to handle in the classroom can be diagnosed and
treated mistakenly for ADHD. Some of these overly
active children may suffer from psychosocial stres-
sors at home, inadequate parenting, or other psychi-
atricdisorders (Blackman, 1999). Distinguishing bipo-
lar disorder from ADHD can be difficult but is crucial
because treatment is quite different for each disorder
(Mohr, 2001).
Onset and Clinical Course
ADHD usually is identified and diagnosed when the
child begins preschool or school, although many
parents report problems from a much younger age.
As infants, children with ADHD are often fussy and
temperamental and have poor sleeping patterns.
Toddlers may be described as “always on the go” and
“into everything,” at times dismantling toys and
cribs. They dart back and forth, jump and climb on
furniture, run through the house, and cannot toler-
ate sedentary activities such as listening to stories.
At this point in a child’s development, it can be diffi-
cult for parents to distinguish normal, active behav-
ior from excessive, hyperactive behavior.
By the time the child starts school, symptoms of
ADHD begin to interfere significantly with behavior
and performance (Pary, Lewis, Matuschka & Lipp-
man, 2002). The child fidgets constantly, is in and out
of assigned seats, and makes excessive noise by tap-
ping or playing with pencils or other objects. Normal
environmental noises, such as someone coughing, dis-
tract the child. He or she cannot listen to directions
or complete tasks. The child interrupts and blurts out
answers before questions are completed. Academic
performance suffers because the child makes hurried,
careless mistakes in schoolwork, often loses or forgets
homework assignments, and fails to follow directions.
Socially, peers may ostracize or even ridicule
the child for his or her behavior. Forming positive
peer relationships is difficult because the child can-
not play cooperatively or take turns and constantly
interrupts others (APA, 2000). Studies have shown
that both teachers and peers perceive children with
ADHD as more aggressive, more bossy, and less
likable (McCracken, 2000a). This perception results
from the child’s impulsivity, inability to share or take
turns, interruptions, and failure to listen to and fol-
low directions. Thus peers and teachers may exclude
the child from activities and play, may refuse to so-
cialize with the child, or may respond to the child
in a harsh, punitive, or rejecting manner.
About two-thirds of children diagnosed with
ADHD continue to have problems in adolescence.
Typical impulsive behaviors include cutting class,
getting speeding tickets, failing to maintain inter-
personal relationships, and adopting risk-taking486 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERSbehaviors such as using drugs or alcohol, engaging in
sexual promiscuity, fighting, and violating curfew.
Many adolescents with ADHD have discipline prob-
lems serious enough to warrant suspension or ex-
pulsion from high school (McCracken, 2000a). The
secondary complications of ADHD, such as low self-
esteem and peer rejection, continue to pose serious
problems.
Previously it was believed that children outgrew
ADHD, but it is now known that ADHD can persist
into adulthood (Wender, 2000). Estimates are that
30% to 50% of children with ADHD have symptoms
that continue into adulthood (Searight, 2000). In one
study, adults who had been treated for hyperactivity
25 years earlier were three to four times more likely
than their brothers to experience nervousness, rest-
lessness, depression, lack of friends, and low frustra-
tion tolerance (Wender, 2000). Adults in whom ADHD
was diagnosed in childhood also have higher rates of
impulsivity, alcohol and drug use, legal troubles, and
personality disorders.Etiology
Although much research is taking place, the defini-
tive causes of ADHD remain unknown. A combination
of factors, such as environmental toxins, prenatal in-
fluences, heredity, and damage to brain structure and
functions, is likely responsible (McCracken, 2000a).Attention deficit