How nurses talk about ADHD in preschool-age children : a discourse analysis

Mental disorder (MD) diagnoses such as attention-deficit/hyperactivity disorder (ADHD) are occurring in U.S. children under the age of 5. Frequency of medication treatment is increasing for preschool-age children beyond what guidelines direct. There is debate among health care professionals (and specifically nurses) about whether MD rates such as those of ADHD constitute an epidemic of disease or a sociological trend toward diagnosing MD as a response to managing behavioral and emotional problems (BEP) of children, or both. How the problem is discussed changes how the problem is perceived and addressed. The purpose of this exploratory descriptive study was to investigate how the discourse of nurses about ADHD and related BEP in children under age six culminates in a child’s receiving an ADHD diagnosis and treatment. The aim was to describe how nurses talk about diagnosing and treating BEP in children under age six (preschool-age) in various settings (clinic, school, and psychiatric). This study’s design was based in a critical realist (CR) epistemology (i.e., reality is socially constructed with discourse and a material/physical dimension). The methodology was discourse analysis (DA, close examination of text) and the method critical DA (CDA) in order to identify discursive and extra-discursive elements related to how nurses talk about ADHD and related BEP in preschool-age children in the interests of considering improvements in nursing care. Thirteen semi-structured interviews were conducted and analyzed using critical discourse analysis. Findings were a variety of discourse stances and relationships to their immediate and wider social environments, demonstrating how nurse practices are determined by their discursive patterns but also producing them. A school-to-clinic-topsychiatry “pipeline” of situational momentum surfaced in the analytic process for preschool-age children being considered for an ADHD diagnosis. Nurses demonstrated in their discourse how children came to be diverted or directed along that diagnosis and treatment pipeline. Almost all participants demonstrated conflicted language – discourse patterns that affirmed psychiatric and DSM-style language and representations, but also alternative language and representations that undermined, replaced, or openly critiqued psychiatric and DSM characterizations of ADHD. Recommendations are made regarding nursing education, theory, practice, research, and policy.