This presentation will explain ADHD and how to manage patients with the disorder.

1. ATTENTION-DEFICIT
HYPERACTIVITY DISORDER
(ADHD)
By: Sheila Bolfa,
Katherine DeVillier, and
Isabelle Dubois

2. MEET YOUR PRESENTERS
Katherine DeVillier, RN, BSN, PMHNP Student
Isabelle Dubois, RN, BSN, MSc, PMHNP
Student
Sheila Bolfa, RN, BSN,
WCC, PMHNP Student

3. LEGEND OF ABBREVIATIONS
Abbreviation Term
ADHD Attention Deficit Hyperactivity Disorder
DA Dopamine
NE Norepinephrine
PFC Prefrontal Cortex
OFC Orbitofrontal Cortex
dACC Dorsal Anterior Cingulate Cortex
DLPFC Dorsolateral Prefrontal Cortex
DAT Dopamine Transporter
NAT Norepinephrine Transporter
SNRI Selective Norepinephrine Reuptake Inhibitor
NDRI Norepinephrine-Dopamine Reuptake Inhibitor
TCA Tricyclic Antidepressant

4. OBJECTIVE
S
4
Understand and recognize how and when to apply
recommended interventions for those with ADHD
3 Understand and describe the diagnostic criteria for ADHD
2 Analyze the neurobiology of ADHD
1
Understand and identify risk factors for ADHD as well as the
prevalence of the disorder
LEARNING OBJECTIVES

5. PRE-TEST
While risk factors for ADHD continue to be researched, which of the
following has not been shown to be a risk factor?
A. Premature birth
B. Substance use during pregnancy
C. Lead exposure during pregnancy
D. Folic acid supplementation during pregnancy

6. PRE-TEST
ADHD is one of the most common neurodevelopmental disorders
in children. Which of the following statements is true about
ADHD?
A. Girls are more likely than boys to be diagnosed with ADHD
B. Children between the ages of 3 and 5 years are the most at
risk age group
C. Children with ADHD rarely have comorbid mental health
diagnoses
D. Adolescents between the ages of 12 and 17 years are the
most at risk age group

7. PRE-TEST
Which of the following is a recommended treatment for ADHD? Select all
that apply.
A. Inpatient hospitalization for immediate medication management
B. Behavioral therapy
C. Medications for all children, starting at age 3
D. School involvement
E. All of the above

8. PRE-TEST
Which of the following is not part of the DSM-V-TR criteria
for ADHD?
A. Inability to sit still
B. Forgetful
C. Difficulty listening when spoken to
D. Loss of interest

9. WHAT IS ADHD?
The most common neurodevelopmental disorder in children
in the United States
Diagnosed in childhood and lasts until adulthood
ADHD is a pattern of behaviors that are impulsive,
inattentive, and inconsistent with the child’s expected
developmental level
Causes impaired functioning in school and social settings
There are three presentations – Inattentive,
hyperactive/impulsive, or combined
(Spaniardi et al., 2017)

10. THREE
PRESENTATION
S
OF
ADHD
The Mini ADHD Coach
(2022)

11. PREVALENCE OF ADHD
It is estimated that ADHD
affects up to 10.2% of
children worldwide
ADHD occurs more often
in males than females
(2:1)
Females are more likely to
present with symptoms of
inattentiveness compared
to males
(American Psychiatric
Association (APA), 2022)

12. DIAGNOSTIC CRITERIA FOR ADHD
A. Persistent pattern of inattention and/or hyperactivity and impulsive behaviors
that affect functioning or development
1. Inattention – including six or more of the following behaviors that have lasted for
a minimum of six months
a) Fails to pay close attention
b) Difficulty with attention span
c) Does not listen when spoken to
d) Does not follow through with instructions
e) Difficulty with organizational tasks
f) Avoids tasks that require focus
g) Loses things
h) Easily distracted
i) Forgetful (APA,
2022, pp. 68-69)

13. DIAGNOSTIC CRITERIA FOR ADHD
2. Hyperactivity & impulsivity – six or more of the following behaviors that have lasted a
minimum of six months
a. Fidgets, taps, squirms
b. Difficulty sitting
c. Frequent running or climbing in inappropriate situations
d. Difficulty participating in quiet activities
e. On the go
f. Excessive talking
g. Described as “on the go” and has trouble sitting still for extended periods
h. Difficulty with waiting
i. Interrupts conversations or activities of others

14. DIAGNOSTIC CRITERIA FOR ADHD
B. Several behaviors present before the age of 12
C. Several behaviors are present in more than one setting
D. Impaired functioning
E. Symptoms are not only present during an episode of a
psychotic disorder
(APA,
2022, pp. 68-69)

15. COMORBIDITIES
 Females have higher rates of comorbidities
 Oppositional defiant disorder, autism, personality disorders, and
conduct disorder are not uncommon in those with ADHD
 Anxiety disorders, mood disorders, obsessive-compulsive disorder,
and intermittent explosive disorder occur more often in those with
ADHD than in those without
 Learning disorders
 Sleep disturbances
 Medical conditions

16. NEUROBIOLOG
Y
OF
ADHD
Hyperactive symptoms (motor)
 PFC
 Impulsive symptoms (limbic)
 OFC
Inattentive symptoms (cognitive)
 Selective attention – dACC
 Sustained attention problem-solving – DLPFC
(Stahl,
2021)

17. NEUROBIOLOGY OF ADHD
Moderation of DA and NE firing is the main component to control
ADHD symptoms (Stahl, 2021).
Memorable Psychiatry and Neurology

18. NEUROBIOLOGY OF ADHD
NE
§Prevents the loss of information and improves signal if NE
binds to α2A receptors
§NE in PFC too low – leads to cognitive dysfunction and
inattention
§NE in PFC too high – leads to increased stress levels, anxiety,
mania, substance use
§Moderate firing of NE and “find the right amount”: better
cognitive functioning (attention, concentration, emotion, and
impulse control)
(Stahl, 2021)

19. NEUROBIOLOGY OF ADHD
DA
Information loss and weak signal if DA binds to D1receptors
DA in PFC too low – leads to cognitive dysfunction
DA is PFC too high (ex. by stress or anxiety, manic symptoms,
and substance use disorders) – worsens cognitive functioning.
Drugs can also stimulate DA.
If increase DA intermittently when pertinent info comes in –
reinforce learning and rewarding events (ex. ability to learn
and connect with others).
To control ADHD symptoms – goal is to increase intermittent
DA
(Stahl, 2021)

20. RISK FACTORS
(Spaniardi et al., 201
NEUROTRANSMITTE
RS
GENETICS
ENVIRONMENT
DIET

21. SCREENING FOR ADHD
Gold Standard Screening
Conners Abbreviated Symptom Questionnaire (for purchase)
https://storefront.mhs.com/collections/conners-3
Vanderbilt ADHD Diagnostic Parent/Teacher Rating Scale (free)
https://www.nichq.org/sites/default/files/resource-
file/NICHQ_Vanderbilt_Assessment_Scales.pdf

22. TREATING ADHD
Pharmacological
Psychostimulants
Methylphenidate (MPH)
Amphetamines
Nonstimulants
Atomoxetine HCL
Bupropion
Alpha-2 agonists
Tricyclic antidepressants
New medications
Non-pharmacological
Behavioral Interventions
Complementary/Alternative Methods
(CAMS)
Collaborative education with
parent/child
(Nazarova et al., 2022; Spaniardi et

23. STIMULANT
S
First-line agent to treat ADHD
FDA approved
• Schedule II controlled substance
• Abuse and dependency
Therapeutic effects
• Decrease hyperactivity
• Decrease impulsivity
• Decrease inattention
• Improve behavior
(Spaniardi et al.,
2017)

24. STIMULANTS
Pharmacology & Pharmacokinetics
 Psychostimulants
Increase central nervous system activity
Increase blood pressure and heart rate
Increase DA and NE at synaptic cleft
Methylphenidates
primary action is DA/NE reuptake
inhibitor
Amphetamines
primary action is a reuptake blocker of
DA/NE
also promotes DA release through the
process of reverse transport
(Spaniardi et al., 2017)

25. METHYLPHENIDATE
(MPH)
&
DEXMETHYLPHENID
ATE
(D-MPH)
Methylphenidates have D & L isomers
• Isomers refer to the chemical compound of the
medication
• They share the same formula but the atoms in the
molecule differ in arrangement
• This arrangement gives the isomer a different property
• D-isomer is more potent than the L-isomer on DA/NE
binding
Dexmethylphenidate or D-methylphenidate
• Chemical compound is a single enantiomer (no L-isomer)
• The compound is more potent and has a longer duration
(Stahl,
2021)

26. D,L-METHYLPHENIDATE FORMULATIONS
(MPH)
Release Name Peak/Duration Dosing PEARL
Immediate
(tablet)
Ritalin Early/3-4 hr BID
Immediate
(solution)
Methylin Early/3-4 hr BID
Extended
(tablet)
Ritalin SR,
Methylin ER,
Metadate ER
Early/3-8 hr QD to BID
Extended
(tablet)
Concerta Small Early/12 hr QAM *cardiac*
Extended
(capsule)
Metadate CD Strong Early/8 hr QAM *cardiac*
Extended
(capsule)
Ritalin LA Strong peak early and at 4
hr/6-8 hr
QAM
Extended
(transdermal)
Daytrana 7-10hr/12 hr QAM *cardiac*
(Stahl,

27. D-METHYLPHENIDATE FORMULATIONS
(D-MPH)
Release Name Peak/Duration Dosing PEARL
Immediate
(tablet)
Focalin Early/4-6 hr BID *antacids*
Extended
(capsule)
Focalin XR 1.5 & 6.5
hr/8-10 hr
QAM
(Stahl,
2021)

28. AMPHETAMIN
ES
Amphetamines have D & L isomers
• Same concept as Methylphenidate isomers
• D-isomer is more potent than the L-isomer on DA binding
• Equal potency on NE binding
• D,L-amphetamines are known as Mixed Amphetamine Salts
Dextroamphetamine (D-amphetamines)
• Formulated as a separate medication from mixed salts
• Stronger stimulate properties
Lisdexamphetamine
• D-amphetamine prodrug
• Linked to amino acid lysine
• Not absorbed until cleaved in the stomach
(Stahl, 2021)

29. AMPHETAMINE (D,L) VS. D-
AMPHETAMINE
 Both are classed as DA/NE reuptake inhibitors
 D-isomers are more potent on DAT binding
 Both D & L isomers are equal on NET binding
 D-amphetamines will have more action on DATs
 Mixed salts will have more action on NETs and DATs combined
because they contain both isomers
Dextroamphetamine is more potent than amphetamine, therefore, d-
amphetamine medication will have more stimulate effects than the
combo d,l-amphetamine
(Spaniardi, 2017; Stahl, 2021)
Pearl

30. D, L-AMPHETAMINE
FORMULATIONS
Release Name Peak/Duration Dosing PEARL
Immediate
(tablet)
Adderall 30min/4-6 hr BID Age 3 and
older
Extended
(capsule)
Adderall XR 6-8 hr/8-12 hr QAM
(Stahl,
2021)

31. D-AMPHETAMINE FORMULATIONS
Release Name Peak/Duration Dose PEARL
Extended
(capsule)
Dexedrine 1 hr/6-8 hrs QAM
Immediate
(tablet)
Zenzedi 30min/4-5 hrs BID Ages 3 and
older
Lisdexampheta
mine
Vyvanse 3.5 hr/12 hr QAM *cardiac*
(Stahl,
2021)

32. BENEFITS OF PSYCHOSTIMULANTS
Benefits > in behavioral domains
over cognitive domains
 Reduction of gross motor overactivity
 Improved behavior
 Improved disruptive behavior
 Academic productivity
 Improved reaction time/reduced
variability
 Improved short term memory
 Increased learning of verbal and non-
verbal material
(Spaniardi, 2017)

33. ADVERSE EFFEC
TS
OF
PSYCHOSTIMULA
NTS
• Decreased appetite; weight loss;
delayed sleep onset; headache;
stomachache; increased BP; increase HR
Common
• Motor tics; Tourette
unmasking; rebound overactivity, impulsivity,
and inattention later in the day
Infrequent
• Visual/tactile hallucination; priapism; self-
directed behavior (nail biting, lip licking,
sore picking)
Rare
(Spaniardi,
2017)

34. ADVERSE EFFECTS OF
PSYCHOSTIMULANTS
• Possible growth suppression in 1st year of treatment
• May be due to reduced caloric intake; the actual disorder; effects on
growth hormone or prolactin
• Monitor height/weight before & during therapy
Growth
• No evidence of abuse with long-term use; protective effect decreases
potential for abuse
• Consider family substance abuse prior to prescribing due to diversion
Substance
Abuse
(Spaniardi,
2017)

35. NORADRENERG
IC
FORMULATION
atomoxetine
(Strattera)
Non-stimulant SNRI
Has antidepressant properties
Blocks NE transport in PFC which increases DA/NE in
the PFC
FDA approved; 6 y/o and older only
bupropion
(Wellbutrin)
Non-stimulant NDRI
Antidepressant
Blocks NE transport in PFC and DA transporters in the
nucleus accumbens, increasing DA/NE
Off label use; black box warning for lowering seizure
threshold
(Stahl, 2021)

36. ALPHA-2 AGONISTS
 Alpha-2 adrenergic receptors highly concentrated in PFC
 α2A most prevalent in PFC
 α2B most prevalent in thalamus (noted for sedative effects)
 α2C most prevalent in locus coeruleus
 Guanfacine and Clonidine Controlled Release (CR)
 Stimulate post-synaptic receptors and increase NE to normal levels
 Low potential for abuse due to the no action on DA
(Stahl, 2021)

37. ALPHA-2 AGONISTS
Guanfacine
 More selective for α2A receptor
 CR approved to treat ADHD
 "Off label" treatment of conduct
and oppositional defiant
disorder, and Tourette syndrome
 Less potential to cause sedation
and hypotension
 More potent enhancement of PFC
function
 Adjunctive use with inadequate
stimulant response (especially
oppositional symptoms)
Clonidine
 Non-selective actions on α2A, α2B,
α2C
 CR approved to treat ADHD
 Increased side effects due to
actions at other receptors
 "Off label" treatment of conduct
and oppositional defiant
disorder, and Tourette syndrome
(Stahl, 2021)

38. ALPHA-2 AGONISTS
Guanfacine
Intuniv (guanfacine ER)
 FDA approved
 Monotherapy and adjunctive
therapy
 6-17 years old
Tenex (guanfacine immediate
release)
 "Off-label" use
Clonidine
Kapvay (clonidine ER)
 FDA approved
 Monotherapy and adjunctive
therapy
 6-17 years old
Catapres (clonidine immediate
release)
 "Off-label" use
(Spaniardi et al., 2017)

39. TRICYCLIC ANTIDEPRESSANTS
 Studies support TCAs in reducing ADHD symptoms
 Caution when prescribing
 Taper down several weeks to discontinue
 Reviewed medications
 Imipramine
 Desipramine
 Nortriptyline
 Serious side effects warrant infrequent use
 Cardiovascular events (slowed conduction; increase PR/QRS interval; heart
block; arrythmias)
 Sudden cardiac death
 Lowered seizure threshold
 Cholinergic side effects (dry mouth, constipation, blurred vision)
(Spaniardi et al., 2017)

40. NEW PHARMACOLOGICAL
TREATMENT
viloxazine ER (Qelbree)
 Inhibitor of NET- SNRI
 Action on serotonin 2B (5HT2B) and 5HT2C receptors
 Mimics stimulant action by increasing DA and NE but less side effects that
stimulants produce
May be useful in patients who do not tolerate stimulants
 Approval by FDA in April 2021 for children 6-17 years old
https://healthpsychologyresearch.openmedicalpublishing.org/article/37018
(Haddad et al., 2022)

41. BEHAVIORAL
INTERVENTIONS
Parent Training Behavior Management (PTBM)
 Recommended first line treatment for preschool-aged
children
 Parents learn age-specific development expectations; tools
to improve relationship with child; how to manage specific
behaviors
Behavioral Classroom Interventions
 Individualized instructional support
 IEP is an Individualized Education Program developed for
special education needs of a student
(Wolraich et al., 2019)

42. BEHAVIORAL
INTERVENTIONS
Cognitive Behavioral Therapy (CBT)
 Recommended when medication has benefitted the
youth but there are still underlying cognitive or
behavioral problems causing functional impairment
 Beneficial in the focused restructuring of
cognitive/behavior patterns
Social skills
Problem-solving
Self-control
Active listening
Coping/expressing feelings
(National Institute for Health and Care Excellence [NICE], 2019)

43. COMPLEMENT
ARY &
ALTERNATIVE
METHODS
Physical Activity (PA)
 Reduced DA/NE = poor cognitive function
 Studies suggests that PA
increases catecholamines, exciting
neurotransmission leading to improvement
in executive function
 Improvement has been seen in
anxiety, depression, aggressive behavior,
and overall social skills
(Nazarova et al., 2022)

44. COMPLEMENT
ARY &
ALTERNATIVE
METHODS
Trigeminal Nerve Stimulation
 FDA clearance to treat ADHD in 2019
 Monarch eTNS
Non-invasive
Generates electrical signal and low-
level stimulation to trigeminal nerve branch
Thought to increase activity of
anterior cingulate, inferior frontal
gyrus, medial/middle frontal gyri
Regulates executive function impaired
in ADHD
Age 7-12 with supervision of caregiver
(Nazarova et al., 2022)

45. EDUCATION
AL
VIDEO
Centre for ADHD Awareness
Canada (2019)

46. LEARNING THEORY
Benner’s “from novice to expert”
A model of skill acquisition and development
Five levels of nursing practice
Novice Advanced beginner Competent Proficient
Expert
(Butts & Rich, 2018)

47. POST-TEST
While risk factors for ADHD continue to be researched, which
of the following has not been shown to be a risk factor?
A. Premature birth
B. Substance use during pregnancy
C. Lead exposure during pregnancy
D. Folic acid supplementation during pregnancy
ANSWER: D

48. POST-TEST
ADHD is one of the most common neurodevelopmental
disorders in children. Which of the following statements is true
about ADHD?
A. Girls are more likely than boys to be diagnosed with ADHD
B. Children between the ages of 3 and 5 years are the most at
risk age group
C. Children with ADHD rarely have comorbid mental health
diagnoses
D. Adolescents between the ages of 12 and 17 years are the
most at risk age group
ANSWER: D

49. POST-TEST
Which of the following is a recommended treatment for ADHD?
Select all that apply.
A. Inpatient hospitalization for immediate medication
management
B. Behavioral therapy
C. Medications for all children, starting at age 3
D. School involvement
E. All of the above
ANSWER: B, D

50. POST-TEST
Which of the following is not part of the DSM-V-TR criteria for
ADHD?
A. Inability to sit still
B. Forgetful
C. Difficulty listening when spoken to
D. Loss of interest
ANSWER: D

51. CONTRIBUTIONS
Sheila
screening tools/pharmacological and non-
pharmacological treatments/legend/design
Katherine
objectives/pre-test/post-test/overview of ADHD/prevalence/diagnostic
criteria/risk factors
Isabelle
Neurobiology/comorbidities/videos/learning theory

52. REFERENCES
American Psychiatric Association. (2022). Diagnostic and statistical manual of
mental disorders (Fifth ed., text rev.). American Psychiatric Publishing.
Butts, J. B. & Rich, K. L. (2018). Philosophies and theories for advanced nursing
practice (3rd ed.).
Jones & Bartlett Learning.
Centre for ADHD Awareness Canada (2019). That’s Me! I have ADHD! [YouTube
video]. https://youtu.be/Y4TELMCf98g
Centers for Disease Control. (2022, August). What is ADHD? Centers for Disease
Control (CDC). Retrieved January
22, 2023 from, https://www.cdc.gov/ncbddd/adhd/facts.html
Ellingwood, E. M. (2014). NICHQ Vanderbilt assessment scales: Used for diagnosing
ADHD [PDF].
NICHQ National Institute for Children’s Health Quality. Retrieved February

53. REFERENCES
Haddad, H. W., Hankey, P. B., Ko, J., Eswani, Z., Bhatti, P., Edinoff, A. N., Kaye, A. M.,
& Kaye, A. D. (2022). Viloxazine, a non-stimulant norepinephrine reuptake inhibitor,
for the treatment of attention deficit hyperactivity disorder: A 3 year
update. Health Psychology Research, 10(2). https://doi.org/10.52965/001c.37018
Memorable Psychiatry and Neurology (2022). Attention Deficit Hyperactivity Disorder
(ADHD) Mnemonics. [YouTube video]. https://www.youtube.com/watch?v=sOimBjnJKJQ
MHS Beyond Assessments. (n.d.). Conners 3®. Retrieved February 8,
2023, from https://storefront.mhs.com/collections/conners-3
Nazarova, V. A., Sokolov, A. V., Chubarev, V. N., Tarasov, V. V., & Schiöth, H. B. (2022).
Treatment of adhd: Drugs, psychological therapies, devices, complementary
and alternative methods as well as the trends in clinical trials. Frontiers
in Pharmacology, 13. https://doi.org/10.3389/fphar.2022.1066988
National Institute for Health and Care Excellence (NICE). (2019). Attention deficit

54. REFERENCES
Spaniardi, A.M., Greenhill, L.L., & Hechtman, L. (2017). Attention-deficit/hyperactivity disorder. In B.J. Sadock,
V.A. Sadock, & P. Ruiz, (Eds.), Kaplan & Sadock’s comprehensive textbook of psychiatry (10th ed., pp. 3587-
3598). Wolters Kluwer.
Stahl, S. M. (2021). Stahl’s Essential Psychopharmacology. Cambridge University Press.
The Mini ADHD Coach (2022). What’s your ADHD type? [YouTube video]. https://youtu.be/fBonqCwyjRA
Wolraich, M. L., Hagan, J. F., Jr, Allan, et al. (2019). Clinical Practice Guideline for the Diagnosis, Evaluation, and
Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. Pediatrics,
144(4), e20192528. https://doi.org/10.1542/peds.2019-2528