Attention deficit hyper-activity

disorders (ADHD)

Prepare by : jumana almomani

 Objectives:
At the end of this lecture the student will be able to:

 Identify of ADHD.

 Discussed for ADHD Biological implications markedly.

 Verbalized for Diagnostic criteria for DSM-5 of ADHD 80% accuracy.

 Identify for medications that are use to managed for ADHD exactly.
 Outlines:

 General Introduction.
 Introduction of ADHD.
 Biological implications.
 Diagnostic Criteria from DSM-5.
 Pharmacological interventions (Medications).
 Introduction

 We explore one neurodevelopmental disorders that significantly

impact children and adolescent ,attention –deficit /hyperactivity
(ADHD) that effect only children and adolescent ,after recent
years have found to also impair the functioning of adults.

 ADHD was the most prevalent diagnosis among children ages 3-

17
 ADHD

 The past four decades, attention-deficit/hyperactivity

(ADHD) has been diagnosis fraught with much
controversy.
 Initially (ADHD) was define as: Hyperkinetic reaction
of childhood, Hyperkinetic syndrome, Hyperactive child
syndrome, minimal brain damage or dysfunction,
minimal cerebral dysfunction, and minor cerebral
dysfunction.
 Today we know that the symptoms related to (ADHD)
are neuro-developmental in origin.
Attention Deficit Hyperactivity Disorder

Primary feature is a persistent pattern of inattention and/or

hyperactivity-impulsivity that interferes with functioning or
development Present before age 12 and manifests in two or
more settings
Three subtypes within the disorder is less known
 Predominantly Inattentive
 Predominantly Hyperactive/Impulsive
 Combined

(American Psychiatric Association, 2013)

 Why ADHD is important

o ADHD contributes much disruption to the (patient educational

,occupational ,family ,and social life)..
Cont…
 ADHD and Biological implications
Differences in neurotransmitter are seen among the three
subtypes of ADHD which contribute to the varying
manifestation of symptoms in children and adults with the
disorder:
1- Changes in their norepinephrine transporter gene ,which
affects levels of norepinephrine in the brain.

2- Patients with primarily the hyperactive impulsive type of

ADHD have changes in the dopamine transporter gene which
regulates dopamine.
 ADHD and Biological implications

3- Studies from Vanderbilt university (2009) have

noted that patient with the combined type of ADHD
have alteration in their choline transporter gene thus
implicating acetylcholine as the modulating
neurotransmitter.
 Diagnostic Criteria from DSM-5.

A. A persistent pattern of inattention and/or hyperactivity-

impulsivity that interferes with functioning or
development, as characterized by (1) and/or (2):

1. Inattention: Six (or more) of the following symptoms

have persisted for at least 6 months to a degree that is
inconsistent with developmental level and that negatively
impacts directly on social and academic/occupational
activities:

.
 Diagnostic Criteria from DSM-5.
a. Often fails to give close attention to details or makes careless mistakes
in schoolwork, at work, or during other activities (e.g., overlooks or
misses details, work is inaccurate).

b. Often has difficulty sustaining attention in tasks or play activities (e.g.,

has difficulty remaining focused during lectures, conversations, or
lengthy reading).

c. Often does not seem to listen when spoken to directly (e.g., mind
seems elsewhere, even in the absence of any obvious distraction).
 Diagnostic Criteria from DSM-
5.does not follow through on instructions and fails to finish schoolwork,
d. Often
chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is
easily sidetracked).

e. Often has difficulty organizing tasks and activities (e.g., difficulty managing
sequential tasks; difficulty keeping materials and belongings in order; messy,
disorganized work; has poor time management; fails to meet deadlines).

f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained

mental effort (e.g., schoolwork or homework; for older adolescents and adults,
preparing reports, completing forms, reviewing lengthy papers).
 Diagnostic Criteria from DSM-5.

g. Often loses things necessary for tasks or activities (e.g.,

school materials, pencils, books, tools, wallets, keys,
papenwork, eyeglasses, mobile telephones).

h. Is often easily distracted by extraneous stimuli (for older

adolescents and adults, may include unrelated thoughts).

i. Is often forgetful in daily activities (e.g., doing chores,

running errands; for older adolescents and adults, returning
calls, paying bills, keeping appointments).
 Diagnostic Criteria from DSM-5.

2. Hyperactivity and impuisivity: Six (or more) of the following

symptoms have persisted for at least 6 months to a degree that is
inconsistent with developmental level and that negatively impacts
directly on social and academic/occupational activities:
 Diagnostic Criteria from DSM-5.

a. Often fidgets with or taps hands or feet or squirms in seat.

b. Often leaves seat in situations when remaining seated is expected

(e.g., leaves his or her place in the classroom, in the office or other
workplace, or in other situations that require remaining in place).

c. Often runs about or climbs in situations where it is inappropriate.

(Note: In adolescents or adults, may be limited to feeling restless.)

d. Often unable to play or engage in leisure activities quietly.

 Diagnostic Criteria from DSM-5.

e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or

uncomfortable being still for extended time, as in restaurants, meetings; may be
experienced by others as being restless or difficult to keep up with).

f. Often talks excessively.

g. Often blurts out an answer before a question has been completed (e.g., completes
people’s sentences; cannot wait for turn in conversation).

h. Often has difficulty waiting his or her turn (e.g., while waiting in line).

i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or

activities; may start using other people’s things without asking or receiving permission;
for adolescents and adults, may intrude into or take over what others are doing).
 Diagnostic Criteria from DSM-5.

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12

years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more

settings (e.g., at home, school, or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of,
social, academic, or occupational functioning.
.
Attention Deficit Hyperactivity Disorder
Indicators

Inattention (six or more)

 Fails to give close attention to details
 Difficulty maintaining attention
 Does not seem to listen when spoken to directly
 Does not follow through on instructions
 Difficulty organizing tasks or activities
 Often avoids tasks requiring sustained attention
 Loses things necessary for completing tasks or activities
 Easily distracted by extraneous stimuli
 Often forgetful in daily activities
(American Psychiatric Association, 2013)
Attention Deficit Hyperactivity Disorder Indicators

Hyperactivity and impulsivity (six or more)

 Often fidgets with or taps hands or feet
 Leaves seat in situations when being seated is expected
 Runs/climbs in situations where it is inappropriate
 Unable to play or engage in leisure activities quietly
 Is often “on the go,” acting as if “driven by a motor
 Often talks excessively
 Blurts out answer before a question has been completed
 Difficulty waiting his or her turn
 Interrupts or intrudes on others
(American Psychiatric Association, 2013)
ADHD: Prevalence and Risk

5 percent of children/adolescents diagnosed with ADHD

Girls most commonly diagnosed with inattentive subtype
Environmental
Low birth weight
History of maltreatment or multiple foster placements,
drinking/smoking/toxin exposure (lead) during pregnancy
Genetic
Higher in first-degree relatives

(American Psychiatric Association, 2013)

ADHD: Assessment and Treatment

Psychologists and psychiatrists use a number of tools

 Parent or primary caregiver interview
 Child interview
 Connors Rating Scales completed by the primary caregiver(s) and
teachers
Treatment
 Individual/parent counseling
 Academic accommodations
 Cognitive behavioral therapy
 Social skills training
 Medication (stimulants, antidepressants)
ADHD: Interventions I

Inattention
Only give one direction at a time and only when in
direct proximity with the child
Develop self-talk messages (“Get back on track!”)
Hyperactivity
Provide structured physical activity
Provide transition cues
Cue to use calming techniques
Soup breathing (inhale 3 seconds/exhale 6 seconds)
Tactile objects (touch a soft object)
Centering (brings knees to chest)
 ADHD: Interventions II

Impulsive
Create think and do plans (think aloud)
Organization
Use color, pictures and apps for routines
Say, “You’re off track! What do you need to be doing?”

Get dressed

Eat breakfast

Pack up for the bus

 Pharmacological interventions (Medications).

The purpose of the psychostimulant and other

medication used in the treatment of ADHD is to
increase dopamine and norepinephrine in the
prefrontal cortex.

essentially both methylphenidate class and mixed

amphetamine salts class of psychostimulant block the
transporter proteins whereas only the amphetamine
salts increase the release of both neurotransmitters
from the presynaptic vesicles .
 Psychostimulant Medication
Both methylphenidate formulation and the amphetamine or mixed
amphetamine formulation.

Target the neurotransmitters norepinephrine and dopamine in the

prefrontal cortex ,They act to block the reuptake of these
neurochemicals in the presynaptic neuron ,thus enhancing their action
in the synapse .

Additionally dextroamphetamine and the mixed amphetamine act as

agonists not only blocking the reuptake of norepinephrine and
dopamine but also stimulating their release from the presynaptic
neuron .
 Psychostimulant Medication
There are exception to the pharmacodynamics of the psychostimulant
medication:
Lisdexamfetamine a prodrug stimulates sympathomimetic activity in
the CNS.

Atomoxetine (strattera) a nonstimulant indicated for ADHD selectively

inhibits only norepinephrine at the presynaptic neuron and improves
concentration and attention while simultaneously reducing anxiety.

Clonidine (catapres) and guanfacine (intuniv) stimulate the alpha 2

adrenergic receptors in the prefrontal cortex ,providing a calming effect
and decreasing impulsivity.
 (Nursing care) Treatment Monitoring
1- Methylphenidate and amphetamine formulation of the
psychostimulants have similar nuisance side effects ,which are not
medically dangerous.

2- The patient may experience decreased appetite ,headaches, stomach

upset, and insomnia (These side effects often dissipate within a week or
so).

3- Taking the medication with food typically helps to reduce these

adverse events.

4- The rebound effects is likely the worst side effect.

(medication begins to wear off), symptoms hyperactivity and
impulsivity return in excess ,Augmenting with a low –dose ,short –
acting psychostimulant can be helpful .
 (Nursing care) Treatment Monitoring
5- Cardiovascular side effect may occur as an adverse event related to
the psychostimulants, so The American Heart Association recommends
obtaining an (ECG)before beginning treatment.

6- Monitor blood pressure and heart rate.

7- Monitor for potential abuse ,these psychotropic medication do have a

black box warning for potential abuse and dependence.

8- Monitor to ensure that the child or adolescent has swallowed the

medication. (report cases sharing drugs in school).
 (Nursing care) Treatment Monitoring

9- It is recommended that grapefruit juice be avoided with

dextroamphetamine (Dexedrine) and the mixed amphetamine salts.