ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

INTRODUCTION
Attention deficit hyperactivity disorder is characterized by a persistent pattern (at least 6 months) of inattention
and/or hyperactivity-impulsivity, with onset during the developmental period, typically early to mid-childhood.

The degree of inattention and hyperactivity-impulsivity is outside the limits of normal variation expected for age
and level of intellectual functioning.

 Inattention refers to significant difficulty in sustaining attention to tasks that do not provide a high level of
stimulation or frequent rewards, distractibility and problems with organization.
 Hyperactivity refers to excessive motor activity and difficulties with remaining still, most evident in
structured situations that require behavioral self-control.
 Impulsivity is a tendency to act in response to immediate stimuli, without deliberation or consideration of
the risks and consequences.

CLINICAL FEATURES

Symptoms of inattention
 Lacks attention to detail; makes careless mistakes.
 has difficulty sustaining attention
 doesn’t seem to listen.
 fails to follow through/fails to finish instructions or schoolwork.
 has difficulty organizing tasks.
 avoids tasks requiring mental effort.
 often loses items necessary for completing a task.
 easily distracted.

Symptoms of hyperactivity

 Fidgets or squirms excessively

 leaves seat when inappropriate
 runs about/climbs extensively when inappropriate
 has difficulty playing quietly
 often “on the go” or “driven by a motor”
 talks excessively
 blurts out answers before question is finished
 cannot await turn
 interrupts or intrudes on others

Other common symptoms

• Sensitive to stimuli, easily upset by noise, light, temperature and other environmental changes.
• More commonly active in crib, sleep little.
• General coordination deficit.
• Short attention span, easily distractable.
• Failure to finish tasks.
• Impulsivity.
• Memory and thinking deficits .
• Specific learning disabilities

In school
• Often fidgets with hands or feet or squirms in seat.
• Answers only the first two questions ; often blurts out answers to questions before they ' have been completed.
• Unable to wait to be called on in school and may respond before everyone else.
• Has difficulty awaiting turn in games or group situations.
• Often loses things necessary for tasks or activities at school.

At Home
• Explosive or irritable.
• Mood is unpredictable.
• Impulsiveness and an inability to delay gratification.
• Often talks excessively.
• Often engages in physically dangerous activities without considering possible consequences (for example, runs
into street without looking).

ETIOLOGICAL FACTORS
 Genetic factors

 There is greater concordance in monozygotic than in dizygotic twins

 Siblings of hyperactive children have about twice the risk of having the disorder as does the general
population
 Biological parents of children with the disorder have a higher incidence of ADHD than do adoptive
parents

 Neurotransmitters

 Dopamine and norepinephrine appear to be depleted in ADHD.

 Serotonin also is reduced in children with ADHD.

• Norepinephrine is thought to play a role in the ability to perform executive functions, such as
analysis and reasoning, and in the cognitive alertness essential for processing stimuli and sustaining
attention and thought.

• Dopamine is thought to play a role in sensory filtering, memory, concentration, controlling

emotions, locomotor activity, and reasoning.

 Functional areas of the brain affected

 Prefrontal cortex: Associated with maintaining attention, organization, and executive function.
 Basal ganglia: Involved in the regulation of high-level movements. Interruptions in these circuits
may result in inattention or impulsivity.
 Hippocampus: Plays an important role in learning and memory.
 Limbic system: Regulation of emotions. A neurotransmitter deficiency in this area may result in
restlessness, inattention, or emotional volatility.
  Prenatal, perinatal and postnatal factors
 Prenatal toxic exposure, prenatal mechanical insult to the fetal nervous system
 Prematurity, fetal distress, precipitated or prolonged labor, perinatal asphyxia and low Apgar scores
 Postnatal infections, CNS abnormalities resulting from trauma, etc
 Environmental influences
 Environmental lead
 Food additives, coloring preservatives and sugar have also been suggested as possible causes of
hyperactive behavior but there is no definite evidence

 Psychosocial factors
 Prolonged emotional deprivation
 Stressful psychic events
 Disruption of family equilibrium

TREATMENT OF ADHD

Pharmacotherapy
 CNS stimulants
 Methylphenidate
 Amphetamines (dextroamphetamine, Lisdexamfetamine)
 Dexmethylphenidate
 Non stimulants
 Atmoxetine
 Guanfacine
 Antidepressants
 Antipsychotics

Psychotherapy
 Behaviorally Oriented Treatments :
 Behavioral management training for parents
 Behavioral parent training
 Parent behavior training
 Parent training

 Specific behavioral therapy techniques include:

Positive reinforcement: 

Reward your child for good behavior.

Example: If you finish your homework properly and on time, you can play a video game.
 Token economy: 

This combines the reward and consequence ideas. Teachers often use this method by giving out things like
star stickers, but the same principle should be used at home, too.

Response cost: 

Unwanted behavior leads to a loss of privileges or rewards. Example: If you don’t do your homework, you
lose your computer time.

Time out: 

This common consequence is often used when preschoolers use bad behavior. Example: If you hit your
sister, you must sit quietly alone for a few minutes.

 Occupational therapy

An occupational therapist, or "OT," helps kids with ADHD improve certain skills, such as:

 Organization,
 Physical coordination,
 Ability to do everyday tasks -- such as take a shower, organize their backpack, or make their bed --
quickly and well
 Control their “energy” levels, hyperactivity, etc.

NURSING DIAGNOSIS

■ Risk for injury related to impulsive and accidentprone behavior and the inability to perceive self-harm

■ Impaired social interaction related to intrusive and immature behavior

■ Low self-esteem related to dysfunctional family system and negative feedback

■ Noncompliance with task expectations related to low frustration tolerance and short attention span