niques can help children to express themselves, for
example, by drawing pictures of themselves, their
family, and peers. These techniques are especially
useful when children are unable or unwilling to ex-
press themselves verbally.
APPLICATION OF THE NURSING
PROCESS: ADHD
Assessment
During assessment, the nurse gathers information
from the child’s parents, day care providers (if any),
and teachers as well as through direct observation.
Assessing the child in a group of peers is likely to
yield useful information because the child’s behavior
may be subdued or different in a focused one-to-one
interaction with the nurse. It is often helpful to use a
checklist when talking with parents to help focus
their input on the target symptoms or behaviors
their child exhibits.
HISTORY
Parents may report that the child was fussy and had
problems as an infant. Or they may not have noticed
the hyperactive behavior until the child was a tod-
dler or entered day care or school. The child probably
has difficulties in all major life areas, such as school
or play, and displays overactive or even dangerous
behavior at home. Often parents say the child is “out
of control,” and they feel unable to deal with the be-
havior. Parents may report many largely unsuccess-
ful attempts to discipline the child or to change the
behavior.
GENERAL APPEARANCE AND
MOTOR BEHAVIOR
The child cannot sit still in a chair and squirms and
wiggles while trying to do so. He or she may dart
around the room with little or no apparent purpose.
Speech is unimpaired, but the child cannot carry on
a conversation: he or she interrupts, blurts out an-
swers before the question is finished, and fails to pay
attention to what has been said. Conversation topics
may jump abruptly. The child may appear immature
or lag behind in developmental milestones.
MOOD AND AFFECT
Mood may be labile, even to the point of verbal out-
bursts or temper tantrums. Anxiety, frustration, and
agitation are common. The child appears to be driven
to keep moving or talking and appears to have little
control over movement or speech. Attempts to focus
the child’s attention or redirect the child to a topic
may evoke resistance and anger.THOUGHT PROCESS AND CONTENT
There are generally no impairments in this area,
although assessment can be difficult depending on the
child’s activity level and age or developmental stage.SENSORIUM AND
INTELLECTUAL PROCESSES
The child is alert and oriented with no sensory or
perceptual alterations such as hallucinations. Ability
to pay attention or to concentrate is markedly im-
paired. The child’s attention span may be as little as
2 or 3 seconds with severe ADHD or 2 or 3 minutes
in milder forms of the disorder. Assessing the child’s
memory may be difficult; he or she frequently answers,
“I don’t know” because he or she cannot pay attention
to the question or stop the mind from racing. The
child with ADHD is very distractible and rarely able
to complete tasks.JUDGMENT AND INSIGHT
Children with ADHD usually exhibit poor judgment
and often do not think before acting. They may fail to
perceive harm or danger and engage in impulsive acts
such as running into the street or jumping off high
objects. Although assessing judgment and insight in
young children is difficult, children with ADHD dis-
play more lack of judgment when compared with those
of the same age. Most young children with ADHD are
totally unaware that their behavior is different from
that of others and cannot perceive how it harms others.
Older children might report, “No one at school likes
me,” but they cannot relate the lack of friends to their
own behavior.SELF-CONCEPT
Again, this may be difficult to assess in a very young
child, but generally the self-esteem of children with
ADHD is low. Because they are not successful at
school, may not develop many friends, and have
trouble getting along at home, they generally feel out
of place and bad about themselves. The negative re-
actions their behavior evokes from others often cause
them to see themselves as bad or stupid.ROLES AND RELATIONSHIPS
The child is usually unsuccessful academically and
socially at school. He or she frequently is disruptive20 CHILD ANDADOLESCENTDISORDERS 489