Attention

Attention-deficit/hyperactivity disorder: A neurodevelopmental approach

Ludwikowski, Kathleen Journal of Child and Adolescent Psychiatric Nursing > Jan-Mar 1998 >

TOPIC. Attention-deficit/hyperactivity disorder is frequently overdiagnosed when a complete evaluation by a knowledgeable clinician is not undertaken. Because of the recent negative media campaign regarding psychostimulant medication, it becomes more imperative that a thorough and accurate evaluation be completed before starting children and adolescents on psychostimulant medications.

PURPOSE. To describe the neurodevelopmental perspective in the assessment and treatment of ADHD.

SOURCES. Published literature and clinical experience.

CONCLUSION. It is useful in practice to conceptualize the developmental path of children with ADHD not as disordered but as delayed, and to build on each child's strengths. The neurodevelopmental approach provides the child psychiatric nurse a child-focused framework for assessment and development of individualized interventions.

Key words: Attention-deficit/hyperactivity disorder, child psychiatry, neurodevelopmental approach

Attention-deficit/hyperactivity disorder (ADHD) is a common neurobiological disorder characterized by inattention, impulsiveness, and in some cases hyperactivity. Because the specific etiology of ADHD is unknown, the diagnostic criteria and clinical description of ADHD have changed as knowledge of the disorder has evolved. Current theories of etiology include both genetics and environment (Gillis, Gilger, Pennington, & DeFries, 1992; Hechtman, 1994); mediated by neurotransmitter dysfunction (Comings et al., 1991; Jensen & Garfinkel, 1988; Riccio, Hynd, Cohen, & Gonzalez, 1993) or abnormalities in brain metabolism (Ernst et al., 1994; Zametkin et al., 1990).

Regardless of the etiology children who present with ADHD display a unique clinical picture, making the diagnosis and treatment challenging in some cases. A neurodevelopmental approach provides a framework for the clinician to assess and treat the specific deficits in each child. The purpose of this paper is to describe our neurodevelopmental perspective in the assessment and treatment of ADHD.

A neurodevelopmental perspective focuses on the maturation of motor control, cognition, language skills, sequencing abilities, auditory and visual processing, as well as interpersonal and adaptive skills (Levine, 1987). This approach applied to ADHD implies that ADHD is not simply the result of deficits in attention, behavioral inhibition, and hyperactivity Although incompletely understood, these neurodevelopmental problems may underlie the inappropriate levels of activity, distractibility, and impulsivity manifest in ADHD. These fundamental problems in neurological "wiring" also may account for the frequency of comorbid learning, processing and emotional disorders observed in children with ADHD (Levine).

Because psychostimulants have proved to be helpful in the management of ADHD symptoms, the medical model has emerged as the most common approach to diagnosis and treatment. The fact that ADHD impinges on all aspects of the child's world only recently has been given more serious consideration (Richters et al., 1995). The impact of having an ADHD child in the family is often overlooked. In order to foster therapeutic gains, child psychiatric nurses who care for children with ADHD should consider all aspects of the child's life. The neurodevelopmental perspective leads nurses to consider each child's strengths and weaknesses, as well as family factors, in order to promote optimal development.

The definition and diagnostic criteria of ADHD have been fraught with controversy (Chen, Faraone, Biederman, & Tsuang, 1994; Frick et al., 1994; Mulhern, Dworkin, & Berstein, 1994; Newcorn et al., 1994). Differences in presenting symptoms are documented in studies by Dykman and Ackerman (1993) and DeQuiros, Kinsbourne, Palmer and Rufo (1994). There also are differences in how to conceptualize the underlying deficit. For example, Barkley (1994) has postulated that ADHD core deficits do not relate primarily to inattention but rather to a delay in the development of the response inhibition. This delay in response inhibition leads to ineffective neuropsychological functioning related to the many cognitive abilities such as the ability to sustain or create mental images, access working memory, imagine hypothetical situations, establish goals and plans, control impulsive responses, regulate affect and behavior, and analyze or synthesize information.

Finally, there has been much debate as to whether ADHD is a disorder primarily of hyperactivity, inattention or impulsivity. For the present, the new diagnostic criteria established in the DSM-IV (American Psychiatric Association, 1994) has quieted this debate by allowing for ADHD "Primarily Inattentive Type", "Primarily Hyperactive Type", or "Combined Type."

DSM-IV Criteria: Diagnosis

The essential features of ADHD as defined in the DSM-IV Training Guide (Reid & Wise, 1995) are: "developmentally inappropriate inattention, impulsiveness, and hyperactivity before age 7, appearing at various levels in more than one setting; and significantly interfering with social, academic, or occupational functioning. In some patients either the inattention or hyperactivity-- impulsivity predominate, temporarily or indefinitely" (p. 50). In an effort to acknowledge the myriad symptoms that are manifested by children with ADHD, the DSMIV now defines four diagnostic categories of ADHD. Diagnosis of the specific type of ADHD is based on the DSM-IV symptom behavior checklist.

If a child meets six of the nine diagnostic criteria for inattention, he or she is diagnosed as ADHD Predominately Inattentive Type. If a child meets six of the nine hyperactivity-impulsivity criteria, he or she is diagnosed as ADHD Predominately HyperactiveImpulsive Type. If a child meets the criteria for both inattention and hyperactivity-impulsivity, the diagnosis of ADHD Combined Type is given. There also can be a diagnosis of ADHD, NOS (not otherwise specified) in which the "symptoms are prominent but do not quite meet" diagnostic criteria for the other types (Reid & Wise, 1995, p. 52).

In our clinic we use a checklist based on the DSM-IV criteria (see Table 1). We review and discuss the symptom checklist with parents during the initial visit in order to assess the severity of symptoms and to discern whether the behaviors occur across environments or are situational or caregiver specific. The checklist has been divided into two categories related to the primary deficits seen in ADHD.

The symptoms of ADHD in many children appear to be situationally specific and may be affected by motivation or environmental factors. Reid and Wise (1995) state that the associated features of ADHD "vary with age, and may include: poor self-esteem, lability of mood, poor frustration tolerance, and temper outbursts" and that "symptoms of Oppositional Defiant Disorder, Conduct Disorder, and specific developmental disorders are often seen" (p. 50). Therefore, the age of the child and the child's environment and interactions with caregivers must be considered during the assessment process. Information must be gathered from as many sources as possible to assess these factors.

We have found in our practice that the DSM-IV list of hyperactive-impulsive symptoms mainly pertains to children and does not adequately reflect the types of impulsive behavior seen in adolescents. Typical impulsive behaviors in adolescents include cutting class, speeding tickets, failed interpersonal relations due to impulsive verbalizations, increased risk-taking behaviors such as use of drugs or alcohol, sexual promiscuity, fighting, and violation of curfew It is uncommon, however, to observe teenagers who also demonstrate childhood ADHD symptoms (e.g., fidgeting, leaving their seats, or running). Adolescents with ADHD may struggle with the cognitive and organizational demands of high school as evidenced by incomplete assignments, forgetting test dates, and the inability to plan or complete long-term projects. Thus, clinicians should consider the child's developmental stage and be aware of the age differences in the presentation of ADHD.

Problems of inattention also may be manifested somewhat differently in different age groups. For example, in middle school, suddenly faced with changing classes, several different teachers, and long-term projects, some children with ADHD fall behind for the first time in their school career due to their impaired organizational skills. Parents become frustrated as their middle school child fails to rise to this developmental challenge. Parents complain that their child is forgetful, loses materials needed for assignments, and does poorly on tests. Careful evaluation in these cases often reveals a child with ADHD Predominately Inattentive Type who also has a higher IQ and has been able to compensate in school until the demands of middle school.

Sources of Information and Clinical Diagnosis

Accurate diagnosis of ADHD and comorbid conditions is essential for the design of effective interventions. Clinicians often have difficulty in obtaining an objective impression of a child's inattention, hyperactivity, or impulsive behaviors directly from the child in a clinical interview. Because symptoms may be situation specific, the diagnostician must rely on the observations of parents and teachers to aid in diagnosis. Standardized rating scales are a convenient and effective method of obtaining information across situations (Barkley, 1991; Scahill & Ort, 1995). They also provide clinicians with a means of evaluating the parents' perceptions of the child versus the teacher's perception. In this way, the clinician can gain insight into the degree of impairment experienced by each of these caregivers and the possible need for intervention with these caregivers.

Although there are many parent and teacher rating scales commercially available for the assessment of ADHD, these rating scales can overestimate the disruptive behavior. In addition, many scales have poor agreement between teacher and parents, and rating scales are susceptible to "halo" effects (Barkley, 1991; Halperin, 1991). In view of these concerns, some researchers recommend direct behavioral observation by trained clinicians. Often this is not feasible for the clinician, but some school districts are now utilizing school nurses, social workers, and psychologists to conduct behavioral observations in the classroom.

Behavioral scales also may not pinpoint the specific neurodevelopmental deficits that the child is having. Therefore, although we make use of various rating scales, we provide parents, teachers, and youth with several scales and questionnaires. Table 2 lists instruments we use in our practice. We also conduct a clinical interview in an effort to screen for psychiatric conditions that may be comorbid or that can mimic ADHD (i.e., pervasive developmental disorder, adjustment disorders, oppositional defiant disorder, conduct disorder, anxiety disorders, post-traumatic stress disorder, depression, bipolar disorder). We then conduct clinical interviews with the parents and the child and conduct a neurodevelopmental exam as well as a complete medical and neurological exam. These exams assess for environmental or medical problems that may mimic ADHD (e.g., hearing/vision problems, fragile X syndrome, fetal alcohol syndrome, seizure disorders, neurodegenerative disorders such as Wilson's disorder, anemia, thyroid conditions, medication side effects, malnutrition, pinworms, lead poisoning.) The full evaluation is conducted in approximately six clinic hours over a 2-6 week period.

We have chosen to use Levine's neurodevelopmental screening tools in our assessment process as they are the most comprehensive and are divided into four age-- specific formats.

The questionnaire data provide a picture of aggregate neurobehavioral student health and an educational profile. The questionnaires assess problems that may have occurred during pregnancy, the newborn and infancy periods, as well as health and functional problems as the child has developed. Historical data regarding early development, family history, specific skills, abilities, and delays also are collected. These questionnaires also gather data related to the child's interests, selective attention, sustained attention, memory, consistency of performance, distractibility, activity level, social skills, behavior, emotional problems, somatic complaints, aggression level, and the child's strengths.

These tests are administered and scored by our pediatric nurse practitioner. They provide an excellent measurement of the child's strengths and weaknesses in the areas of: neuromaturation, eye-hand coordination, pencil control, fine motor skills, receptive language, language retrieval, expressive language, gross motor function, temporal-sequential organization, visual processing, visual-motor function, visual memory, selective attention, retrieval memory, active working memory, strategy use, general organization, affect, and behavioral adaptation. We rely heavily on these neurodevelopmental exams to design interventions that consider each child's strengths and weaknesses.

We also conduct a computerized Continuous Performance Test (CPT) as an objective measure of attentional deficits and to screen for more severe neurological deficits. The CPT requires the child to observe the rapid presentation of stimuli on a computer screen. The child is instructed to respond when the target stimuli are presented and to refrain from responding to nontarget stimuli. The targets missed are considered errors of omission and are a measure of inattention. Responses to a nontarget stimulus are considered errors of commission and thought to assess impulsivity. Deterioration of test performance over time is thought to reflect a measure of sustained attention.

There are several different CPT programs currently available. We use the Test of Variables of Attention (TOVA) (Greenberg & Dupuy, 1993). This program purports to measure the deficits in attention impulsivity and processing that correlate to the behaviors that define the constructs of ADHD (Greenberg & Dupuy). TOVA does not purport to measure hyperactivity except by means of direct observation of the child while taking the test. We have found TOVA to reflect an accurate diagnosis of attentional deficits approximately 80% of the time. We also use TOVA to monitor medication dosage effectiveness as it has been shown to be sensitive to medication effects (Greenberg & Dupuy).

Comorbidity

We find that conducting such a thorough initial assessment leads us to an accurate and complete picture of the child's attentional deficits, comorbid conditions, and cognitive strengths and weaknesses. A study by Barkley, Fischer, Edlebrock, and Smallish (1990) followed 123 hyperactive children for 8 years. They found that these children had higher rates of antisocial acts, their family status was much less stable, and "they were 3 times more likely to have failed a grade or been suspended and more than 8 times as likely to have been expelled or dropped out of school compared to the normal controls at adolescent outcome" (Barkley et al., p. 555). In adolescence, 80% of the sample continued to meet the diagnostic criteria for ADHD, and 60% had a comorbid diagnosis of either oppositional defiant disorder and or conduct disorder (Barkley et al.). The authors conclude that their findings show ADHD to be a "chronic and often socially disabling condition, placing the children at high risk for later negative outcomes across many domains of adjustment" (Barkley et al., p. 556).

When comorbid conditions are present (e.g., oppositional defiant disorder, conduct disorder, learning disorders, mood disorders, anxiety disorders), it is difficult to determine if the undiagnosed and untreated ADHD has led to the development of these comorbid conditions and whether these conditions will improve as we treat the ADHD. Therefore, if possible, we regard the ADHD as the primary condition and then reevaluate and treat comorbid conditions. Often the severity of comorbid conditions decreases as successful interventions for ADHD are implemented. On the other hand, some children with other disruptive behavior disorders such as ODD, CD, or anxiety disorders may be diagnosed incorrectly with ADHD, so a thorough evaluation always is indicated.

Treatment

Although all the psychostimulants have been shown to be used in the management of ADHD, methylphenidate is the most commonly used agent (Scahill & Lynch, 1994). Before initiating treatment with psychostimulant medications we review the medical and neurological assessments carefully making sure that we have screened the child for hypertension, tachyarrhythmias, tics and dyskinetic movements, or a family history of Tourette syndrome (TS). Stimulants may worsen tics in some children with a personal or family history of TS (Riddle et al., 1995), though some children with tics apparently can tolerate stimulant medications (Gadow, Sverd, Sprafkin, Nolan, & Ezor, 1995). We often obtain the parents- permission to conduct a further evaluation for the use of stimulants via a methylphenidate (MPH) challenge test in order to assess whether the child exhibits a positive response to psychostimulant medication.

A medication challenge is possible because of the rapid onset of methylphenidate, and the response to this medication can be made by direct observation and the use of TOVA. As part of our initial assessment, we conduct a baseline measurement of the child's performance on TOVA. In this challenge test, a 5-10 mg dose of methylphenidate is given to the child and TOVA is repeated in an hour and a half (medication peak). If the child demonstrates below-age norm before medication and improved performance on TOVA, we presume a positive response to the medication is likely. In some cases the response is dramatic-as much as two or more standard deviation scores on TOVA. This test cannot determine whether methylphenidate will be the best psychostimulant or the optimal dose schedule, but it does provide an indication of response to psychostimulants.

An adverse response would be indicated by increased levels of inattention or impulsivity or deterioration in processing time or increased agitation, aggression, emotional lability, or motor tics. If there is an adverse response or psychostimulants are contraindicated, other medications such as tricyclic antidepressants, clonidine, guanfacine, bupropion (Scahill & French, 1996), and the SSRIs might be considered. Comorbid conditions also can necessitate the use of other or concurrent medications. Physical side effects or adverse psychiatric reactions may require the clinician to adjust the dose or timing of stimulant medications or switch to other medications. For example, children with tic disorders may exhibit increased tics following the initiation of stimulant medication (Scahill, Lynch, & Ort, 1995). Twenty-five percent of children with ADHD are unresponsive to stimulant medication or cannot take stimulant medication due to side effects or adverse reactions (Scahill & French).

As noted above, methylphenidate is the most common psychostimulant medication used for the treatment of ADHD and is usually our first choice. It has been shown to be safe and effective and has a short half-life (3-6 hours), which means it will not accumulate in the body and that frequent dosages (2-4 times a day) will be required. The sustained release form can be used alone or in combination with the faster acting forms, thus eliminating the need for such frequent medication administration (see Table 3).

Dextroamphetamine (DEX) is very similar to MPH in effects and side effects. We usually try MPH first, then DEX if there is no positive response or an adverse response (e.g., weepiness, aggression) to MPH. Some children do respond to DEX when MPH has been found to be ineffective. DEX is about 1.5 to 2 times more potent than MPH, so the dosage of DEX is two thirds to one half as much as MPH. DEX also has a slightly longer duration of action, so it can be given twice a day.

The newest psychostimulant now being used in the treatment of ADHD is a dextroamphetamine combination of dextroamphetamine sulfate, dextroamphetamine saccharate, amphetamine sulfate, and amphetamine aspartate. This is not a sustained release tablet, but the effect lasts 8-10 hours. The tablet can be split to create individualized smaller doses. If this drug proves to be effective, it alleviates the need for the continued administration of medications throughout the day. Unfortunately, there is little empirical support for the use of this medication at this time.

D-amphetamine, methylphenidate, and the dextroamphetamine combination are considered to be controlled substances by the Food and Drug Administration (FDA) because of their perceived abuse potential. In most states, these medicines cannot be phoned in to the pharmacy; renewals require a new prescription, and the prescriptions often must be filled within 48 - 72 hours. This can become problematic if clients miss a scheduled appointment and run out of medication.

Another psychostimulant not generally considered to be a controlled substance is pemoline, which can be prescribed and refilled much easier. Some clinicians prefer to use this medication with adolescents due to concerns about stimulant abuse. Pemoline lasts for 24 hours, eliminating the need for multiple doses throughout the day. The drawback of this medication is that depending on the dose schedule, it can take several weeks to reach full effect. In addition, although rare, cases of liver damage have been reported, so liver function tests are needed every 3 to 6 months.

The usual beneficial effects of psychostimulant medications are improved sustained attention, frustration tolerance, attention, and capacity for solitary play, and decreased impulsivity and task-irrelevant physical activity. Underactive inattentive ADHD children often feel more energy while hyperactive-impulsive ADHD children feel calmer and more in control of their impulses.

In our practice we have found that in children with ADHD Predominately Hyperactive-Impulsive Type, a decrease in activity level is not always an indicator of improved attention. In fact, based on CPT measures of inattention, sometimes the psychostimulants actually cause attention and cognitive processing to deteriorate. In some of these cases, alternative agents such as clonidine or carbamazepine may be more appropriate as they assist with the overactive behaviors without adversely affecting attention.

Even when a positive response to psychostimulant medications has been obtained, the timing of dosages often requires adjustment. Some children metabolize the psychostimulants much more quickly than reported in the dosage recommendation literature (Greenhill, 1995). Some metabolize a dose in as quickly as 2 hours. Other children exhibit a prominent "rebound" effect from psychostimulant medications. This rebound effect occurs when the medication is clearing the system and is manifested by an increase in impulsiveness and activity level. Careful monitoring of each child's response may reveal the need for more frequent dosing or the use of sustained release preparations.

In contrast to the rapid onset of action of regular methylphenidate (30-60 minutes) and the relatively brief duration (up to 4 hours), the sustained release preparation has a slower onset (up to 3 hours) and a longer duration of action (6-8 hours). In some cases, sustained release preparation can be used in combination with the regular preparation to obtain maximum effectiveness. Careful monitoring of each child's response to medication and knowledge of the child's daily schedule is essential in setting up a dosage schedule. For example, many adolescents need their medication during the school day and to do their homework in the evening but do not wish to experience the medication effect during football practice in the afternoon. Thus, with the psychostimulant medications, "timing is everything."

For children who have difficulty getting up and functioning in the morning, we recommend waking the child 1/2 hour before his or her normal awakening, administering 5 mg of methylphenidate, and letting the child return to sleep until his normal waking time. Then, when the child wakes up for the morning routine, the methylphenidate already is at work and the child can now maintain the attention and organization necessary in order to get ready for school.

Generic forms of methylphenidate can differ in equivalence from the name brand Ritalin (FDA, 1993). We usually prescribe methylphenidate (generic) when starting a child on medication and then keep prescribing the generic. This method is cost-effective for the family and usually is effective because we can regulate the dose based on the child's response to generic methylphenidate. For children who initiated treatment on Ritalin, it is advisable to continue with it to prevent a decrease in effectiveness. If we reach the usual maximum dosage of 20 mg in a single dose with the generic methylphenidate without clear positive effect, we often change to Ritalin and see improvement in some cases. When using sustained release methylphenidate we prefer Ritalin-SR, as we have encountered problems with the release time in the generic forms.

The need for medication and the dose required to manage the symptoms of ADHD may change as the child grows. In general, children require less medication in mg per kg of body weight as they get older. Some children may even outgrow the need for medication in adulthood, though it is becoming clearer that some adults who had symptoms of ADHD as children can benefit from psychostimulant medications during adulthood (Spencer et al., 1994).

Ongoing medication management includes the assessment of the side effects, although these usually are minor with the psychostimulants. In many cases, side effects subside after the first few weeks of treatment or can be addressed by adjusting the dose or timing of the dose. Common side effects include: gastrointestinal upset, nausea, abdominal cramps, anorexia, insomnia, mild tachycardia. Less common side effects include: headache, dizziness, nervousness, irritability, emotional lability, psychotic symptoms, and tics. Rare adverse reactions include: irregular heartbeat, palpitations, tachyarrhythmias, elevated blood pressure, hair loss, decreased white blood cell count, anemia, rash, and, with pemoline, elevated liver enzymes. A rare hypersensitivity reaction consists of hives, fever, and easy bruising. Occasionally, children taking psychostimulants will experience a personality change manifested by dejection, lifelessness, tearfulness, and oversensitivity. Conversely, some develop a state of excitement, confusion, and withdrawal. If these adverse effects are severe, psychostimulant treatment should be discontinued. We provide parents with a side-effect checklist and usually see clients every 2 weeks during the dosage adjustment period, monthly for about 3 months, then once every 3 months after the optimal dose has been obtained.

Limitations and predictors of stimulant response. Although medication is not the only approach to treatment of ADHD, medication can reduce the impact of ADHD on the child's development. The effectiveness of psychostimulant medication in controlling the symptoms of ADHD is well documented (Swanson et al., 1993). It is also well documented that symptoms return when the medication is discontinued (Rapport, Denney, DuPaul, & Gardner, 1994). Ialongo et al. (1993) concluded that "stimulant medication is highly effective in the treatment of the cardinal features of ADHD and to maintain gains obtained with stimulant medication, most children must remain on medication for relatively long periods of time" (p. 188).

Stimulants may not specifically improve academic or social skills, but it does appear that these agents enable the child to make better use of education and therapy. Moreover, the improvement in the level of impulsivity often is reflected by improvements in deportment, aggression social interactions, and academic productivity.

Positive stimulant response may be influenced by the individual behavioral and metabolic characteristics of the child. Buitelaar, Van der Gaag, Swaab-Barneveld, and Kuiper (1995) found that "high I.Q., considerable inattentiveness, young age, low severity of disorder, and low rates of anxiety" were predictors of a strong methylphenidate response (p. 1025).

Barkley (1994) points out that the most effective interventions for ADHD have been shown to be those that are in place at the points when the behavior occurs. Therefore, while pharmacological intervention is in place within the child, often the children lack the skills to modify their behavior. In essence, they are less impulsive but do not know how to "do it differently" so they respond to stimuli in a manner that is familiar to them. Therefore, there remain significant areas for intervention, which are not addressed by psychopharmacological intervention. As clinicians we must recognize the limitations of pharmacological intervention and intervene in those areas not addressed my medication. In our practice, to further facilitate the care plan of the child with ADHD, we offer peer group social skills classes, a group parent education and support group, and individual and family counseling.

Child and Family Education

Once an evaluation is completed and the course of treatment is decided, it is useful to educate the parents and child about ADHD and how it is manifested in the child. We discuss ADHD as a wiring problem in the brain and body and explain that medication can help make all the appropriate electrical connections. Children often can relate to our description of ADHD, and many are relieved to find out they are not "stupid," "bad," or "mental." Younger children may be unable to understand the explanation, but they usually can understand that they will take medicine to help them think better. In the words of a 7-year-old girl, "My thinking pill makes doing my math problems easier, and I remember stuff better."

We also use Levine's Concentration Cockpit Exercise (Levine, 1994) to demystify ADHD in the child's mind. The Concentration Cockpit exercise breaks down the concept of ADHD into manageable pieces with which the individual child can identify. The child is educated about the mental energy controls (alertness, consistency, mental effort, and sleep controls), processing controls (intake, concentration depth, concentration time, mind activity, and want and excitement controls), and production or output controls (monitoring, past experience, possible choices, preview and speed controls).

Some parents expect medication to fix all the problems within their child. Through education, however, this misconception can be identified and dismantled. We inform parents that ADHD is a chronic neurobiological condition that can last into adulthood. We also stress that the behaviors exhibited and the subsequent management of them will take many forms as the child grows, develops, and encounters different environmental challenges.

Parents often have difficulty understanding the nature of their child's impulsivity. Parents may waiver between expecting no control of impulsive behavior to expecting too high a level of control. Throughout the course of treatment we constantly remind parents that they cannot expect their child to display age-appropriate levels of impulse control or organizational skills as that of their peers. We frame these problems as developmental delays rather than a fixed deficit by suggesting to parents that "in some areas your child's behavior and skills are 3-5 years behind those of his peers." This may mean that the parent has to provide additional structure at home, keep track of the child's assignments, or supervise homework more closely. Although medication can be helpful, medication alone cannot give children the skills they need to succeed in the world, and we encourage the parent to assist the child as needed.

Conclusion

We find it useful in practice to conceptualize the developmental path of children with ADHD not as disordered, but as delayed. Removing the stigma of ADHD as an illness, deficit, disorder, or disability and building on each child's strengths may better serve the child diagnosed with ADHD. Although we rely on DSM-IV to define ADHD, each child with ADHD has a unique cluster of symptoms. A neurodevelopmental perspective provides the clinician with a child-focused framework for conducting an assessment that can serve as a starting point from which to develop individualized interventions.

Clinicians also must recognize that, although medication is extremely helpful, medication alone cannot compensate for all the difficulties that are commonly manifested by children and adolescents with ADHD. Medication cannot give a child skills that he or she has not yet developed or, by itself, compensate for learning or emotional problems. Optimal clinical care requires implementation of interventions in various settings such as home and school. These interventions are best derived from a thorough assessment across environments and must be based on each child's specific strengths and weaknesses. Comprehensive clinical care requires that the child and adolescent psychiatric nurse assume many roles including therapist, medication monitor, educator to parent and child, and case manager. Every child diagnosed with ADHD deserves such comprehensive treatment.

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Kathleen Ludwikowski, MS, RN, CS, is Pediatric Nurse Practitioner and owner, Child Assessment Services, Marengo, IL, and Adjunct Faculty, University of Illinois, College of Nursing, Chicago, and Northern Illinois University, College of Nursing, DeKalb; Marcia DeValk, BA, RN, C, is Child and Adolescent Psychiatric Nurse Consultant, Child Assessment Services, Marengo, IL, and a doctoral student, University of Illinois, College of Nursing, Chicago.