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UNIT VII • Care of Children and Adolescents

when the Feingold diet was introduced (Feingold, 1975). Over the years, interest in the link between food and behavior continues to spark interest in ADHD as an issue related to food. Agreement exists that in some children the behaviors associated with ADHD can be decreased with diet changes (Chatfield, 2023). The free foods diet may be an option in ADHD treatment. The few foods diet includes basic foods that are not likely to produce adverse effects such as lamb, chicken, potatoes, bananas, and apples. Grains, dairy products, and processed foods are avoided in the few foods diet. The restricted elimina tion diet includes all-natural, chemical-free foods. Fruits, vegetables, nuts, nut butters, beans, seeds, gluten-free grains such as rice and quinoa, fish, lamb, wild game meats, organic turkey, and large amounts of water are consumed. This diet is very restricted and consequently difficult to follow all of the time. The polyunsaturated diet suggests that children with ADHD have low levels of omega-3 polyunsaturated fatty acids. Supplements are encouraged for these individuals (Lange et al., 2023; Liu et al., 2023). Supplementation with free fatty acids has been shown to be helpful for children who have deficiencies in free fatty acid such as omega-3 free fatty acid, omega-6 free fatty acid, and linolenic acid. This supplementation is usually achieved with capsule-containing oils or diets rich in fish products (Chatfield, 2023). If patients adhere to any of these diets, the nurse should support the patient and family in providing the nutritional information needed for the diet. In addition, the patient and family will need education regarding those foods that are chemical free. A referral to a dietitian will benefit both patient and family. Children with ADHD seem to be more susceptible to being overweight and developing obesity, with over half of children with ADHD demonstrating atypical eating behaviors. Factors contributing to the relationship between ADHD and being overweight may include the child’s environment, genetics, atypical eating patterns, executive dysfunction, low physical activity, and sleep disturbances (Zhu et al., 2024). Because of the impul sivity and inattention characteristic of ADHD, children with ADHD may be unable to self-regulate and engage in healthy eating behaviors. They are more likely to consume sweetened beverages, sweets, candies, and other types of junk foods (Khazdouz et al., 2024). The nurse can help the family and patient structure the external environment, so the child has healthy choices available. Promoting Sleep Up to 70% of children with ADHD experience difficulty with sleep. Issues include bedtime resistance, sleep onset difficulties, lighter sleep, poor-quality sleep, fragmented sleep due to restlessness, and shorter sleep duration. Sleep disturbance contributes to poorer academic performance,

higher parental stress, and poorer parental health (Larsson et al., 2022). There are many things contributing to sleep disturbance, including the overactivity of the disorder itself and the side effects of the psychostimulants. A sleep history should be taken before medications are prescribed. If issues exist, atomoxetine should be considered before the psychostimulants (see next section). If sleep issues arise while taking medications, sleep diaries should be kept. Sleep hygiene and behavior therapy techniques, including emphasis on a bedtime routine, electronic media restriction, caffeine restriction, exposure to morn ing light, scheduling physical activity during the day and optimization of the sleep environment should be imple mented (Russell & Arnold, 2023). See Chapter 34. Medication Interventions Approved medications for ADHD in children as young as 6 years include stimulants and nonstimu lants. Psychostimulants, including methylphenidate, dextroamphetamine, and mixed amphetamine salts (see Chapter 11), are by far the most commonly used medica tions for the treatment of ADHD and are found to effec tive in reducing ADHD symptoms in 70% to 80% of children. These medications enhance dopamine and nor epinephrine activity, which thereby improves attention and focus, decreases hyperactivity and impulsivity, and decreases disruptive behaviors (CDC, 2024b; Cortese, 2023; NIMH, 2024a; Peterson et al., 2024). Methylphenidate has a total duration of action of about 4 hours (Box 37.7). Thus, parents or teachers often describe a return of overactivity and distractibility as the first dose of medication wears off. This “rebound effect” can often be managed by moving the second dose of the day slightly closer to the first dose. Longer-acting preparations of methylphenidate or amphetamine–­ dextroamphetamine do not require such frequent dosing and may be a better fit with a school day schedule. The most common side effects associated with stimulants for ADHD include appetite suppression, insomnia, dry mouth, and nausea. Drug holidays are sometimes imple mented to determine the need for continued medication and to manage side effects. One major concern with psychostimulants is the potential for misuse. With the increase in recognition of ADHD, psychostimulant prescriptions have increased, as well as an increase in diversion for cognitive enhance ment or appetite suppression. These misused prescrip tion medications are most often acquired from peers who share, sell, or trade their medication. Nurses should caution parents about the potential for misuse and pre vent their child’s medication from being a source of rec reational use (Cortese, 2023). Nonstimulant medications do not work as quickly as stimulants, though they are an alternative for those who do not tolerate stimulants well, when a stimulant is

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