CP

Family and Pediatric Nurse Practitioner

Counseling Points
Enhancing Patient Communication for the
™

Family and Pediatric Nurse Practitioner

November 2008 Volume 1, Number 1

Caring for Individuals with

ADHD Throughout the Lifespan
An Introduction to ADHD

A Publication of the American Psychiatric Nurses Association and

the National Association of Pediatric Nurse Practitioners

This program is supported by an educational grant from McNeil Pediatrics, Division of Ortho-McNeil-Janssen
Pharmaceuticals, Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC.
Faculty:
Judith A. Vessey, PhD, MBA, PNP, Counseling Points™
FAAN Caring for Individuals with ADHD Throughout
Lelia Holden Carroll Professor of
Nursing
the Lifespan: An Introduction to ADHD
Boston College William F. Connell Continuing Education Information
School of Nursing
Chestnut Hill, Massachusetts Target Audience
This educational activity is designed to educate family and pediatric nurse practitioners about
Ann M. Wilkinson, MSN, APRN, issues related to caring for individuals with attention deficit hyperactivity disorder (ADHD)
throughout their lifespan.
PMHCNS-BC
Psychiatric Clinical Nurse Specialist, Learning Objectives
Upon completion of this educational activity, the participant should be able to:
Private Practice
• State the prevalence and economic burden of attention deficit hyperactivity disorder
Redwood City, California
(ADHD)
• Discuss the pathophysiology and risk factors for ADHD
Faculty Disclosure Statements
• Determine the signs and symptoms of ADHD and common co-morbidities that may con-
Judith A. Vessey and found diagnosis
Ann M. Wilkinson have no • Identify ADHD across the lifespan
conflicts of interest to report.
NAPNAP Disclaimer
Publishing Information: The National Association of Pediatric Nurse Practitioners’ (NAPNAP) approval of this
activity or continuing education credit does not imply product endorsement.
Publishers
Joseph J. D’Onofrio APNA Disclaimer
Frank M. Marino The American Psychiatric Nurses Association (APNA) presents the information in Counseling
PointsTM as a service to its members. While APNA makes every effort to present accurate and
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disclaims all liability for damages of any kind arising out of use, reference to, or reliance on
Tel: 201-612-7676
such information.
Fax: 201-612-8282
Website: www.delmedgroup.com Continuing Education Credit
This program has been approved for 1.0 NAPNAP contact hours, of which 0 contain
Editorial Director Pharmacology (Rx) content. Approved program #A10-08-E31.
Nancy Monson This program expires November 30, 2009.

Art Director Disclosure of Unlabeled Use

James Ticchio
Cover photo credit: ©SIS Illustration/Veer
©2008, Delaware Media Group, Inc. All
rights reserved. None of the contents may be
reproduced in any form without prior written
permission from the publisher. The opinions
expressed in this publication are those of the
faculty and do not necessarily reflect the
opinions or recommendations of their affiliat-
ed institutions, the publisher, APNA, NAP-
NAP, or McNeil Pediatrics, Division of Ortho-
McNeil-Janssen Phar maceuticals, Inc.,
administered by Ortho-McNeil Janssen Sci-
entific Affairs, LLC.
This educational activity may contain discussion of published and/or investigational uses of
agents that are not indicated by the FDA. The American Psychiatric Nurses Association
(APNA), NAPNAP, McNeil Pediatrics, Division of Ortho-McNeil-Janssen Pharmaceuticals,
Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC, and Delaware Media
Group do not recommend the use of any agent outside of the labeled indications. The opin-
ions expressed in the educational activity are those of the faculty and do not necessarily repre-
sent the views of the APNA, NAPNAP, McNeil Pediatrics, Division of Ortho-McNeil-Janssen
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Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance
patient outcomes and their own professional development. The information presented in this
activity is not meant to serve as a guideline for patient management. Any medications, diag-
nostic procedures, or treatments discussed in this publication should not be used by clinicians
or other healthcare professionals without first evaluating their patients’ conditions, considering
possible contraindications or risks, reviewing any applicable manufacturer’s product informa-
tion, and comparing any therapeutic approach with the recommendations of other authorities.

COUNSELING POINTS™ 2
welcome
Dear Colleague,

Welcome to the first issue of Counseling PointsTM, Caring for Individuals with ADHD Through-
out the Lifespan, an official publication of the National Association of Pediatric Nurse Practi-
tioners (NAPNAP) and the American Psychiatric Nurses Association (APNA).

In this issue, two experts provide an overview of attention deficit hyperactivity disorder
(ADHD). Although ADHD was once thought to be a disorder of childhood, it is now known
that symptoms often persist into adulthood. While many individuals may be able to manage
their symptoms as children, with the challenges and demands of college, employment, and
forming intimate relationships, as adults they may have more difficulty functioning adequately
to meet their daily demands.

The goal of the issue is to inform and empower you so you can recognize ADHD in children,
adolescents, and adults, distinguish it from other disorders that may confound diagnosis, and
provide the best care possible. Future issues will focus on treatment strategies and the
nurse/NP’s role in supporting and educating children, adolescents, and adults with ADHD
throughout the course of the condition.We are committed to the integration of evidence into
nursing practice education. This educational program will incorporate the best available evi-
dence in an explicit fashion. Evidence may include research, integrative reviews, practice guide-
lines, quality improvement data, and case studies.

We would like to thank McNeil Pediatrics, Division of Ortho-McNeil-Janssen Pharmaceuti-

cals, Inc., administered by Ortho-McNeil Janssen Scientific Affairs, LLC, for sponsoring this
publication under an educational grant. When there is commercial support for an educational
activity, the role of the commercial supporter is to facilitate conduct of the activity by providing
funding to support the activity. NAPNAP, as the CE provider, is responsible for the content and
scientific integrity of all CE activities approved for credit and does not accept advice or services
concerning authors or other education matters, including content, from a commercial support-
er as conditions of contributing funds or services.

We encourage you to learn more about NAPNAP if you are not already a member by visiting
our website at www.napnap.org and reviewing the box on page 12. We also welcome your
suggestions for topics you would like to see covered in future issues of Counseling PointsTM. A
space is provided for your input on the evaluation form on page 15.

Sincerely,

Linda L. Lindeke, PhD, RN, CNP

NAPNAP President

3 NOVEMBER 2008
 Caring for Patients with ADHD
Throughout the Lifespan
An Introduction to ADHD
A
ttention deficit hyperactivity disorder (ADHD) is
the most common psychiatric condition affecting
children in the United States and often persists
into adulthood, something that many clinicians and the
public may not recognize.1
Health care professionals who treat people with
ADHD should be aware that the condition manifests
itself differently throughout the course of life, and that
early identification and treatment can greatly improve
outcomes and quality of life.2,3 When recognized and
appropriately managed with pharmacologic and/or non-
pharmacologic strategies, individuals with ADHD lead
very productive lives. In fact, they can excel, as swimmer
Michael Phelps, the star of the 2008 Beijing Olympics,
demonstrates. Diagnosed with ADHD at age 9, Phelps’
mother Debbie was told by his teachers that he would
never be able to focus on anything. She refused to accept
this prognosis as his destiny, instead devising creative solu-
tions to help her son overcome his inability to concen-
trate. She encouraged his athletic interest, which proved
to be a great outlet for his energy. She countered his lack
of focus to do his schoolwork by giving him the sports
section of the newspaper to read and framing math prob-
lems in the context of swim times. “I knew that, if I col-
laborated with Michael, he could achieve anything he set
his mind to,” Debbie has said.4
Likewise, Yvonne Pennington, the mother of Ty Pen-
nington, the star of Extreme Makeover: Home Edition, used
her son’s passion for building things to channel his ener-
gy. Pennington had trouble concentrating in the class-
room, but graduated high school. A lack of structure led
to his dropping out of the first college he attended, but
with the help of stimulant medication he was able to
learn to focus on his school work and ultimately gradu-
ate with honors from the Art Institute of Atlanta. “Many
parents in this situation focus on what their kids are
doing wrong,” Yvonne told Additudes magazine. “I
encourage them to focus on what they’re doing right.
Do that, and the possibilities are endless.”4
Both of these young men demonstrate striking scenar-
ios for managing ADHD throughout the lifespan.
COUNSELING POINTS™
Through partnerships with their parents, schools, and cli-
nicians, they were able to identify their strengths and
manage their weaknesses.They offer much hope for peo-
ple with ADHD and their families, and provide insight
into strategies we may employ to help our patients suc-
cessfully overcome their condition.
Definition of ADHD
The most widely accepted definition of ADHD is pub-
lished in the American Psychiatric Association’s (APA)
Diagnostic and Statistical Manual IV-TR (Table 1).5 ADHD
is defined as a “persistent pattern of inattention and/or
hyperactivity-impulsivity that is more frequent and severe
than is typically observed in individuals at a comparable
level of development.”5 For a diagnosis of ADHD, a child’s
symptomatology must interfere with academic perform-
ance, social functioning, and activities of daily living that
would be appropriate for his/her developmental level.5 In
addition, some symptoms must occur prior to age 7, be
present for at least 6 months, and manifest themselves in
two or more settings.5
Three subtypes of ADHD are defined:
1. ADHD that is predominantly inattentive (ADHD-I);
2. ADHD that is predominantly hyperactive-impulsive
(ADHD-H/I); and
3. ADHD that combines both inattentive, hyperactive,
and impulsive components (ADHD-C).5
Incidence and Prevalence
ADHD is the most common chronic health condition
seen in childhood, affecting an estimated 4.5 million chil-
dren between the ages of 3 and 17.6
The incidence of ADHD varies by age. Diagnoses of
ADHD begin in the preschool period, peak by the late
school-age years, and then begin decreasing in adoles-
cence.7 Widely disparate prevalence rates of ADHD in
children have been reported, ranging from 0.2%-27%;
generally accepted prevalence rates, however, range
between 7% and 10% for children.8,9 The highest preva-
lence rates are found in school-age children, as this is the
age when symptomatology congruent with the APA’s
definition is most clearly identified. Current prevalence
4
 Table 1. DSM IV-TR Diagnostic Criteria for ADHD5
A. Either (1) or (2):
(1) Six (or more) of the following symptoms of inattention
have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:
Inattention
a. Often fails to give close attention to details or makes
careless mistakes in schoolwork, work, or other activities
b. Often has difficulty sustaining attention in tasks or play
activities
c. Often does not seem to listen when spoken to directly
d. Often does not follow through on instructions and fails to
finish schoolwork, chores, or duties in the workplace (not
due to oppositional behavior or failure to understand
instructions)
e. Often has difficulty organizing tasks and activities
f. Often avoids, dislikes, or is reluctant to engage in tasks
that require sustained mental effort (such as schoolwork
or homework)
g. Often loses things necessary for tasks or activities (e.g.,
toys, school assignments, pencils, books, or tools)
h. Is often easily distracted by extraneous stimuli
i. Is often forgetful in daily activities
((2) Six (or more) of the following symptoms of hyperactivity-
impulsivity have persisted for at least 6 months to a degree
that is maladaptive and inconsistent with developmental
level:
Hyperactivity
a. Often fidgets with hands or feet or squirms in seat
ADHD=attention deficit hyperactivity disorder; DSM IV-TR= Diagnostic and Statistical Manual of Mental Disorders IV-TR.
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders IV-TR. Washington; DC: American Psychiatric
Association. 2000, pp 92-93.
rates for preschool children are estimated at 2%-6%.10 The
majority of adolescents diagnosed with ADHD earlier in
life continue to meet the diagnostic criteria for an
ADHD diagnosis.
The prevalence of ADHD is higher in males than
females. Boys are diagnosed more frequently than girls at a
ratio of 2-4:1, probably because boys are more likely to
exhibit hyperactivity and impulsivity and have their symp-
toms noticed. 9,11 Girls, who are more likely to have
ADHD-I, tend to have symptoms that are less noticeable,
which often leads to later or under-diagnosis. Children
from low socioeconomic backgrounds and differing cul-
tures may be diagnosed less frequently. Different diagnostic
standards used by practitioners and the availability of com-
munity services affect prevalence rates, with under-, over-,
and misdiagnosis of ADHD still being common problems.
Estimated prevalence rates for adults are between 3.4%
and 4.4%.9,12,13
5 NOVEMBER 2008
b. Often leaves seat in classroom or in other situations in
which remaining seated is expected
c. Often runs about or climbs excessively in situations in
which it is inappropriate (in adolescents or adults, may
be limited to subjective feelings of restlessness)
d. Often has difficulty playing or engaging in leisure activi-
ties quietly
e. Is often “on the go” or often acts “as if driven by a
motor”
f. Often talks excessively
Impulsivity
g. Often blurts out answers before questions have been
completed
h. Often has difficulty awaiting turn
i. Often interrupts or intrudes on others (e.g., butts into
conversations or games)
B. Some hyperactive-impulsive or inattentive symptoms that
caused impairment present before age 7 years.
C. Some impairment from the symptoms present in two or
more settings (e.g., at school [or work] and at home).
D. There must be clear evidence of clinically significant impair-
ment in social, academic, or occupational functioning.
E. The symptoms do not occur exclusively during the course
of a Pervasive Developmental Disorder, Schizophrenia, or
other Psychotic Disorder and are not better accounted for
by another mental disorder (e.g., Mood Disorder, Anxiety
Disorder, Dissociative Disorder, Personality Disorder).
Socioeconomic Burden
Because ADHD can lead to impairments in virtually
every aspect of a child’s life, it has a considerable impact
on the child, family, and community. Approximately 30%
of students with ADHD repeat a grade, up to 33% fail to
complete high school, and only 5%-10% complete col-
lege.14 Approximately 50% of adolescents, and especially
those with co-existing mental health conditions, engage
in antisocial activities.14 Children with ADHD are also at
increased risk for unintentional injuries compared with
children without ADHD.10
Children diagnosed with ADHD are more frequent
users of medical, mental health, and educational services
than their nonaffected peers. The intensity and long-term
nature of recommended multi-modal treatment approach-
es (academic interventions, social- and behavioral-skills
training, and pharmacologic approaches) are expensive.
These treatments can rapidly become cost-prohibitive for
families and school districts required to provide numerous
services. A child’s health insurance coverage frequently has
limited behavioral/mental health benefits; thus, the costs
of mental health counseling and behavioral training
become the responsibility of the child’s school system and
parents. School districts, although responsible for provid-
ing the majority of academic and behavioral interven-
tions, have few, if any, options for seeking reimbursement
for these services and must support them out of the gen-
eral school budget. Many school districts are frankly
unsympathetic to families of children with ADHD, and
parents can find themselves in an adversarial position
while advocating for their child.15 Because of the all-
encompassing nature of ADHD and the numerous issues
faced by families, many parents of children with ADHD
experience significant stress, as well as depression and
marital discord.15,16
The societal burden is increased when children are
not diagnosed in a timely manner and/or receive inef-
fective treatment. Such children are more likely to expe-
rience academic failure, difficulty in maintaining peer
relationships, substance abuse, and mental health prob-
lems, all of which augur poorly for successful long-term
interpersonal relationships and occupational success in
adulthood.7,10,17,18
Pathophysiology
ADHD is a highly heterogeneous, nonprogressive, neuro-
logical condition. The exact pathophysiological mecha-
nisms are not confirmed, although genetic, neurological,
and environmental influences all play a role. ADHD is
considered to be highly inheritable, with estimates that
range from 60%-90% across generations.7,14 Twin studies
confirm a genetic link between monozygotic twins.7
Because of these strong familial patterns, ADHD is
thought to be a polygenic disorder that interferes with
the encoding of the function of neurotransmitters and
their receptors.8,15,19
Current investigations center around identifying affect-
ed genes and the resultant mechanisms responsible for the
dysregulation of neurotransmitters—primarily the cate-
cholamines dopamine and norepinephrine, their recep-
tors, and their transporters.20 These neurotransmitters
influence attention, arousal, impulsivity, and mood.
Defects in the neurotransmission process result in insuffi-
cient amounts of catecholamines being available to mod-
ulate the behaviors they influence.7,20 The role of neuro-
COUNSELING POINTS™
transmitter dysregulation in causing ADHD is supported
by the fact that effective ADHD medications work on the
dopaminergic and noradrenergic systems.
Other research is attempting to identify structural
anomalies in the brain, with an emphasis on the neurocir-
cuitry of the prefrontal cortex, an area that is rich in
dopamine receptors. Recent studies have demonstrated
anatomic differences in individuals with ADHD com-
pared with individuals who do not have ADHD. For
instance, the right prefrontal cortex, caudate nucleus, and
globus pallidus often are somewhat smaller and demon-
strate less blood flow and decreased electrical activity.7,14
As these are key areas of the brain that help children
process stimuli, control emotions, develop social aware-
ness, and sustain attention while inhibiting untoward
behaviors, these findings support the idea that neu-
roanatomic differences play a role in ADHD.
Risk Factors
Numerous risk factors for ADHD have been identified.
Symptoms of ADHD can be seen in association with neu-
rological impairment resulting from infection (e.g.,
meningitis, encephalitis), injury (e.g., closed head trauma,
lead intoxication), hypoxia, or maternal substance abuse
during pregnancy.14,15 ADHD is also more common in
children who were very low birth weight infants. 7
Although ADHD can occur with other disabling condi-
tions (e.g., sensory impairment, intellectual disability, and
serious psychosocial and emotional disturbances) or in the
presence of other extrinsic influences (e.g., dysfunctional
parenting or a poor socioeconomic background), it is not
a direct result of those conditions or influences.They may,
however, exacerbate the symptomatology, and higher rates
of ADHD have been noted in such populations.14,15 In
addition, there is no proof that nutritional intake of free
sugars or artificial additives causes ADHD.21,22
ADHD Signs and Symptoms
Signs and symptoms of ADHD are determined, in part,
by the age of the child and the form of ADHD that the
child has. For ADHD-H/I and ADHD-I, at least six of
the nine characteristics in each of the diagnostic cate-
gories specified in Table 1 must be present.5 For ADHD-
C, at least six symptoms from both diagnostic categories
are required.5 The individual who does not have docu-
mented symptoms of ADHD before the age of 7 years
but who meets the criteria at the time of diagnosis is usu-
ally classified as ADHD—Not Otherwise Specified.5 The
6
symptoms listed as part of the APA’s diagnostic criteria
are most commonly seen in school-age children.
When preschoolers are diagnosed with ADHD, it is
usually because they are exhibiting symptoms of hyperac-
tivity and impulsivity: They have difficulty sitting still for
quiet activities, following simple instructions, and waiting
their turn, and often demonstrate other developmentally
immature behaviors. Many preschool children with
ADHD have poor social skills with their peers and may
become aggressive, pushing other children or grabbing
toys away. Because many toddlers or preschoolers exhibit
behaviors such as inattention or impulsivity, care must be
taken to differentiate whether the symptomatology is
merely part of the normal developmental trajectory or
diagnostic of ADHD.
ADHD symptoms in adolescents differ somewhat from
those seen in school-age children and may include sleep
problems, restlessness, and disorganization; teens may also
demonstrate heightened motor activity (e.g., foot tap-
ping).15 Other symptoms include significant academic dif-
ficulties and school failure, anxiety disorders, poor social
interaction skills with possible antisocial behavior, and
illicit substance and/or alcohol use.15 Many adolescents
meet less than six of the necessary designated APA symp-
toms within a specific category, but still have significant
impairment concomitant with an ADHD diagnosis.8
The Diagnostic Process
To date, there are no genetic or neuroimaging tests that
clearly establish the diagnosis of ADHD. In addition, there
continues to be controversy regarding the overdiagnosis
of ADHD in children and adolescents.
When evaluating a person for ADHD, it is important
to consider the pattern, severity, and pervasiveness of
symptoms, and to what extent the disorder interferes with
normal daily functioning. For instance: Is this just a tem-
porary reaction to a situation (parental divorce, family
death, etc.) or is it an ongoing problem? Do the symp-
toms occur in more than one setting? In order to make a
definitive diagnosis of ADHD, the evaluation must
include a complete cognitive, psychosocial, and psychi-
atric assessment, as well as a review of the appropriateness
of the school setting and the individual’s social and
employment functioning. Although the majority of chil-
dren with ADHD have an unremarkable medical history,
a more comprehensive medical evaluation may be
required in some children to rule out metabolic or brain
dysfunction. A physical examination that includes thor-
7 NOVEMBER 2008
ough vision and hearing tests as well as appropriate labo-
ratory testing may be indicated. Unless there is strong
evidence in the medical history, tests such as an electroen-
cephalogram (EEG), magnetic resonance imaging (MRI)
scan, single photo emission computed tomography
(SPECT) scan, or positron emission tomography (PET)
scan are not indicated.8 When appropriate, the individual
should be referred to a specialist for further evaluation
and testing.
When examining the individual’s school, employment,
and social functioning, it is critical to gather information
regarding his/her overall functioning and performance;
the school environment and grade placement; special
education services or work modifications provided to the
person; involvement in extra-curricular activities; and
overall behavior at school or work. A classroom or work
observation, including during social interactions with
peers and employment managers and staff, will further
help to assess the individual’s level of functioning. It is
also important to interview the family and observe the
family relationships/dynamics.
A complete psychiatric assessment should include a
structured diagnostic interview; clinical review of perti-
nent records; psychological and neuropsychological test-
ing; family, child and teacher feedback; use of specific
diagnostic tools (Table 2); review of the patient’s sleep
patterns and use of substances and alcohol; and additional
information from counselors, daycare workers, school
nurses, and psychotherapists.
Table 2. Rating Scales Utilized in ADHD
• SSQ-01 Barkley School Questionnaire
• ACTeRS Parent Report Form
• Connors Teaching Rating Scale*
• Connor’s Parent Rating Scale*
• Child Attention Profile
• Child Behavioral Check-List (CBCL—Teacher/Parent
Report Form)*
• Adult ADHD Self-Report Scale Symptom Checklist
• Home/School Situations Questionnaire
• Academic Performance Rating Scale ( APRS)
*Most commonly used and best-normed tools.
Differential Diagnosis
Many conditions can produce symptoms that mimic
those seen in ADHD, and may even co-exist with ADHD,
making the differential diagnosis of ADHD complex
(Table 3). These conditions include but are not limited
to learning disabilities, sensory deficits (e.g., hearing or
vision problems), Tourette syndrome, insufficient sleep
syndromes (e.g., too few hours of sleep or obstructive
sleep apnea), poor nutrition resulting in hypoglycemia
(e.g., skipped breakfast), allergies (e.g., pruritus), depres-
sion, anxiety, conduct disorder (CD), and oppositional
defiant disorder (ODD).14,18,22 In addition, the side effects
of many medications (e.g., first-generation antihistamines,
anti-epileptics) may be mistaken for symptoms of
ADHD.15
ADHD and Co-morbid Conditions in
Children and Adolescents
The lifetime prevalence of co-morbid psychiatric and/or
lear ning disorders with ADHD may be as high as
84%.8,18,22 The incidence of co-morbid conditions with
ADHD increases with the individual’s age.23
Recent studies support the early identification and
treatment of ADHD to help prevent the subsequent
development of co-morbid disorders.23 Psychotherapy, in
additional to pharmacotherapy, is useful in children with
co-morbid ADHD and other psychiatric disorders.
Co-morbid Anxiety Disorders. Children with signifi-
cant anxiety may have co-morbid ADHD, or they may
have symptoms that merely mimic ADHD. Patients with
severe anxiety will often internalize their anxiety and
appear distracted or disorganized. In addition, their anxi-
ety may drive externalizing behaviors, such as tantrums,
agitation, and sleep dysregulation. Findings from both
clinical and epidemiologic studies have concluded that
concomitant ADHD and anxiety disorders are present in
approximately 25% of children.24 If the clinician does not
detect the co-morbid anxiety and treat it first, stimulant
therapy may worsen the person’s anxiety, panic (if pres-
ent), and agitation. For example, in clinical practice it has
sometimes been observed that people with obsessive-
compulsive disorder (OCD) may experience increased
obsessive thoughts and compulsive behaviors from stimu-
lant therapy.
Co-morbid Depression. ADHD and depression have
common symptoms that include psychomotor agitation
and distractability. The lifetime rate of major depressive
disorder among children with ADHD is estimated to be
about 26%.24,25
Co-morbid Tic Disorders. Recent research indicates
that most children with co-morbid ADHD and tic disor-
COUNSELING POINTS™
ders either do not experience an exacerbation of tic
symptoms with methylphenidate; others may find that
the benefits of treatment outweigh any minor increase in
tics.8,26 It is important to evaluate the severity and func-
tional impairment from the individual’s tics prior to
treating ADHD symptoms. Stimulant therapy has been
shown to improve ADHD behaviors, social skill deficits,
and aggression in children with chronic tics or Tourette
syndrome.23 Many children with ADHD and a co-mor-
bid tic disorder do tolerate stimulant therapy, but it is
important to use stimulants with caution and monitor
the individual closely.23
Co-morbid Conduct Disorder and Oppositional
Defiant Disorder. ADHD can be co-morbid with both
CD and ODD.18 In children with severe oppositional
behavior, it is important to determine if there is an
underlying, untreated, mood disorder. In many children,
once the mood is stabilized, oppositional behavior
improves.
Individuals with ADHD and co-morbid CD are at an
increased risk to develop antisocial behavior as well as
substance abuse disorders.18,23
Table 3. Differential Diagnosis of ADHD
• Organic disorder
• Sensory integration disorders
• Medication-induced effects (e.g., antihistamines,
phenobarbital, beta-agonists)
• Seizure disorder (e.g., absence seizures)
• Learning disabilities
• Thyroid abnormality (e.g., hyperthyroidism)
• Mental retardation
• Brain neoplasm or frontal lobe abscess
• Lead intoxication (e.g., neurocognitive deficits)
• Pervasive developmental disorder
• Anxiety disorder (e.g., generalized anxiety disorder,
obsessive-compulsive disorder)
• Juvenile bipolar disorder—manic presentation
• Post-traumatic stress disorder (e.g., from abuse or
neglect)
• Adjustment disorder
• Tourette syndrome/multiple tic disorder
• Age-appropriate hyperactivity
• Multiple life stressors and transitions (e.g., divorce,
move, chronic illness in family member)
• Inappropriate school or work placement
• Family conflict or psychopathology
• Inconsistent limit-setting and disciplining by parents
8
Co-morbid Bipolar Disorder. It is often quite chal-
lenging to differentiate between symptoms of ADHD and
a mood disorder such as bipolar disorder, because both
disorders have overlapping symptoms of inattention,
hyperactivity, and impulsivity.5 If a child’s diagnosis is not
clear or if there are complicating factors, the child needs
to be referred to a specialist for further evaluation.
Co-morbid Substance Abuse Disorders. In chil-
dren and adolescents with ADHD and a co-morbid sub-
stance abuse disorder, difficulties in daily functioning may
persist into adulthood resulting in poor academic and
occupational achievement, social impairment, and an
increased rate of separation and divorce.23
Health care professionals need to remember that
ADHD symptoms may interfere with substance abuse
interventions. Individuals with ADHD and a co-morbid
substance abuse disorder should be referred to a mental
health specialist in substance abuse disorders.They should
be carefully and closely monitored and participate in a
substance abuse cessation program in addition to receiv-
ing pharmacological treatment.
Co-morbid Sleep Disorders. Recently, there has
been an increased awareness of the co-morbidity of
ADHD with sleep disorders. Sleep dysregulation may be
related to the ADHD or to use of medications such as
psychostimulants. From clinical experience, we have
observed that changes in sleep patterns can cause cogni-
tive impairments as well as attention and memory issues.
It is important to take a thorough sleep history and edu-
cate individuals and families about sleep hygiene tech-
niques to diminish insomnia. In addition, clinical experi-
ence suggests that the effects of some of the long-acting
stimulants may last up to 12 hours; therefore they should
be given early in the morning to decrease the likelihood
of insomnia.
If sleep dysregulation persists, it may be important to
refer the child or adolescent with ADHD to a sleep spe-
cialist and further evaluate him or her.
ADHD in Adults
The research literature on ADHD in adults is sparse, so
we must rely largely on clinical expertise and patient
presentation, along with extrapolations from child
research for guidance. Because we often lack early child-
hood records for adults with ADHD, it is difficult to doc-
ument an adult’s earliest demonstration of impulsive or
9 NOVEMBER 2008
inattentive symptoms. In addition, symptom presentation
changes somewhat over the lifespan.
It is anticipated that the DSM Task Force of the Amer-
ican Psychiatric Association will adjust the diagnostic cri-
teria for adults in the DSM V, due for publication in
2012, helping to clarify diagnosis in adults.
Adult Symptomatology
In young adults, ADHD presents with inattentiveness,
impulsivity, difficulty focusing, and hyperactivity (a more
common symptom in young males than in females). The
most hyperactive children, especially males, by adoles-
cence or young adulthood may have come into conflict
with school authorities or with law enforcement, or may
have suffered a higher than average incidence of serious
accidents. ADHD adolescent males in particular tend to
be exaggerated risk-takers. Even without engaging in
risky behaviors, the inattentiveness and distractibility of
ADHD can result in a higher frequency of automobile
accidents for these individuals.21
As individuals with ADHD mature, hyperactivity tends
to calm down or to become less visible to others; adults
with ADHD tend to be more internally restless or fidgety
than hyperactive.They may experience difficulty relaxing,
concentrating, or persisting with sedentary activities, have
poor organizational skills, be chronically late, often lose
things, and be serious procrastinators.They may complain
of being energetic project starters, but not “deal closers.”
They may abuse substances, and can be chronically bored,
moody, or short-tempered.
In the adult health care setting, people with ADHD
frequently present with mood disorders, alcohol and
drug abuse, or injuries from accidents or physical con-
frontations. Women particularly (for whom inattention is
more common than hyperactivity) tend to present with
anxiety, depression, or a feeling of being overwhelmed. It
can be challenging to determine if these individuals are
constitutionally depressed along with their ADHD, or if
depression reflects the social and intellectual demoraliza-
tion of a lifetime of feeling inadequate and “not quite
knowing” what is wrong. This is a typical pattern
described by adult women.
Because distraction and school or work difficulties can
also be the result of mood instability, substance use, med-
ication interaction, neurological compromise, learning
disabilities, or life events, diagnosis in adults is complex.
Adults, after all, are not brought to our office by parents
frightened by disruptive behaviors. Instead, they refer
 Case Study

M
aureen, an 18-year-old preparing for college, comes to the therapy office for relief of “depression and anxiety attacks.”
She has been engaged in interpersonal psychotherapy and has been receiving a selective serotonin reuptake inhibitor
for 6 years with only partial resolution of mood symptoms. She reports excellent school achievement in the primary
grades. However, as academic demands intensified in middle school, she says she felt less and less able to keep up with her
peers despite stepping up her efforts. She changed high schools, hoping for smaller, less competitive classrooms. She recalls
that a drop in her grades preceded her current feelings of anxiety and low self-esteem. She has struggled with anxiety and
depression throughout high school, and now is very concerned about starting college and facing additional pressures.
Maureen denies hyperactivity or impulsivity and has no history of learning disabilities. She reads well and her mathematical
skills are adequate. She was never identified by teachers as having “learning difficulties,” and has been described as a “good
student.” However, Maureen knows that she has had difficulty with organizational skills at school, and shyly admits to procrasti-
nation. She has successfully held part-time retail jobs during the summers. She reports no symptoms of exaggerated, fluctuating
mood, but describes feeling easily overwhelmed by school deadlines. She denies a history of a decreased need for sleep
accompanied by increased energy. She reports neither alcohol nor use of other substances. There is no family history of sub-
stance abuse. She has had neither grandiose nor morbid thoughts (differential symptoms of bipolar disorder and suicidality), but
does complain of feeling depressed sometimes to the point of sleeping most of the day and arising at night.
Upon investigation, Maureen reveals that her brother, away at college, has recently been diagnosed with ADHD. At first, she
is reluctant to consider a diagnosis of ADHD for herself, but when she is educated about the signs and symptoms of the disor-
der and its familial nature, Maureen is eventually relieved to receive the diagnosis.
In September, Maureen leaves for art college. She continues on her antidepressant, with the addition of a long-acting stimu-
lant. She is referred for cognitive behavioral therapy (CBT) to manage her anxiety and panic symptoms, which is a big success.
Maureen has discovered patterns in her behavior. She has learned to ask for help at her college’s Learning Center BEFORE
becoming overwhelmed by academic deadlines. With the documented diagnosis of ADHD, Maureen now qualifies for addition-
al time for test-taking and assignments. Perhaps most importantly, as her family has recently said, “We have our star back. Mau-
reen believes in herself again.” Maureen’s ADHD has not been cured, but she now has many more tools to help her pursue a
healthy, happy, and productive life.

themselves because their work or relationships are not
going well. They may also seek help upon referral of the
evaluators of their children, the courts, or be brought to
couple’s therapy by a chagrined and frustrated spouse.
Sometimes, they self-refer; as their children’s behavior is
identified and explained, they reflect upon their own sim-
ilar life-long challenges with schedules, organization,
impulsivity, concentration, and moodiness.
While children may be diagnosed with ADHD over
the course of an office visit or two (especially if school
records accompany the child), adult diagnosis takes longer,
and should include expert interviews by an advanced
practice psychiatric nurse, or by a psychiatrist, develop-
mental pediatrician, clinical psychologist, or clinical social
worker, with adequate time given to recall memories.
Recovery of school records should be attempted. If possi-
ble, symptom corroboration from family members,
friends, or associates should be sought.21,27 With pro-
longed interviews and evaluations, the clinician begins to
find out about life events or struggles that point toward
underlying attention problems and their possible causes.
Identification of ADHD in Parents and Other
Family Members
Because ADHD is now understood to be so inheritable,
the health care professional should consider that other
family members, including one or both parents, may also
carry some measure of the disorder. This information
should be presented carefully and sensitively to the parent
or family. A mother who struggles with undiagnosed
ADHD herself may feel guilty that her little girl has been
described as “spacey,” “lacking focus,” “underachieving,” or
worse yet, “lazy.” The mother whose husband has ADHD
may be extra sensitive to the way men and boys “don’t lis-
ten to what they’re told” or “don’t think before they act.”
Parents can become scared, angry, and frustrated at being
reminded of the hidden shortcomings of their own child-
hood expressed in their child’s behavior. For instance, the
father with undiagnosed ADHD who has struggled to
contain his own impulsivity and temper may have little
patience for the son who is disruptive or inattentive.
Dyslexia can limit the usefulness of printed materials
intended to teach the parent more about the child’s disor-

COUNSELING POINTS™ 10
der. Instructions should be stated and questions asked in a
variety of ways to accommodate the parent’s own learn-
ing style (auditory, visual, kinesthetic, mathematical, etc).
Realizing that attention may be at a premium, the health
care professional can help by repeatedly checking back
with an attention-challenged child or parent to ensure
that the clinician and family are communicating well.
Useful communication strategies can include the follow-
ing phrasing:
• “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 diag-
nosis, although adults and their families may first feel dis-
belief, disappointment, or grief, in the long run, the diag-
nosis can come as a huge relief.
Adults with ADHD and Psychiatric Co-morbidity
Few clinical trials have examined patterns of co-morbidi-
ty 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.12,13,28 Overall,
lifetime prevalence rates of psychiatric co-morbidities
have been estimated to be as high as 89% in adults with
ADHD.12,29
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 diffi-
cult adult behavior of people with various personality
disorders. Early childhood behavioral evidence (before
Join APNA today…Together we can make a difference!
The American Psychiatric Nurses Association (APNA) is the voice of psychiatric nursing. A professional organization of over
5,000 members, we are committed to the specialty practice of psychiatric-mental health nursing, health and wellness promotion
through identification of mental health issues, prevention of mental health problems, and the care and treatment of persons
with psychiatric disorders.
Go to www.apna.org for membership application.
11
age 7) may be unavailable. Hyperactivity may have turned
into “relaxation avoidance” or been channeled into work-
ing too many jobs for too many hours, compromising
family relationships. 30 Adults may appear under- or
hyperfocused, or both, with decreased facility in “switch-
ing” focus. ADHD appears co-morbidly with and must
be differentiated from anxiety disorders, depression, bipo-
lar 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, depres-
sion, 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 ade-
quate trial of a medication before determining that it is
or is not effective. If a patient does not respond to a num-
ber of medications, the clinician should re-examine the
diagnosis and consider use of other medications or psy-
chotherapy. Combined pharmacotherapy is usually
required with co-morbid psychiatric disorders.8 Care
must be taken to avoid the potential for drug-drug inter-
actions and to monitor for treatment-emergent side
effects. It is also important to periodically reassess the
individual’s need for treatment and determine if symp-
toms 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
NOVEMBER 2008
 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.
Member Benefits
• Access to employment opportunties through the NAPNAP Career Connection
• Quality educational content through PNP SOURCE—NAPNAP's online learning community
• Comprehensive and quality educational sessions through providers of continuing nursing education
• FREE subscriptions to the Journal of Pediatric Health Care magazine, the Pediatric Nurse Practitioner newsletter, and
Pediatric News
Information & Opportunities
• Acccess to Special Interest Groups (SIGs) to network with peers who practice in a similar field of interest
• A network of local chapters to support you where you live and work
• Grants and scholarships for research and professional development
• Significant savings on the annual conference registration
• A resourceful website at www.napnap.org
• Patient education publications
• Discounts on liability, health, and disability insurance
• Low-fee credit cards
Support for Members, Children & Families
• A team of respected Washington representatives to advocate for children’s health and PNP practice issues
• Position statements on child health and professional issues serve to educate professionals, decision-makers, and the
public about the advanced practice nursing perspective on specific topics.
• National programs developed to address and improve the health care of infants, children, adolescents, and young adults.
Visit www.napnap.org to apply online.

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 strategies to “work around” their
limitations and pursue very successful lives while enjoying
their “gifts” for spontaneity, creativity, and exuberance.
References
1. Zimmerman ML. Attention-deficit hyperactivity disorders. Nurs Clin N Am.
2003;38:55-66.
2. Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disor-
der across the lifespan. Annu Rev Med. 2002;53:113-131.
3. Faraone SV, Biederman J, Mick E. The age-dependent decline of atten-
tion deficit hyperactivity disorder: a meta-analysis of follow-up studies.
Psychol Med. 2006;36(2):159-165.
4. Dutton J. ADHD parenting advice from Michael Phelps’ mom. Additudes.
April/May 2007. Accessed 9/3/2008 at www.additudemag.com/adhd/arti-
cle/1998.html.
5. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, 4th ed. text revision. Washington, DC: American Psychi-
atric Association. 2000.
6. US Department of Health and Human Services. Summary Health Statistics
for U.S. Children: National Health Interview Survey, 2006. Series
10(234).Atlanta, Ga: Centers For Disease Control and Prevention. Septem-
ber 2007.
7. Kieling C, Goncalves R, Tannock R, et al. Neurobiology of attention deficit
hyperactivity disorder. Child Adolesc Psychiatr Clin N Am. 2008;17:
285-307.
8. Pliszka S and the AACAP Work Group on Quality Issues. Practice parame-
ter for the assessment and treatment of children and adolescents with
attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychia-
try. 2007;46:894-921.
9. Polanczyk G, Jensen P. Epidemiologic considerations in attention deficit
hyperactivity disorder: A review and update. Child Adolesc Psychiatr Clin
N Am. 2008;17:245-260.
10. Greenhill L, Posner K, Vaughan B, et al. Attention deficit hyperactivity dis-
order in preschool children. Child Adolesc Psychiatr Clin N Am. 2008;17:
347-366.
11. Froehlich T, Lanphear B, Epstein J, et al. Prevalence, recognition, and
treatment of attention-deficit/hyperactivity disorder in a national sample
of US children. Arch Pediatr Adolesc Med. 2007;161:857-864.
12. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of
adult ADHD in the United States: Results from the National Comorbidity
Survey Replication. Am J Psychiatry. 2006;163:716-723.
13. Fayyad J, DeGraaf R, Kessler R, et al. Cross-national prevalence and corre-
lates of adult attention-deficit hyperactivity disorder. Br J Psychiatry.
2007;190:402-409.

COUNSELING POINTS™ 12
 CP Counseling Points
Caring for Individuals with ADHD Throughout the Lifespan
An Introduction to ADHD
™

• Attention deficit hyperactivity disorder (ADHD) is the most common psychiatric condition affecting chil-
dren in the United States.
• The prevalence of ADHD is higher in males than females.
• It is now recognized that most children with ADHD continue to experience symptoms in their teen years
and many find ADHD persists into adulthood.
• The Diagnostic and Statistical Manual of Mental Disorders IV-TR defines ADHD as a “persistent pattern
of inattention and/or hyperactivity/impulsivity that is more frequent and severe than is typically
observed in individuals at a comparable level of development.”
• To date, there are no genetic or neuroimaging tests that clearly establish the diagnosis of ADHD.
• Co-morbid disorders that may accompany ADHD in children and adults include learning disabilities,
oppositional defiant disorder, conduct disorder, Tourette syndrome, anxiety and depression, and sub-
stance abuse.
• The literature on ADHD in adults is quite sparse, but adults with ADHD tend to demonstrate symptoms
of uncomfortable, internal restlessness and fidgeting rather than hyperactivity.
• Treatment of ADHD symptoms should continue as long as symptoms are present and cause significant
functional impairment.

14. Barkley R. Attention-Deficit Hyperactivity Disorder: A Handbook for Diag-
nosis and Treatment. New York: The Guilford Press. 2006.
15. Selekman J. Attention deficit hyperactivity disorder. In: Allen, PJ, Vessey
JA, Shapiro NA, eds. Primary Care of the Child with a Chronic Condition,
5th ed. St. Louis, Mo.: Mosby-Yearbook. In press.
16. Wymb BT, Pelham WE Jr, Molina BS, et al. Rate and predictors of divorce
among parents of youths with ADHD. J Consult Clin Psychol. 2008;76:
734-744.
17. Rostain AL. Treatment resistance in youths with ADHD and co-morbid
conditions. Psychiatric Times. 2007;24:1-3.
18. Biederman J. Impact of comorbidity in adults with attention deficit/hyper-
activity disorder. J Clin Psychiatry. 2004;65(Suppl 3):3-7.
19. Mick E, Faraone S. Genetics of attention deficit hyperactivity disorder.
Child Adolesc Psychiatr Clin N Am. 2008;17:261-284.
20. Solanto MV. Dopamine dysfunction in AD/HD: Integrating clinical and
basic neuroscience research. Behav Brain Res. 2002;130(1-2):65-71.
21. National Institute of Mental Health. Attention deficit hyperactivity disor-
der. 2008. Accessed 9/8/08 at www.nimh.nih.gov/health/publications/
adhd/complete-publication.shtml#pub8.
22. Cormier E. Attention deficit/hyperactivity disorder: A review and update. J
Pediatr Nurs. 2008;23:345-357.
23. Spencer T. ADHD and comorbidity. In: Biederman, J, ed. ADHD Across
the Lifespan: An Evidence-Based Understanding from Research to Clinical
Practice. Veritas Institute for Medical Education, Inc. and MedLearning,
Inc. 2006; 271-305.
24. Root RW, Resnick RJ. An update on the diagnosis and treatment of atten-
tion-deficit/hyperactivity disorder in children. Prof Psychol: Res Pract.
2003;34:34-41.
25. Fischer M, Barkley RA, Smallish L, et al. Young adult follow-up of hyperac-
tive children: Self-reported psychiatric disorders, comorbidity, and the role
of childhood conduct problems and teen conduct disorder. J Abnorm
Child Psychol. 2002;30:463-467.
26. Palumbo D, Spencer T, Lynch J, et al. Emergence of tics in children with
ADHD: Impact of once-daily OROS methylphenidate therapy. J Child
Adolesc Psychopharmacol. 2004;14:185-194.
27. Treating ADHD. Expert interview with Jefferson Prince, MD. The Carlat
Psychiatry Report. April 2003. Accessed 9/8/08 at www.thecarlatreport.
com/index.asp?page=wp3202007123142.
28. Wilens TE, Dodson WA. A clinical perspective of ADHD into adult-
hood. J Clin Psychiatry. 2004;65:1301-1313.
29. Spencer TJ. The epidemiology of adult ADHD. CNS Spectr. 2008;13:
8(Suppl 12);6-8.
30. Adler LA. Epidemiology, impairments, and differential diagnosis in adult
ADHD: Introduction. CNS Spectr. 2008;13:8(Suppl 12);4-5.

13 NOVEMBER 2008
 Counseling PointsTM Continuing Medical Education Posttest
Caring for Individuals with ADHD Throughout the Lifespan: An Introduction to ADHD
There are two ways to earn National Association of Pediatric Nurse Practitioners (NAPNAP) contact hours:
Via Mail/Fax Online
1. Please read the newsletter in its 1. Read the Counseling PointsTM issue,“An Introduction to ADHD.”
entirety. 2. Go to http://www.napnapce.org and click on “NAPNAP Posttest” under Course Categories –
2. Complete the post-test questions and Counseling PointsTM (direct course link http://www.napnapce.org/course/view.php?id=36).
program evaluation on page 15. 3. If you already have an account with PNPSourCESM, log in using your username and password. If
3. Mail or fax the Program Evaluation you are a NAPNAP member, log in with your member ID number and password. (If you do not
Form to NAPNAP, 20 Brace Road, know your member ID and Password, please contact NAPNAP at 877-662-7627.) If you are not a
Suite 200, Cherry Hill, NJ 08034- member of NAPNAP and this is your first time visiting PNPSourCESM, click on “Create New
2634, Fax 856-857-1600. Account.”
There is no charge for CE credit. 4. From the Course Outline screen, click on the “Take Test” button.
4. A certificate will be mailed within 5. After receiving a passing grade on the posttest, complete the evaluation survey and print your
4-6 weeks. CE certificate.
A certificate from NAPNAP will be awarded for a score of 70% (7 correct) or better. To contact a NAPNAP Customer Service representative,
please e-mail cesec@napnap.org or call (877) 662-7627 (M-F, 8:00 AM- 4:30 PM, Eastern Time).

1. According to the Diagnostic and Statistical Manual of 6. The differential diagnosis of ADHD includes ruling
Mental Disorders IV-TR, in order to make a diagnosis out:
of attention deficit hyperactivity disorder (ADHD), A. a thyroid abnormality
a patient must exhibit: B. a seizure disorder
A. three or more symptoms of inattention or hyperactivity/ C. medication side effects
impulsivity for at least 3 months D. all of the above
B. four or more symptoms of inattention or hyperactivity/ 7. The lifetime prevalence of co-morbid psychiatric
impulsivity for at least 4 months and/or learning disorders with ADHD may be as
C. five or more symptoms of inattention or hyperactivity/ high as:
impulsivity for at least 5 months A. the lifetime prevalence has not been studied
D. six or more symptoms of inattention or hyperactivity/ B. 26%
impulsivity for at least 6 months C. 66%
2. Which of the following is a subtype of ADHD? D. 84%
A. Predominantly inattentive 8. Recent studies support the early identification and
B. Predominantly hyperactive-impulsive treatment of ADHD to prevent the subsequent
C. Predominantly disorganized development of co-morbid disorders.
D. Both A and B A. True
3. Boys are diagnosed with ADHD at a ratio of ___ B. False
compared with girls: 9. ADHD and which of the following disorders share
A. 1: 1 overlapping symptoms of inattention, hyperactivity,
B. 2-4:1 and impulsivity?
C. 5-6:1 A. Asperger’s syndrome
D 7-9:1 B. Bipolar disorder
4. ADHD is considered to be a highly inheritable C. Both of the above
disorder. D. Neither of the above
A. True 10. When a co-morbid psychiatric disorder accompa-
B. False nies ADHD in adults, it is critical to treat:
5. Current evidence suggests that risk factors for A. the more severe disorder first
ADHD include all BUT which of the following? B. both disorders together
A. Meningitis C. the less severe disorder first
B. Lead intoxication D. the disorders in the order in which they first manifested
C. Very low birth weight symptoms
D. Nutritional intake of free sugars or artificial additives

COUNSELING POINTS™ 14
 Counseling Points™: Program Evaluation Form
Caring for Individuals with ADHD Throughout the Lifespan: An Introduction to ADHD
Please mail or fax the completed form to NAPNAP, 20 Brace Road, Suite 200, Cherry Hill, NJ 08034-2634, Fax 856-857-1600.
There is no fee for this educational activity but you must complete this form to receive acknowledgement for the activity.
1 = Strongly Disagree 2 = Disagree 3 = Somewhat Disagree 4 = Somewhat Agree 5 = Agree 6 = Strongly Agree
Did you participate in the preassessment survey? ❒ Yes ❒ No
To what extent do you agree with the following statements? (Please circle the appropriate number on the scale.)
1. ADHD is a highly inheritable psychiatric disorder. .......................................................................................................................................... 1 2 3 4 5 6
2. Long-term nutritional intake of free sugars or artificial additives causes ADHD. ............................................................................................... 1 2 3 4 5 6
3. Tests such as an electroencephalogram (EEG), magnetic resonance imaging (MRI) scan, single photo emission computed
tomography (SPECT) scan, or positron emission tomography (PET) scan are not usually needed to diagnose ADHD. .................................... 1 2 3 4 5 6
4. Psychiatric co-morbidities are common in patients with ADHD. ..................................................................................................................... 1 2 3 4 5 6
To what extend were the following objectives satisfied?
5. State the prevalence and economic burden of attention deficit hyperactivity disorder (ADHD)........................................................................ 1 2 3 4 5 6
6. Discuss the pathophysiology and risk factors for ADHD................................................................................................................................... 1 2 3 4 5 6
7. Determine the signs and symptoms of ADHD and common co-morbidities that may confound diagnosis....................................................... 1 2 3 4 5 6
8. Identify ADHD across the lifespan.................................................................................................................................................................... 1 2 3 4 5 6
To what extent was the content well-organized?
9. State the prevalence and economic burden of attention deficit hyperactivity disorder (ADHD)........................................................................ 1 2 3 4 5 6
10. Discuss the pathophysiology and risk factors for ADHD ................................................................................................................................. 1 2 3 4 5 6
11. Determine the signs and symptoms of ADHD and common co-morbidities that may confound diagnosis..................................................... 1 2 3 4 5 6
12. Identify ADHD across the lifespan .................................................................................................................................................................. 1 2 3 4 5 6
To what extent was the content easily understandable?
13. State the prevalence and economic burden of attention deficit hyperactivity disorder (ADHD) ...................................................................... 1 2 3 4 5 6
14. Discuss the pathophysiology and risk factors for ADHD ................................................................................................................................. 1 2 3 4 5 6
15. Determine the signs and symptoms of ADHD and common co-morbidities that may confound diagnosis ..................................................... 1 2 3 4 5 6
16. Identify ADHD across the lifespan................................................................................................................................................................... 1 2 3 4 5 6
General Comments
17.The topic was current and relevant to my area of professional interest. ................................................................................................... 1 2 3 4 5 6
18.The program was free of commercial bias. ................................................................................................................................................. 1 2 3 4 5 6
19.The program increased my awareness and understanding of the subject matter. ..................................................................................... 1 2 3 4 5 6
20.As a result of this continuing education activity (check only one):
❒ I will modify my practice.
❒ I will wait for more information before modifying my practice.
❒ The program reinforces my current practice.
Suggestions for future topics/additional comments: __________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
Follow-up
As part of our continuous quality improvement effort, we conduct post-activity follow-up surveys to assess the impact of our educational interven-
tions on professional practice. Please check one:
❒ Yes, I would be interested in participating in a follow-up survey.
❒ No, I would not be interested in participating in a follow-up survey.
Patient Education Follow-up

Would you be interested in receiving an educational magazine on ADHD to distribute to your patients? ❒ Yes ❒ No

Posttest Answer Key 1 2 3 4 5 6 7 8 9 10

A10-08-E31
Request for Credit
Name ___________________________________________________________ Type of Degree ________________________________________
Organization___________________________________________________________ Specialty ________________________________________
Address_________________________________________________________________________________________________________________
City _____________________________________________________________________________ State __________ ZIP ________________
Phone _____________________________ Fax _____________________________ E-mail __________________________________________
Signature_________________________________________________________________ Date ______________________________________

Fax form to 856-857-1600

15 NOVEMBER 2008
CP

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