Attention Deficit Hyperactivity Disorder

 It is a disorder that is characterized by a persistent pattern of inattention and/or

hyperactivity/impulsivity that interferes with functioning or development which often persists
into adolescence and adulthood.
 The diagnosis of ADHD demands thorough history taking, application of standardized rating
scales, and close attention to the patient’s behavior and subjects’ reports.
 It is a developmental condition of inattention and distractibility, with or without accompanying
hyperactivity.
 ADHD is characterized by inattentiveness, overactivity, and impulsiveness.
 ADHD is a common disorder, especially in boys, and probably accounts for more child mental
health referrals than any other single disorder.
 The essential feature of ADHD is a persistent pattern of inattention and/or hyperactivity and
impulsivity more common than generally observed in children of the same age.

Statistics and Incidences

In 2016, an estimated 6.1 million US children aged 2-17 years (9.4%) were diagnosed with ADHD.
 Of these children, 5.4 million currently had ADHD, which was 89.4 % of children ever diagnosed
with ADHD and 8.4% of all US children 2-17 years of age.
 According to a study by CDC researchers, more than 1 in 10 (11%) US school-aged children (4–17
years) had received an ADHD diagnosis by a health care provider by 2011, as reported by
parents.
 ADHD prevalence varies by race and ethnicity, with Mexican children having consistently lower
prevalence compared with other racial or ethnic groups.
 In children, ADHD is 3–5 times more common in boys than in girls.
 The percentages in each group are not well established, but at least an estimated 15–20% of
children with ADHD maintain the full diagnosis into adulthood.
 According to the Attention Deficit/Hyperactivity Disorder (AD/HD) Society of the Philippines, an
estimated 3 to 5 percent of the population aged 0 to 14 years in the Philippines have ADHD.

Causes

Psychodynamic theory
 The child is fixed in the symbiotic phase of development and has not differentiated self from
mother.
 Ego development is retarded
 The impulsive behavior is dictated by the ID

Biologic theories
 Genetics - Parents and siblings of children with ADHD are 2-8 times more likely to develop ADHD
than the general population, suggesting that ADHD is a highly familial disease.
 CNS abnormalities, such as presence of neurotoxins, cerebral palsy, epilepsy and other
neurological disorders
 Neuro maturational delays, catecholamine deficits, altered glucose metabolism in the brain and
frontal lobe dysfunction.
 Perinatal insults such as substance abuse during pregnancy, poor maternal nutrition, premature
labor, and anoxia; brain injuries during or after birth.
Theories of family dynamics
 There is a dysfunctional spousal relationship, the focus of the disturbance is displaced into the
child, whose behavior in time begins to reflect the patterns of the dysfunctional system.
 Disorganized or chaotic environment and child abuse or neglect may also be a factor.

Environment
 According to one study, exposure to second-hand smoke in the home is associated with a higher
frequency of mental disorder among children.

Personality factors
 Although there remains much evidence for the genetic etiology of ADHD, one study indicated
that the contribution of personality aspects in combination with genetics may be significant.

Criteria

 In DSM-5, people with ADHD exhibit a persistent pattern of inattention and/or hyperactivity-
impulsivity that interferes with functioning or development

Inattention
Six or more symptoms of inattention for children up to age 16 years, or five or more for adolescents age
17 years and older and adults; symptoms of inattention have been present for at least 6 months, and
they are inappropriate for developmental level:
 Often fails to give close attention to details or makes careless mistakes in schoolwork, at work,
or with other activities.
 Often has trouble holding attention on tasks or play activities.
 Often does not seem to listen when spoken to directly.
 Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in
the workplace (e.g., loses focus, side-tracked).
 Often has trouble organizing tasks and activities.
 Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of
time (such as schoolwork or homework).
 Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools,
wallets, keys, paperwork, eyeglasses, mobile telephones).
 Is often easily distracted.
 Is often forgetful in daily activities.

Hyperactivity and Impulsivity

Six or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or five or more for
adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present
for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental
level:
 Often fidgets with or taps hands or feet, or squirms in seat.
 Often leaves seat in situations when remaining seated is expected.
 Often runs about or climbs in situations where it is not appropriate (adolescents or adults may
be limited to feeling restless).
 Often unable to play or take part in leisure activities quietly.
  Is often “on the go” acting as if “driven by a motor”.
 Often talks excessively
 Often blurts out an answer before a question has been completed.
 Often has trouble waiting their turn.
 Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:

 Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
 Several symptoms are present in two or more settings, (such as at home, school or work; with
friends or relatives; in other activities).
 There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school,
or work functioning.
 The symptoms are not better explained by another mental disorder (such as a mood disorder,
anxiety disorder, dissociative disorder, or a personality disorder).
 The symptoms do not happen only during the course of schizophrenia or another psychotic
disorder.

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
 Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-
impulsivity were present for the past 6 months
 Predominantly Inattentive Presentation: if enough symptoms of inattention, but not
hyperactivity-impulsivity, were present for the past six months
 Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-
impulsivity, but not inattention, were present for the past six months.
 Because symptoms can change over time, the presentation may change over time as well.

All criteria must be met for a diagnosis of ADHD in adults:

 Five or more symptoms of inattention and/or ≥5 symptoms of hyperactivity/impulsivity must
have persisted for ≥6 months to a degree that is inconsistent with the developmental level and
negatively impacts social and academic/occupational activities.
 Several symptoms (inattentive or hyperactive/impulsive) were present before the age of 12
years.
 Several symptoms (inattentive or hyperactive/impulsive) must be present in ≥2 settings (eg, at
home, school, or work; with friends or relatives; in other activities).
 There is clear evidence that the symptoms interfere with or reduce the quality of social,
academic, or occupational functioning.
 Symptoms do not occur exclusively during the course of schizophrenia or another psychotic
disorder, and are not better explained by another mental disorder (e.g., mood disorder, anxiety
disorder, dissociative disorder, personality disorder, substance intoxication, or withdrawal).

Assessment and Diagnostic Findings

The diagnosis requires the symptoms of ADHD to be present both in school and at home; furthermore,
all patients must have a full psychiatric evaluation and physical examination.

Laboratory studies
 The diagnosis of attention deficit hyperactivity disorder (ADHD) is based on clinical evaluation;
no laboratory-based medical tests are available to confirm the diagnosis.
  Basic laboratory studies that may help confirm diagnosis and aid in treatment are serum CBC
count with differential, electrolyte levels, liver function tests, and thyroid function tests.

Imaging studies
 Brain imaging, such as functional MRI or single photon emission computed tomography (SPECT)
scans have been useful for research, but no clinical indication exists for these procedures
because the diagnosis is clinical.

Treatment
 Psychosocial interventions like behavioral interventions
 Social skills training: modeling appropriate behavior
 Medical Management
No one treatment has been found to be effective for ADHD; ADHD is chronic, goals of treatment involve
managing symptoms, reducing hyperactivity and impulsivity, and increasing the child’s attention so that
he or she can grow and develop normally.
 Diet - For decades, speculation and folklore have suggested that foods containing preservatives
or food coloring or foods high in simple sugars may exacerbate ADHD.
 Activity - In one study of the effect of physical activity on children’s attention, researchers found
that intense exercise has a beneficial effect on children with ADHD.

Pharmacologic Management
Although health care providers, parents, and teachers have hoped for effective therapies and methods
that do not involve medications for children with attention deficit hyperactivity disorder (ADHD),
evidence to date supports that the specific symptoms of ADHD are poorly treated without medication.
 Psycho stimulants are commonly used in treating ADHD in young children but not in
adolescents.
e.g., methylphenidate (Ritalin, Methylin), Dextro amphetamine (Dexedrine, dextrostat, adderall)
 It has a calming effect on children with ADHD.
 It stimulates inhibitory efferent neurons in the cerebral cortex at low dosage levels, causing
a decrease in motor activity.
 It stimulates afferent neurons on the reticular activating system, increasing input constancy,
thus enabling the brain to concentrate longer on a particular task.
 These agents are known to treat ADHD effectively.

Other psychiatry agents

 Selective norepinephrine reuptake inhibitors have been shown to be effective in the treatment
of ADHD.
Atypical antidepressants
 Recent studies support efficacy of venlafaxine and bupropion in ADHD; they may have a slower
onset of action than stimulants but potentially fewer adverse effects.
Tricyclic antidepressants
 Imipramine inhibits the reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT) at
presynaptic neurons; it may be useful in pediatric ADHD.
Central-acting alpha 2 agonists
 Centrally acting antihypertensives clonidine and guanfacine have been used to treat children
with ADHD; inhibition of norepinephrine release in the brain may be the mechanism of action.
 Nursing Management

Nursing Assessment
During assessment, the nurse gathers information through direct observation and from the child’s
parents, daycare providers (if any), and teachers.
 History. Parents may report that child is fussy and had problems as an infant; or they may have
not noticed the hyperactive behavior until the child was a toddler or entered daycare or school.
 General appearance and motor behavior. The child cannot sit still in a chair and squirms and
wiggles while trying to do so; he or she may dart around the room with little or no apparent
purpose; the child may appear immature or lag behind in developmental milestones.
 Mood and affect. Mood may be labile, even to the point of verbal outbursts or temper
tantrums; anxiety, frustration, and agitation may be common.
 Sensorium and intellectual processes. Ability to pay attention or to concentrate is markedly
impaired; the child’s attention span may be as little as 2 or 3 seconds with severe ADHD or 2 or 3
minutes in milder forms of the disorder.

Nursing Diagnosis
 Risk for injury related to inability to remain still or seated for a short period of time.
 Ineffective role performance related to being intrusive or disruptive with siblings or playmates.
 Impaired social interaction related to inability to perceive the consequences of their actions.
 Compromised family coping related to disruptive or intrusive behavior with siblings, which
causes friction.

Nursing Goals
 The client will be free of injury.
 The client will not violate the boundaries of others.
 The client will demonstrate age-appropriate social skills.
 The client will complete tasks.
 The client will follow directions.

Nursing Interventions
 Ensuring safety. Ensuring the child’s safety and that of others; stop unsafe behavior; provide
close supervision; and give clear directions about acceptable and unacceptable behavior.
 Improving role performance. Give positive feedback for meeting expectations; manage the
environment (e.g. provide a quiet place free of distractions for task completion).
 Simplifying instructions. Simplifying instructions/directions; get child’s full attention; break
complex tasks into small steps; and allow breaks.
 Promoting a structured daily routine. Structured daily routine; establish a daily schedule; and
minimize changes.
 Providing client and family education and support. The nurse must listen to parents’ feelings;
including parents in providing and planning care for the child with ADHD is important.
 Take time to work with the child and help the child with school assignments. Focus on the
child’s positive accomplishments
 They will need extra time and patience
 Reinforce acceptable behaviors immediately.
 They will change behavior only when rewards are immediate and wont change if delayed.
 Manipulate the environment for safety.
 The child will not be able to discriminate between safe and unsafe environment.
 Reinforce the child for not talking too much in groups and for waiting his turn in games.
 This feedback helps the child to know when to focus energies on self-control
 Develop activities that will not strain limited attention span. Keep explanation short and
simple.
 It will help the child to stay on task and experience success
 Provide an environment relatively free of extraneous stimuli.
 Cutting down distractions conserves the child’ energy.