Evidence Based Nursing:: Far Eastern University - Institute of Nursing

Far Eastern University Institute of Nursing
Nicanor Reyes St., Manila
Evidence Based Nursing:

Can Attention Deficit Hyperactivity Disorder (ADHD), a common neuro-developmental
disorder of childhood, reverberate until adolescence and adulthood?
Submitted by:
Fernandez, John Michael S.
BSN403/ Group 10
Submitted to:
Ms. Padual
Professor
I. Clinical Question
Is an adenovirus-based multivalent vaccine effective in for the protection against Avian
Influenza viruses?
II. Citation
1. Vemula, S. V., Ahi, Y. S., Swaim, A., Katz, J. M., Donis, R., Sambhara, S., & Mittal, S. K.
(2013). Broadly Protective Adenovirus-Based Multivalent Vaccines against Highly
Pathogenic Avian Influenza Viruses for Pandemic Preparedness. Plos ONE, 8(4), 1-12.
doi:10.1371/journal.pone.0062496
III. Study Characteristics
a. Patients Included
1. Journal: Mortality, ADHD, and Psychosocial Adversity in Adults With Childhood
ADHD: A Prospective Study
The subjects of the study were chosen via birth cohort consisting of all children
which were born from January 1, 1976 and December 31, 1982 whose mothers were
residing in townships which encompasses the Minnesota Independent School District
535, continued to live in Rochester until 5 years of age and granted their permission for
the use of the medical records (N = 5718). Subjects were characterized to perform in the
research study if the medical records reveal the combination of the following: (1)
documentation in medical and school records of behavioral symptoms consistent with the
criteria for ADHD from the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV TR), (2) positive ADHD questionnaire results and (3)
documented clinical diagnosis of ADHD. From this birth cohort, identification of
childhood ADHD cases was performed and a total of 379 subjects were identified to have
the diagnosis of ADHD. The remaining non-ADHD subjects (N=4946) who had lived in
the community after 5 years of age and had not fulfilled the research criteria were also
recognized. Moreover, subjects with severe intellectual disability (N=19) and subjects
who denied the access of their medical records (N=369) were excluded from the study.
2. Journal: Clinical and Functional Outcome of Childhood ADHD 33 Years Later
The subjects of the study were identified via referrals from teachers between 1970
and 1978 to subjects 6 to 12 years of age and were exhibiting ADHD symptoms such as
hyperactivity, impulsivity or other behavioral problems. Furthermore, a total of 135
Caucasian males diagnosed with ADHD during their childhood and 136 male
comparisons without childhood ADHD were the identified.
3. Journal: Adolescent ADHD and Adult Physical and Mental Health, Work Performance
and Financial Stress
The subjects of the study were chosen families residing at 2 upstate New York
countries. First study conducted last 1975 (T1) wherein subjects were assessed for any
behavioral problems as observed by their mothers. Additional information was obtained from
subjects in 1983 (T2, N=756), 19851986 (T3, N = 739), 1992 (T4, N = 750),1997 (T5, N =
749), 2002 (T6, N = 673), and 20052006 (T7, N = 607). A total of 551 subjects have been
positive in the ADHD assessments at both T2 and T3 which also participated in the study at
T7.
4. Journal: Attention Deficit Hyperactivity Disorder in Australian Adults: Prevalence,
Persistence, Conduct Problems and Disadvantage
The subjects in the study were monozygotic (MZ) and dizygotic (DZ) twins and their
siblings recruited via the National and Medical Council Twin Registry (ATR). ATR members
born between 1972 and 1976 were invited to participate in the study. Thus, a total of 1369
men and 2426 women were ascertained.
5. Journal: Predictors of Persistent ADHD: An 11 Year Follow-Up Study
The subjects of the study were 110 male Caucasian, non-Hispanic subjects diagnosed
with ADHD and 105 subjects without the diagnosis of the disorder were ascertained; the
subjects who participated in the research study were aged 6-17 years old at baseline
assessment and 15 to 31 years old during the follow-up assessment
b. Intervention Compared
Vital status was gathered at the time of the recruitment of the subjects chosen to
participate in the research study. For each member of the birth cohort, follow-up assessment was
determined based from the date of metresearch, criteria for ADHD to their date of death, death of
study participation or date last known alive, based on the last documented medical visit in the
Rochester Epidemiology Project records before 2009. Incarceration status for childhood ADHD
cases was determined at the time of recruitment with basis to the responses received during
telephone contacts, monthly screening of websites containing public data on criminal convictions
and attempted mail. Furthermore, all of the subjects in the study were administered to a interview
called Mini International Neuropsychiatric Interview (M.I.N.I), a structured diagnostic interview
for BSM-IV TR and International Classification of Diseases, 10th Revision psychiatric disorders.
Assessment of the subjects were performed by the researchers through close supervision
of psychological data, gathering of detailed information about employment history, education,
medical history, social functioning, psychiatric status, marital history, occupational adjustment,
living circumstances and family composition. Moreover, brain scan and informant interviews
were conducted.
Assessment based on the adaptations of the Diagnostic Interview Schedule for Children
were administered to the subjects to assess psychiatric disorders including Attention Deficit
Hyperactivity Disorder. Assessment of the subjects general physical health included perceived
role limitations due to physical health and physical functioning while assessment of the general
mental health included measures of general mental health and role limitations due to emotional
problems. Examination on adult anti-social personality disorder was initiated through the use of
an adaptation of University of Michigan Composite International Diagnostic Interview ASPD
measure and the subjects work performance consisted of a variable of being laid off at work,
measures of skipped work and work responsibility or unemployment.
The subjects of the study were assessed through the use of a diagnostic tool as follows:
(1) full DSM-IV criteria, (2) excluding the age 7 in the onset criterion (no age criterion) and (3)
subjects who experienced difficulties due to ADHD symptoms or problem symptoms.
The research study reports on the 11-year follow up assessment of the subjects where 112
ADHD and 105 control subjects were successfully re-examined. Psychiatric assessment of the
follow-up study was based on the DSM-IV based K-SADS-E-IV assessing DSM-IV disorders for
the subjects less than eighteen years of age while the Structured Clinical Interview for DSM-IV
(SCID) was used for the subjects eighteen years and older. Also, direct interviews with the
subjects and indirect interviews about the subjects with their mothers were conducted.
c.
Outcomes Monitored

The research study was designed to examine the long-term effects of attention-deficit
hyperactivity disorder (ADHD) in a population-based sample of childhood ADHD cases and
controls, prospectively assessed as adults.
2. Journal: Clinical and Functional Outcome of Childhood ADHD 33 Years Later.
The research study was designed to determine whether subjects diagnosed with
childhood ADHD experience different educational, occupational, economic, social and
marital outcomes when such disorder persists until adulthood.
The research study was designed to determine the relationship between ADHD
diagnosed in adolescence and impaired general physical health, impaired general mental
health, antisocial personality disorder, impaired work performance and high financial stress
in adulthood.
The research study was designed to indicate whether different factors such as career,
health and childhood risk factors has a significant difference for people with ADHD
symptoms and ADHD symptoms with conduct problems.
The research study was designed evaluate different predictors in the persistence of
Attention Deficit Hyperactivity Disorder (ADHD) in a wide selection of boys with and
without diagnosis of ADHD and follow-up assessment made prospectively for 11 years into
young adulthood.
d. Does the study focus on the significant problem in clinical practice?

Yes, the study focuses on a foreseen significant problem in the clinical practice since
untreated and undiagnosed ADHD during childhood can persist later in an individuals life,
hence, poses various complications and consequences which require the attention and
intervention of clinician, health care providers and significant others.
IV. Methodology/Design
a. Methodology
Adults with diagnosis of ADHD and without diagnosis of ADHD during childhood on the
same birth cohort (N=5718) were invited to participate in the research study and identification of
the vital status of birth cohort members was done. To compare overall and cause specific
mortality between the childhood ADHD cases and controls, standardized mortality ratios (SMRs)
were constructed by the researchers; also, incarceration status was determined and standardized
neuropsychiatric interviews was also administered to the subjects of the study.

The subjects who participated in the study were assessed and examined by the
researchers through close supervision of psychological data, gathering of detailed information
about employment history, education, marital history, occupational adjustment, living
circumstances, family composition, medical history, social functioning and psychiatric status.
Informant interviews were conducted.
The research study was composed of six assessments where the subjects mean ages were
from 14 to 37 years old. Two baseline assessments were taken and performed between the ages
of 14 to 16 years while five outcome assessments were obtained at mean age of 37 years to
determine if any changes have occurred. Subjects were assessed through the use of
questionnaires and structured interview.

Highly trained and knowledgeable interviewers gathered the information about the
subjects experience with Attention Deficit Hyperactivity Disorder (ADHD), conduct problems,
employment, education, childhood experience and relationship and health variables. In the
assessment, three diagnostic of ADHD were used which are the following: (1) full DSM-IV
criteria, (2) excluding the age 7 in the onset criterion (no age criterion) and (3) subjects who
experienced difficulties due to ADHD symptoms or problem symptoms.
The subjects of the study were derived via longitudinal case-control family study of
referred youth with and without the diagnosis of ADHD. From this, 140 male Caucasian subjects
diagnosed with ADHD and 120 subjects without the diagnosis of the disorder were ascertained;
the subjects recognized in the study were aged 6-17 years old. Furthermore, the present study
embarks upon the 11-year follow-up assessment of the subjects previously chosen wherein only
110 subjects with ADHD and 105 without ADHD were successfully identified. Comprehensive
assessments of the subjects were performed through structured diagnostic interviews and
assessments of cognitive, social, school, and family functioning.
b. Design
All of the five research studies chose indicated the use of the same research design called
prospective cohort study. Prospective cohort study is an analytic study to determine the condition
and characteristic shared by the participants involved. The subjects of the study were identified
based on the exposure status prior to the development of the disease, hence, how Attention
Deficit Hyperactivity Disorder (ADHD) progresses and affects individuals if it reverberates later
in life. Per se, the outcomes are measured through the baseline and follow-up assessments over
time and are examined whether any significant differences have occurred.
c. Setting
The research study was conducted at Mayo Clinic, Rochester, Minnesota, USA.

The research study was undertaken at NYU Langone Medical Center, New York, New
York, USA.
The research study was conducted at New York University School of Medicine, New
York, New York, USA.
The research study was undertaken at the Queensland Institute of Medical Research,
Queensland, Australia.
The research study was conducted at Massachusetts General Hospital, Boston,
Massachusetts, USA.
d. Data sources
Information relevant to the study was obtained from the subjects who agreed to
participate in the conduction of the research. Furthermore, follow-up assessment of the subjects
with and without the diagnosis of childhood ADHD was administered after a few years from first
assessment in order to determine whether there are significant changes which occurred in every
developmental stage.
e. Has the original study been replicated?
Most of the research studies were replication of past researches and reflects similar
findings on the progression of the implications of ADHD across the lifespan and its high
prevalence among adults diagnosed with childhood ADHD.
f. What are the risk and benefit of the nursing actions or interventions tested in
the study?
The benefits of the nursing interventions tested in the study are to determine the
implications and outcomes of childhood ADHD as it reverberate later in life and to provide the
necessary interventions to be provided for the individuals diagnosed with the disorder. On the
other hand, the risk
V. Results Study
Among the 367 childhood ADHD cases identified, 7 (1.9%) of them were deceased and
10 (2.7%) were incarcerated. The standardized mortality ratio for the total number of survived
subjects diagnosed with childhood ADHD as compared to the number of controls was 1.88 and
for accidents resulted in only 1.70. The study showed that there is a higher mortality cases of
suicide among the ADHD cases. Furthermore, among the 232 subjects who participated in the
follow-up, prospective assessment, 29.3% ADHD reverberated into adulthood.
Findings from the examinations and assessments performed showed that subjects
exhibited worse occupational, educational, social and economic outcomes which also resulted
into more divorces than comparisons. Results shows that higher rates of ongoing ADHD (22%),
anti-social personality disorder (16%) and substance disorders (14%) but, lower rates of mood or
anxiety disorders. As the study progresses, it was observed that the subjects possesses more antisocial personality disorders and substance disorders. Furthermore, psychiatric disorder with
onsets at the age of 21 was significantly elevated but, subjects without ongoing psychiatric
disorder experienced worse social functioning.
The results of the study depict the adjusted odd ratios for the occurrences of ADHD in
adolescence with accordance to internal factors during adulthood are as follows: 1.82 (95%) for
impaired general physical health, 3.28 (95%) for antisocial personality disorder and 2.36 (95%)
for impaired general mental health. However, the adjusted odd ratio for adolescence diagnosed
with ADHD as related to external factors are the following: 2.46 (95%) for impaired work
performance and 3.33 (95%) for high financial stress.
The results of the study showed the prevalence of ADHD in adulthood to be: 1.1%, 2.3%
and 2.7% according to the categorization respectively given. Furthermore, the reverberation of
childhood ADHD into adulthood according to gender was 55.3% with the full criteria given,
50.3% with no age criterion and 40.2% for the problem symptoms encountered. The ADHD
symptoms were associated with poor health, being sexually assaulted during childhood, parental
conflict, income loss, higher unemployment and lower education.
According to the 11-year follow-up assessment conducted in the study, a total of 78% of
the subjects with diagnosis of ADHD continued to possess a full 35% or partial persistence
(22%) of the symptoms of ADHD by which 15% exhibited impaired functioning. It was
concluded that the predictors of the persistence of ADHD into adulthood were the following: (1)
psychiatric comorbidity, (2) severe impairment of ADHD and (3) exposure to maternal
psychopathology.
VI. Authors Conclusion/Recommendation
Conclusion: The findings of the study identified the substantial implications in the
effectiveness of care rendered to children afflicted with ADHD and the kind of interventions to
meet the needs of the individuals diagnosed with the disorder across the lifespan. Furthermore,
results indicated that only minority of children with ADHD were able to proceed to adulthood
without suffering the serious problems which comes hand-in-hand with ADHD; this commends
that interventions given were not effective. Thus, the information gathered indicates the
improvement of care that clinicians and health care systems provide for adults diagnosed with
ADHD.
Conclusion: Various disadvantages were reflected by subjects with ADHD during their
childhood as it persists into adulthood. The symptoms emerged in adolescence, without other
onset of new disorders after the age of 20. The findings stressed the vitality of frequent
monitoring and early treatment of children diagnosed with ADHD.
Conclusion: Findings of the research study focused on the major outcomes for the
prevention and treatment of ADHD and the consequences affiliated with it. Data were gathered
through the use of a community sample of adults both with and without the diagnosis of ADHD
during adolescence and the results indicated that there is indeed a linkage between ADHD in
adolescence and the different internal factors (e.g. physical difficulties) and external factors (e.g.
financial and occupational problems) based on the 23-year follow-up study. The information
revealed the possible implications and consequences in ADHD, thus, importance of early
diagnosis and treatment is emphasized to prevent severe long-term repercussions. Furthermore,
future research is advised to focus in the clarification of the factors that can change the course of
ADHD from adolescence to adulthood and further examination how the mechanisms of internal
and external stress affect the individual.
Conclusion: Subjects who met the full diagnostic criteria and inattention indicated in the
study showed the highest ratio in the persistence of ADHD into adulthood which were affiliated
with the greatest loss of income and various disadvantages. These disadvantages (with regards to
conduct problems) are distinct in terms of the severity and ratio of adults afflicted with the
disorder. The indication of the treatment and etiology needs reveal that men with ADHD are at
greater risk to be associated with childhood adversity. Moreover, further study about the reports
of different sexual assaults during childhood by the subjects with ADHD and impact and
treatment needs on adults with ADHD and conduct problems is highly recommended.
Conclusion: The findings of the research study strongly suggest and confirm that
reverberation of ADHD occurs over time and affects adolescents and adults diagnosed with
ADHD during childhood. Moreover, long term prognosis is predictable from psychiatric
comorbidity and psychosocial adversity confirmed 11 years earlier.
a. What contribution to the clients health status does the nursing action or
intervention make?
The contribution of the nursing action to the clients health status is to provide
appropriate care to the subjects afflicted with Attention Deficit Hyperactivity Disorder (ADHD)
depending on the developmental stage where the subject is diagnosed with. This is to prevent the
severity of the implication and consequences involved in such disorder to obtain clients full
potential of functioning.
b. What overall contribution to nursing knowledge does the study make?
Attention Deficit Hyperactivity Disorder (ADHD) is viewed to be a common neurodevelopmental disorder among children but, when long-term prognosis of such disorder occurs,
can lead to serious psychological comorbidities. Therefore, the overall contribution of the
research studies chosen is to further delve in and recognize the long-term impacts of ADHD as it
persist later in life. Furthermore, the recognition of such differences between childhood and adult
ADHD can revamp the approach of the health providers and help render appropriate nursing care
to patients affiliated with such disorder across the lifespan.
VII. Applicability
a.
Does the study provide direct enough answer to your clinical question in
terms of type of subject intervention and outcome?
Yes, it has a direct answer to the formulated clinical question because the results reflect
that there is a significant increase in the prevalence of adult ADHD (with childhood diagnosis of
the disorder) in accordance to the follow-up studies generated. Moreover, the outcomes
successfully showed the difference between the symptoms of ADHD in each age group.
b. Is it feasible to carry out the nursing action in the world?
Yes, it is feasible to carry out the nursing action in the world since persistence of ADHD
into adulthood can be halted by understanding its long-tem implications and is also solely
dependent on the effectiveness of care rendered to individuals afflicted with the disorder across
the lifespan. Moreover, early diagnosis and treatment of such disorder may lessen the complexity
of symptoms according to the care rendered.
VIII. Reviewers Conclusion
The onset of Attention Deficit Hyperactivity Disorder (ADHD) typically occurs during
childhood but, can now reverberate well-beyond this stage until adolescence and adulthood,
affecting different countries around the world including the Philippines. The consequences in
hand with the disorder can greatly distort and affect the normal living of a person, thus, the
results of this study may help not only the people afflicted but also the health care institutions in
discovering a more suitable and effective way in protecting and reducing the deteriorating effects
of ADHD.
IX. Evaluating Nursing Care Practices
c. Safety
Prior to the administration of the various examinations and assessments of the research
study, informed consents were deliberately given to the subjects in order to ensure safety.
Moreover, the assessment was composed of a series of tests to determine the diagnosis of ADHD
across the lifespan; symptoms of the disorder were noted on each age criterion.
d. Competence of the care provide
Highly competent and extensively trained researchers were chosen to conduct and
supervise the assessment and examination in each research study. Therefore, it can be concluded
that subjects in the study were given due attention, respect and care by the researchers.
e. Acceptability
Results of the study are acceptable and consistent as it reflects the persistence of
childhood ADHD into adolescence and adulthood. Information gathered were significant to the
present condition since prevalence of adult ADHD is rapidly increasing and appropriate
intervention should be respectively provided.
f. Effectiveness
In my own perspective, interventions in each research study were effective as it provided
similar results in all five research studies chosen as to whether reverberation of ADHD can occur
later in childhood. Furthermore, the assessments rendered were suitable to the age criterion since
there is a significant difference in the care provided for children, adolescents and adults.
g. Appropriateness
Various assessments and examinations were performed prior the formulation of the
conclusion and refinement of the results in order to provide appropriate outcomes of the desired
objectives of each research study. Moreover, these actions were performed to ensure relevant
information about ADHD was gathered throughout the course of the study.
h. Efficiency
Adequate interventions were subsequently provided to the subjects since researchers and
interviewers who initiated the study were equipped with the necessary skills needed to execute
tasks involved in the completion of the results and are knowledgeable about Attention Deficit
Hyperactivity Disorder.

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Far Eastern University Institute of Nursing

Nicanor Reyes St., Manila

Evidence Based Nursing:

1. Journal: Mortality, ADHD, and Psychosocial Adversity in Adults With Childhood

d. Does the study focus on the significant problem in clinical practice?

2. Journal: Clinical and Functional Outcome of Childhood ADHD 33 Years Later

4. Journal: Attention Deficit Hyperactivity Disorder in Australian Adults: Prevalence,

2. Journal: Clinical and Functional Outcome of Childhood ADHD 33 Years Later.

b. What overall contribution to nursing knowledge does the study make?

IX. Evaluating Nursing Care Practices

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