of Fidgety Philip” was printed in the Lancet in 1904 and claimed that this “might be the first published account of ADD in the medical literature” (¶2).
After the influenza epidemic of 1917–1918 (with many cases of encephalitis), the term post-encephalitic behavior disorder appeared, and patients were subsequently treated with Benzedrine® (Hoffman, 2007). George Frederic Still, a British pediatrician, wrote “On the Child’s Temper” in 1934, hypothesizing that temperament might be congenital. Still’s thinking about the biological basis for behavior was an outgrowth of a study he conducted in which 20 children had satisfactory parenting but “were defiant, excessively emotional, passionate, lawless, spiteful, and had little inhibitory volition” (Hallowell & Ratey, 1994, ¶5).
Organic driveness was another term applied to the attention-deficit disorder (ADD) symptoms of distractibility, impulsivity, and restlessness (Hallowell & Ratey, 1994). Hallowell and Ratey (1994) summarized the work of Kahn and Cohen, who provided further arguments for the relationship between organic disease and ADD. After World War II, these children were referred to using yet another name, minimal brain dysfunction and treated with methylphenidate (Ritalin®) and pemoline (Cylert®). In 1980, the third edition of the DSM (American Psychiatric Association [APA], 1980) included ADD, with or without hyperactivity. By 1987, the APA renamed the disorder ADHD.
Because psychiatric nurses are often called on by families, neighbors, friends, and work associates to provide the most current and reliable information on a wide range of health concerns, this focus issue of the Journal of Psychosocial Nursing and Mental Health Services provides the latest answers to the questions and controversies that often surround ADHD.
Van Cleave and Leslie suggest that when ADHD is treated using a chronic care model, as asthma is, the benefits increase for both children and adolescents with the condition, as well as their parents. Importantly, a nurse plays a prominent role in the example the authors use to demonstrate how the chronic care model works. Another critical element in the example is the use of a synchronized and linked medical record system.
Although the model they suggest was originally designed for treating adults, it has subsequently been used with youth. Van Cleave and Leslie provide a chart in which they apply the six “pillars” of the chronic care model for child health to treating ADHD. The pillars include decision support, delivery system design, clinical information systems, family and self-management support, community resources and policies, and health care organizations.
In the second article, Lerner and Wigal examine the research literature to provide answers to questions about the long-term safety of stimulant medications. They point out that changes in the past 2 decades have dramatically altered the way ADHD medications are prescribed. The earlier pattern of prescribing short-acting drugs used for only part of the day and week have been replaced by prescribing longer acting drugs that last 12 or more hours, for 7 days per week. These longer acting stimulants have been “associated with increased duration of daily action, increased total daily stimulant dosage, and even increased adherence to prescribed ADHD medication regimens” (p. 40).
The authors include a reader-friendly chart that summarizes the common effects (e.g., cardiovascular, growth, tics) of long-term stimulant therapy on safety outcomes. They also include the practice approval (or disapproval) of using stimulant medications in children younger than age 6 and address the evidence regarding carcinogenic and reproductive effects. Readers are cautioned that well-designed studies, with randomized controls of youth in treatment versus placebo groups, occurring over long periods of time, are lacking. The authors remind prescribers of the black-box warning on all amphetamines that states, “Administration of amphetamines for prolonged periods of time may lead to drug dependence and must be avoided” (p. 39).
Evans, Schultz, and Sadler move beyond the common treatment of ADHD with stimulant medications and focus on the safety and efficacy of psychosocial interventions. They emphasize basic behavior management principles, evidence-based interventions, and safety issues. They include reminders about the concept of contingencies and how both rewards and punishments fall into positive and negative categories. Sections on daily behavior report cards and homework management plans reinforce the importance of a strong and positive relationship between parents and teachers for effective treatment of ADHD.
As they discuss parent training, Evans et al. provide cautions and reminders that parents need to be carefully assessed before implementing the programs. For example, parents may have psychopathology or may themselves meet diagnostic criteria for ADHD and/or depression. The success of programs for youth with ADHD cannot go forward without adjunctive treatment for parents, when needed. In the safety section, the authors describe the negative consequences of inconsistency and minimalist attempts to use techniques.
Dr. Teena McGuinness, our Youth in Mind section editor, tries to answer many questions parents ask as they decide on treatment for their children with ADHD. She offers an interesting perspective, from a study in Finland, where medications are rarely used. The study showed that “by late adolescence, those who had received medications for attentional deficits were faring about as well socially and academically as were those who did not” (p. 24). Data about both parent and teacher training in coping with the challenges of youth with ADHD suggest strategies that can be implemented fairly easily. Specific suggestions for nurses are provided.
Dr. Robert Howland, our Psychopharmacology section editor, contributes news about lisdexamfetamine (LDX, Vyvanse®), a prodrug stimulant to treat ADHD. The U.S. Food and Drug Administration approved LDX for ADHD in children ages 6 to 12 in February 2007 and for ADHD in adults age 18 and older in April 2008.
As in all of his articles, Dr. Howland provides clear, straightforward material in an explicatory style that makes the learning easy. In this article, he begins with an explanation of prodrugs and then describes both short-term and long-term studies of LDX, as well as its abuse liability. Dr. Howland ends with a suggestion that “nurses should understand the unique pharmacology of LDX that distinguishes it from other amphetamine products” (p. 22).
Shirley A. Smoyak, RN, PhD,
FAAN
Editor