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SYSTEMATIC REVIEW
published: 22 February 2022
doi: 10.3389/fpsyt.2022.676528
Frontiers in Psychiatry | www.frontiersin.org 1February 2022 | Volume 13 | Article 676528
Edited by:
Kerstin Jessica von Plessen,
Centre Hospitalier Universitaire
Vaudois (CHUV), Switzerland
Reviewed by:
Karol Machiñena,
Nurse & Clínica Universidad de
Navarra, Spain
Alessandra Carta,
University of Sassari, Italy
Francesco Perrotta,
University of Catanzaro, Italy
*Correspondence:
Liv Kleve
liv.kleve@helse-bergen.no
Specialty section:
This article was submitted to
Child and Adolescent Psychiatry,
a section of the journal
Frontiers in Psychiatry
Received: 05 March 2021
Accepted: 10 January 2022
Published: 22 February 2022
Citation:
Kleve L, Vårdal L and Elgen IB (2022)
The Nurse Role in the Management of
ADHD in Children and Adolescent: A
Literature Review.
Front. Psychiatry 13:676528.
doi: 10.3389/fpsyt.2022.676528
The Nurse Role in the Management
of ADHD in Children and Adolescent:
A Literature Review
Liv Kleve 1
*, Lisa Vårdal 1and Irene Bircow Elgen 1,2
1Division of Mental Health, Department of Child and Adolescent Psychiatry, Haukeland University Hospital, Bergen, Norway,
2Department of Clinical Medicine, University of Bergen, Bergen, Norway
Objective: To review literature regarding existing and recommended roles for nurses in
the management of children with ADHD.
Methods: MEDLINE and CINAHL were searched from 2010 to the end of 2019
with the following keywords: ADHD, nurse, child, and inclusion criteria published in an
English journal.
Results: Forty-three records were found. However, only five articles scientifically
evaluated the nurse role. The nurse role in ADHD management seemed to vary
across countries with nurses working independently or as part of a team with
delegated responsibility.
Conclusion: The literature review gave information to suggest that nurses can have a
significant role in providing a range of medical and non-medical management.
Keywords: ADHD, ADHD management, nurse role, ADHD treatment, inattention
INTRODUCTION
Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder, and for many
of the children, this will last until adulthood and is often referred to as a chronic condition (1–3).
Symptoms are manifested across several areas of life and may vary between home, school, and
leisure activities. Attention-deficit/hyperactivity disorder is also often associated with comorbid
conditions (4). Management can be difficult and time consuming, and there is a need to ensure
that evidence-based approaches are implemented. The life course perspective in ADHD becomes
crucial where detection and intervention in early life have implications for later outcomes (5).
Several families also describe their daily living as demanding and ask for additional support with
siblings (6).
In 2019, AAP introduced a revised edition of Clinical Practice Guidelines for the diagnosis,
evaluation, and treatment of ADHD in children and adolescents (7,8). The guidelines give
several detailed recommendations including comprehensive follow-up programs, in addition to
pharmacotherapy and behavioral intervention. The implementation of these extended guidelines
challenges child and adolescent mental health services (CAMHS) both in relation to the
organization of the service and in how to collaborate across service levels.
Some studies have identified that the shortage of psychiatrists in CAMHS often becomes a
bottleneck both for diagnostics and for treatment of ADHD children (4,9,10). In response to
Kleve et al. ADHD Nurse, a Literature Review
this, some have suggested that nurses are a resource in the
management of ADHD (4). In addition, there is an ongoing
discussion whether primary health care should play a more
pronounced role in the assessment process (4,11). Coghill,
however, argues that because of the ongoing need to monitor
symptoms, impairments, functioning, and comorbidities, the
overall responsibility for ADHD should remain within specialist
mental health services (4,11).
Given the above challenges and the fact that ADHD is a major
aspect of the work within CAMHS, it is pertinent to explore
which of the tasks suggested in the American Psychological
Association (AAP) guidelines need to be profession-specific. The
aim of this study was to review literature regarding existing and
recommended roles for nurses in the assessment and treatment
of children with ADHD.
METHODS
Literature Search
We performed a systematic review of the literature based on
the keywords ADHD, nurse, and child. The search strategy
was developed in collaboration with a university librarian
experienced in systematic literature searches. The searches were
conducted in MEDLINE (1946 to February 2020) and CINAHL
(1981 to current).
After the first search in MEDLINE and CINAHL, we retrieved
652 articles. Then we removed duplicates and narrowed the
search from 2010 to the end of 2019, to 205 articles.
We screened 205 articles, including main and running titles,
for nurse role, and ADHD. Of these, 128 records were excluded
because of non-relevant topics. For the 77 abstracts, 58 were
available and assessed. Reference list for these 58 articles was
reviewed, and five more articles were found and included (n=
63). Full-text articles were excluded because of other conditions
than ADHD, nurse role but not ADHD-specific related, language,
or age limitations were 20 years, leaving 43 articles for evaluation.
Results are presented in Figure 1.
Inclusion Criteria
In order to be included in the review (Figure 1), a study had to (1)
be published, or in press, in an English language journal and (2)
be available at the University Library of Bergen. Twenty articles
identified were excluded from the review because of different
reasons, that is, other conditions such as prematurity where
ADHD is mentioned (given in Figure 1).
RESULTS
Results from the literature search are described in the flowchart in
Figure 1. Among the 77 identified references, abstract reviewed
identified 43 references as eligible for further assessment. In the
review process, we identified the following topics:
1. Nurse role description for ADHD assessment, treatment, and
management for children and adolescents (Table 1) (1,2,4,6,
10–33).
2. Evaluation of the nurse role (Table 2) (9,34–37).
3. Articles with a textbook formation presenting knowledge
about ADHD and related conditions (Table 3) (3,38–46).
The Nurse Role in ADHD Management
Articles describing the nurse role identified several aspects such
as different nurse titles highlighting that nurses worked in a
variety of specialties, that is, school nurse, nurse practitioner, and
specialist care nurse. The training requirements for the different
nurse specialties, however, varied between countries.
Twenty-eight articles described the content of the nurse
role and different tasks (Table 1). These included prescreening
and diagnostic assessment for ADHD either as a part of a
multidisciplinary team or independently. Further, both medical
and non-medical treatments were described and recommended
to be delivered by nurses. Several records had more consensus
from experts in nurse management of ADHD.
The topic in eight articles related to the organization of
ADHD services and the role of nurses in the management of
these (Table 1). Themes varied significantly including how to
collaborate across service levels (17), running a pilot charity drop
in clinic (30), and managing a well-established protocol-driven
clinical care pathway based within CAMHS (4). In describing the
Dundee ADHD Clinical Care Pathway, Coghill argues for nurse-
led continuing care clinics with annual reviews of patients (4,
11). Shared-care agreement as a collaboration between primary
and specialist health care is also highlighted (4,11). Coghill
referred to two official audits of a nurse-led care pathway (4,
47,48), concluding that the pathway was compliant with all the
major recommendations of the Scottish Intercollegiate Guideline
Network and the National Institute for Clinical Excellence [(49),
Attention Deficit and Hyperkinetic Disorders in Children and
Young People. A National Clinical Guideline (50,51)].
One thesis explored provider receptiveness to referring
patients to a nurse-managed center for the diagnosis and
management of ADHD. While most providers expressed
willingness to refer to a specialty center for ADHD, a majority
of the physician group were negative to refer to a nurse-managed
center. It was concluded that the number of potential referrals for
establishing this type of center was insufficient (31).
The other thesis (19) assessed five family nurse practitioners
and one pediatrician regarding the use and evaluation of a
community treatment guideline packet to assist with diagnosing
ADHD in children. Overall, providers felt that being more aware
of the potential referrals and resources in the community would
allow a multimodal approach of care, therefore improving their
management of children, aged 4–11 years, with ADHD.
Evaluation of the Nurse Role
Five articles examined the acceptability/safety of nurse-led
ADHD interventions and management (9,34–37). Summarized
in Table 2, only two studies compared nurses’ prescription
pattern of medication practice with physicians and found no
significant differences between the two groups (9,36). Foreman
et al. compared 36 specialist nurses with 34 doctors regarding
ADHD care in an ADHD follow-up clinic. Outcomes consisted
of predicted diagnostic category from Strengths and Difficulties
Questionnaire, patient satisfaction, and side-effect evaluation.
Frontiers in Psychiatry | www.frontiersin.org 2February 2022 | Volume 13 | Article 676528
Kleve et al. ADHD Nurse, a Literature Review
FIGURE 1 | Review of ADHD–Nurse–Child and adolescent.
Few differences were found, although it was suggested to add
structured behavioral screening if nurses were managing the
ADHD follow-up. Another survey examined nurses’ use of
guidelines. For the 89 nurses, approximately 50% of the AAP
guideline for assessment and treatment was adhered to, but use
of all criteria was less than optimal (34).
One study evaluated a solution-focused approach to increase
self-efficacy in ADHD adolescents and supported specialist
nurses to carry out this intervention for patients with low self-
esteem (35).
Savill et al. described a study of atomoxetine administered by
nurse advisers giving support to the patients in order to increase
compliance of treatment compared to naturalistic medication.
The effect was the result of the support rather than the role of
the nurse.
Professional Opinions
Several articles presented opinions, consensus, or guidelines from
experts in nursing, identifying knowledge gaps and suggestions
for further training in ADHD management. Suggested training
needs for nurses are given in Table 3.
DISCUSSION
The nurse role in ADHD management seemed to vary, and the
requirements for training and certification for specialties within
nursing differed between countries. In this review, we found
nurses working either independently or as a part of a team with
delegated responsibility. With only a few scientific evaluations
available, we also included articles describing the nurse role and
Frontiers in Psychiatry | www.frontiersin.org 3February 2022 | Volume 13 | Article 676528
Kleve et al. ADHD Nurse, a Literature Review
TABLE 1 | Summary of recommendations regarding nurse role in ADHD
diagnostic assessment, treatment, and management: a literature review.
• Independent diagnostic assessment and in team context
• Independent medical treatment and monitoring ADHD
medication and in collaboration with clinicians.
• Non-medical treatment:
◦Developing coordinated treatment plans involving patient,
family, local community, and CAMHS
◦Psychoeducation to patients and families
◦Behavioral treatment programs
◦Care and support to the families, counseling, coping
strategies
◦Coaching the patient (adolescence)
• Educational work in the community i.e., school nurses and
teachers
• Argued for school nurse to avoid emergency room visit
• Argued for nurse as a part of the team
• Described nurse led ADHD management
• Coghill argued for nurse led treatment of ADHD in specialist
health care service
• Transitioning from adolescence until adulthood
• Argued for nurse led ADHD management instead of
physician
• Argued for school nurse to take a more active role in ADHD
management
• Described nurse could help monitoring ADHD medication as
well as diagnostic assessment
• Argued for nurse to prescribe ADHD medication and
organize collaboration with family doctor and CAMHS
• SN provide a bridge between CAMHS and school
TABLE 2 | Review of studies evaluating nurse role.
• Treatment prescription patterns for nurse and physician with no
significant differences
• 36 nurses were compared to 34 physician regarding ADHD
prescription with no differences
• Survey of NP’s use of guideline
• Nurses can use solution-focused approach when providing care. A
mixed design randomized controlled study
• Nurse support in medication adherence
TABLE 3 | Review of consensus of nurses working with children and adolescents
with ADHD.
• What is ADHD?
• Comorbidity and ADHD
• Medical treatment in ADHD
• Side effects of medication
• Psycho-education and ADHD
• Behavioral therapy and ADHD
• Bipolar disorder and ADHD
• Sleep apnea
• How to identify ADHD school children among school nurses?
• Knowledge about school nurse role as an integral part of helping
children with ADHD
• Auditory processing disorders and ADHD
• Neuro-feedback and ADHD
knowledge gaps. This was done in order to get an overview
and gain knowledge in how nursing roles are designed across
different countries.
In the present literature review, we found five articles formally
evaluating the nurse role with two for medical prescription,
one for ADHD follow-up care, one survey of nurses’ use of
guidelines in diagnostics and treatment, and lastly one evaluating
the effect of a nurse-led solution-focused approach. No concerns
about safety were identified regarding the prescription and
monitoring of ADHD medication. However, more studies
are needed.
Nurses’ compliance with guidelines was found to
be low. In addition, this was not compared with
doctors’ use of guidelines, making the results difficult
to interpret.
Even though no studies were found, several articles
described nurses both assessing and diagnosing
children for ADHD. Independent assessment by nurses
seemed to vary between different regions, and nurses
were recommended to undertake specialized training
in ADHD.
In addition, two Scottish Healthcare reports included audits
of a nurse-led clinical care pathway (Scotland, H.I.). From these
reports, it was concluded that long-term follow-up of children
and adolescents with ADHD appeared useful, in particular from
a user perspective. Regular reviews are identified as crucial, given
that ADHD symptoms change during the course of development
and during times of change, for instance, during transfer to
infant and secondary school. Furthermore, continuity of care
has been highlighted as important and recommended to be
delivered by nurses. The follow-up of children and adolescents
with ADHD is different from other chronic conditions, for
example, diabetes mellitus, which can be maintained through
simple medical consultations. Impairment associated with
ADHD often includes more than core symptoms such as
emotional and social impairments in addition to comorbid
conditions. Qualitative studies (6,13) focused on families’ need
for support and for collaboration across home, school, and
primary care.
In this review, we found descriptions of nurses involved
with ADHD management in 28 articles. Nurses already carry
out many key tasks relating to children and adolescents
with ADHD, although the extent of this practice seems
to vary between areas and countries. In fact, nurses were
recommended to be involved in almost every aspect of
ADHD management including assessment and diagnostics,
psychosocial support, medical, and non-medical treatment, and
in the lead of entire ADHD services. The contribution of
nurses was suggested by some authors to involve a caring
and supportive quality. Providing support and care may
be of particular importance for lifelong chronic conditions
(5,52,53). Anker found that ADHD outcomes are largely
associated with social characteristics and history of depression
rather than intellectual functioning or ADHD symptom
severity (52).
The reports evaluating a nurse-led care pathway gave
favorable reviews of implementation and adherence to
clinical guidelines.
Although there is a need for further evaluation
and development of the nurse role, there seem to be
Frontiers in Psychiatry | www.frontiersin.org 4February 2022 | Volume 13 | Article 676528
Kleve et al. ADHD Nurse, a Literature Review
good indications that nurses are already successfully
integrated in teams for children and adolescents with
ADHD and that they can provide a life course and
family perspective (13) and support in both medical and
non-medical treatment. For medical treatment, nurses
can have a role in both prescribing medication and the
monitoring process.
CONCLUSION
This literature review gives information to suggest
that nurses can play a major role in providing
continuity of care for children and adolescents
with ADHD.
DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included
in the article/supplementary material, further inquiries can be
directed to the corresponding author/s.
AUTHOR CONTRIBUTIONS
LK has participated in preparing the literature search, in
reviewing papers, and writing of the manuscript. LV has
conducted the literature search. IE has participated in preparing
the literature search, reviewing papers, writing of the manuscript,
and for the method and result section. All authors contributed to
the article and approved the submitted version.
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Frontiers in Psychiatry | www.frontiersin.org 6February 2022 | Volume 13 | Article 676528
