ATTENTION DEFICIT/HYPERACTIVITY

DISORDER
MR.ASHOK KUMAR
M. s c Nursing 2nd year
INTRODUCTION
Attention-deficit hyperactivity disorder is a
neurobehavioral developmental disorder and is
primarily characterized by” the co-existence of
attention problems hyperactivity with each behavior
occurring infrequently alone.” While symptoms may
appear to be innocent and merely annoying nuisances
to observers
Children with ADHD may be hyperactive and unable
to control their impulse or they may have trouble
paying attention
DEFINITION
ADHD is a persistent pattern of in attention and or
hyperactivity-impulsivity that is more frequent and
severe than is typically observed in individuals at a
compatible level of development (APA, 2000).
ADHD is a brain disorder marked by an ongoing
pattern of inattention and hyperactivity impulsivity
that interferes with functioning or development
EPIDEMIOLOGY:
It is four to nine times more common in boys than in
girls.
Prevalence of ADHD is 3 to 7 percent of school-age
children.
It is most commonly present in school children.
PREDISPOSIG FACTORS
Biological Influences
GENETICS:
Twin studies indicate that the disorder is highly
heritable and that genetics are a factor in about 75% of
ADHD.
Siblings of hyperactive children have higher incidences
of ADHD.
BIOCHEMICAL FACTORS:
An elevation in the catecholamines dopamine and
norepinephrine have been implicated in the overactivity
causes to ADHD.
Norepinephrine modulates attention, arousal, and
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Dopamine is involved in reward, risk taking,
impulsivity and mood.
One study found that in adults with ADHD, the
dopamine transporter in the brain was elevated by
70percent compared to people without ADHD (Med-
scape Health, 2002).
PRENATAL FACTORS:
Alcohol and tobacco smoke exposure during pregnancy.
Hypoxia (Lack of oxygen) to the fetus.
Premature birth.
 ENVIRONMENTAL INFLUENCES
 Environmental Lead: The adverse effects on cognitive and behavioural
development in children with elevated body levels of lead.
 DIET FACTORS
 Artificial food colours.
 Preservative sodium benzoate.
 Another diet factor that has been receiving much attention in its
possible link to ADHD is sugar. One study reported that ADHD
children had fewer problems after a high-carbohydrate breakfast than
after a high-protein one (Med scape Health,2002).
 PSYCHOSOCIAL INFLUENCES:
 Family dysfunction.
 Inadequacies in the educational system.
 A high degree of psychosocial stress, maternal mental disorder,
paternal criminality, low socioeconomic status, and foster care have
been implicated (Dopheide &Theesen, 1999).
DSM-IV-TR Diagnostic Criteria for
Attention-Deficit/Hyperactivity
Six (or more) of the following symptoms of Disorder
inattention
have persisted for at least 6 months to a degree that is
maladaptive and inconsistent with developmental level:
Inattentiveness: It involves ,
Short attention span or a tendency to make careless errors
in schoolwork or other activities.
Difficulty with sustained attention in tasks or play
activities.
Apparent listening problems.
Difficulty following instructions.
Problems with organization.
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Avoidence or dislike of tasks that require mental effort.
Tendency to lose things like toys, notebooks, or
homework.
Distractibility.
Forgetfulness in daily activities.
Six (or more) of the following symptoms of
hyperactivity-impulsivity have persisted for at least 6
months to a degree that is maladaptive and
inconsistent with developmental level:
 Hyperactivity
Difficulty remaining seated.
Fidgets with hands or feet or Squirms in seat.
Excessive running and climbing.
Difficulty playing quietly.
Difficulty waiting for a turn or in line.
 Impulsivity: It includes .
Some hyperactive-impulsive or inattentive symptoms that
caused impairment were present before age 7years.
Some impairment from the symptoms is present in two or
more settings (e.g; at school or work and at home).
There is clear evidence of clinically significant
impairment in social, academic, or occupational
functioning.
Anxiety can accompany ADHD as a secondary feature,
and anxiety alone can be manifested by over activity
and easy distractibility.
A child with ADHD to become demoralized and to
develop depressive symptoms in reaction to persistent
frustration with academic difficulties and resulting low
self-esteem.
Mania and ADHD share many core features such as
excessive verbalization, motor hyperactivity, and high
levels of distractibility. Mania and ADHD can coexist,
children with bipolar-1 disorder exhibit more waxing
and waning of symptoms than those with ADHD.
MANAGEMENT
Pharmacotherapy: Pharmacologic treatment is
considered to be the first line of treatment for ADHD.
Central nervous system stimulants are the first choice
of agent in that they have been shown to have the
greatest efficacy with generally mild tolerable side
effects.
Methylphenidate (Ritalin) initial dosage: 5mg before
breakfast and lunch. Dosage may be increased
gradually in increments of 5 to 10mg/day at weekly
intervals, PO(Children age 6 and older)
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Pemoline (Cylert) initial dosage:37.5mg/day,

administered as a single dose each morning Dosage may
be gradually increased at 1-week intervals in increments
of 18.75mg/day until the desired effect is achieved.
Effective dosage usually ranges from 56.25 to 75mg/day
PO. Clinical benefit may not be observed for 3 to 4
weeks.
Bupropion (wellbutrin): 3mg/kg/day PO.
Imipramine (Tofranil) 1mg/kg/day in divided doses,
with increases every 2 to 3 weeks up to a maximum of
2.5mg/kg/day.
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BEHAVIOURAL THERAPY: Behavioral therapy
attempts to change behavior pattern by,
Recognizing a child’s home and school environment.
Giving clear directions and commands.
Setting up a system of consistent rewards for
appropriate behaviors and negative consequences for
inappropriate ones. Behavioral strategies that may
help a child with ADHD:
 Create a routine.
 Get organized.
 Avoid distractions.
 Limit choices.
 Change your interactions with your child.
 Use goals and rewards.
 Discipline effectively.
 Help your child discover a talent.
 ALTERNATIVE TREATMENTS
 Occupational therapy
 Body treatments
 Diet manipulation
 Allergy treatment
 Attention training
 Visual training
 Traditional one-on-one “talking” psychotherapy.
 PARENT TRAINING: Parent education and support groups to help family
members accept the diagnosis and to teach them how to help kids organize their
environment,
NURSING MANAGEMENT
Risk for injury R/T impulsive & accident-prone
behavior & inability to perceive self harm
 Impaired social interaction R/T intrusive
behavior.
Nursing intervention
Ensure that client has safe environment.
-Remove objects from immediate area on which
client could injure self as a result of random,
hyperactive movement.
-Provide adequate supervision and assistance.
-Limit client’s participation if adequate
supervision is not possible.
-Identify deliberate behavior that put the child at
risk.
Reference
Kaplan & Sadock's Synopsis of Psychiatry: Behavioral
Sciences/Clinical Psychiatry, 10th Edition.
Semple David Oxford handbook of psychiatry 1st
edition 2005
Townsend M.C Essentials of psychiatric mental health
nursing 4th edition
Lipincott manual of nursing practice 8th edition.