This document discusses attention deficit disorder (ADD), including its four types and their characteristics. It provides details on symptoms, causes, diagnosis criteria, and treatment approaches for ADD with hyperactivity (ADHD). Key information includes that ADHD is one of the most common childhood disorders, affecting 3-5% of school-aged children. It involves inattention, hyperactivity, and impulsivity. Treatment may involve behavioral therapy, pharmacological therapy with stimulants or non-stimulants, or a combination approach depending on the child's age. Nursing management focuses on ensuring a safe environment and developing a trusting relationship to encourage the child.

1. Prepared by- Isha Thapa Magar
Nursing Instructor
PBBN 2st Year

2. Attention deficit disorder (ADD)
ADD is of four clinical types:
1. ADD with hyperactivity
2. ADD without hyperactivity
3. ADD residual types &
4. Hyperkinetic disorder with conduct
disorders.

3. 1.Attention deficit disorder with hyperactivity
(Hyperkinetic disorder):
- This is the commonest type.
2. Attention deficit disorder without
hyperactivity:
- It is a rare disorder with similar clinical
features, except hyperactivity.

4. 3. Residual type:
- It is usually diagnosed in a patient in
adulthood, with a past history of ADD &
presence of few residual features in adult
life.
4. Hyperkinetic disorder with conduct
disorder (Hyperkinetic conduct disorder).

5. Attention Deficit Disorder with
Hyperactivity (ADDH)

6. ADHD is the most common neurobehavioral
disorder of childhood, affecting school-aged
children.
ADHD refers to a
-persistent pattern of inattention, including
increased distractibility & difficulty sustaining
attention;
-poor impulse control & decreased self inhibitory
capacity; &
-motor over activity & motor restlessness.

7. The average age of onset is 7 years old.
 It affects 3-5% of school-age children
 60% of children who experience ADHD in
childhood continue to have symptoms as
adults.
OR
It is the developmentally inappropriate degrees
of inattention, impulsiveness and hyperactivity
that may begin in early childhood and can continue
into adulthood.

8. If not treated on time, it will significantly interfere
with normal course of emotional & psychological
development of child.

9. Affected children commonly experience;
academic underachievement,
problems with interpersonal relationships with
family members and peers.
low self-esteem
ADHD often co-occurs with other emotional,
behavioral, language, and learning disorders

10. Etiology

11. Genetic factors
• monozygotic twins → 59- 92%
• dizygotic twins→ 29-42%.
• 50% chance to have if one parent has ADHD,
20-25% chance if a first degree relative is
affected.
Biochemical Factors;
 Deficit of dopamine and nor epinephrine
This deficit of neurotransmitters is believed to
lower threshold for stimuli input.

12. Pre, peri and postnatal factor
Birth complications e.g. lengthy labor, complicated
delivery.
Prenatal toxic exposure or physical Trauma.
Fetal distress
Prematurity Precipitated or prolonged labor

13. Low birth weight
 Prenatal asphyxia and low apgar scores
Infection after birth e.g. meningitis,
encephalitis
CNS abnormalities resulting from trauma
Common exposures in uteri tobacco smoke,
lead exposure include alcohol

14. Environmental Toxins & Dietary Factors
• Pesticides
• Lead toxicity
• Iron & Zinc deficiency
• Poly Unsaturated Fatty Acid deficiency
• Food additives
• Food high in sugar content

15. Psychosocial Factors
• Poverty
• Low parental education
• Disturbed or inadequate family (Negative
parenting, neglect, over protection, divorce)
• Prolonged emotional Deprivation
• Stressful psychic events
• Bullying & peer victimization

16. Severe traumatic brain injury.
Structural or functional abnormalities
Prefrontal cortex
Basal ganglia
Cerebellum
 widespread small-volume reduction
throughout brain
abnormalities of cerebellum.

20. Symptoms of Inattention
Easily distracted
 Miss details
 Forget things
 Frequently switch from one activity to
another
 Difficulty focusing on one thing
 Becomes bored easily
 Difficult to focus attention on organizing &
completing a task or learning something new

21. Trouble completing or turning in homework
assignments
 Doesn’t seem to listen when spoken to
 Becomes easily confused, and moves slowly
 Difficulty processing information as quickly &
accurately as others
 Struggles to follow instructions

22. Symptoms of hyperactivity
 Talks nonstop
 Dashes around, touching or playing with
anything & everything in sight
 Trouble sitting still during dinner, school, and
story time
 Constantly in motion
 Difficulty doing quiet tasks or activities

23. Symptoms of Impulsivity
 Very impatient
 Blurts out inappropriate comments
 Shows emotions without restraint
 Acts without regard for consequences
 Difficulty waiting for things they want or
waiting their turns in games
 Often interrupts conversations or others
activities
 May often come off as aggressive or unruly.

24. Child in the Classroom
They demand attention by talking out of turn
or moving around the room.
 They have trouble following instructions.
 They often forget to write down homework
assignments, do them, or bring completed work
to school.

25. They often lack fine motor control, which
makes note-taking difficult & handwriting a trial
to read.
 They often have trouble with operations that
require ordered steps, such as long division or
solving equations.
 They usually have problems with long-term
projects where there is not direct supervision.

26. They don’t pull their weight during group
work & may even keep a group from
accomplishing its tasks.
 Tend to have low grades.

27. Hallmark symptoms of ADHA
Short Attention spam
Distractibility
Disorganization
Procrastination
Poor internal supervision

29. 1.Predominantly hyperactive-
impulsive
Most symptoms (six or more) are in the
hyperactivity-impulsivity categories.
 Fewer than six symptoms of inattention are
present, although inattention may still be present
to some degree.

30. 2. Predominantly inattentive
 The majority of symptoms (six or more) are
in attention category & fewer than six
symptoms of hyperactivity-impulsivity are
present, although hyperactivity-impulsivity may
still be present to some degree.

31. 3. Combined hyperactive-impulsive and
inattentive
 Six or more symptoms of inattention
and six or more symptoms of hyperactivity-
impulsivity are present.
 Most children have the combined
type of ADHD.

33. The American Psychiatric Association has defined
consensus criteria for diagnosis of attention deficit
disorder (ADHD), which are published in Diagnostic
and Statistical Manual of Mental Disorders Fifth
Edition (DSM-5)

34. For children <17 years, the DSM-5 diagnosis of
ADHD requires
≥6 symptoms of
hyperactivity
and impulsivity
≥6 symptoms of
inattention
OR

35. 1- Occur often.
2- Be present in more than one setting (eg,
school and home).
3- Persist for at least six months.
4- Be present before age of 12 years.
The symptoms of hyperactivity/impulsivity
or inattention must:

36. 5- Impair function in academic, social, or
occupational activities.
6- Be excessive for developmental level of the
child.

37. Treatment Modalities

38. Behavioral
Therapy
Pharmacological
Therapy
Combined
Therapy

39. Behavioral Therapy
Behavioral interventions includes modifications
in physical & social environment that are designed
to change behavior using rewards & non-punitive
consequences.
-

40. Behavior therapy and environmental changes
include:
1- Maintaining a daily schedule.
2- Providing specific & logical places for child to
keep his schoolwork, toys, & clothes.

41. 3- Rewarding positive behavior (eg, with a
“token economy”).
4- Using charts and checklists to help the child
stay "on task”.
5- Limiting choices.
6- Finding activities in which child can be
successful (e.g, hobbies,
sports).

42. Seat child where distractions are minimized.
 Structure student’s environment to
accommodate his/her needs.
 Seat child away from potentially distracting areas
e.g. doors, windows, and computers
 Child should sit at front of class, where it is
easier to pay attention
 Use a signal to help child stay on task.

43. Find ways to praise child.
 Find opportunities to allow hyperactive
children to use their energy.
 When giving directions, keep them short &
simple.
 Create a system to make it easy for parents &
students to get homework
assignments.

44.  Reduce homework assignments.
 Give directions to one assignment at a time
instead of directions to multiple tasks all
at once.
 Vary pace & type of activity to maximize
student’s attention.

45. Pharmacological Therapy
Several different types of medications may be
used to treat
ADHD:
1- Stimulants are best-known & most widely used
treatments.
-Between 70-80 % of children with ADHD respond
positively to these medications.
-E.g. Dextro-amphetamine & Methylphenidate.

46. 2- Non-stimulants were approved for treating
ADHD in 2003.
- This medication seems to have fewer side
effects than stimulants such as Antidepressants

47. Combination Therapy
-Combination therapy uses both behavioral
interventions and medications.
- Combination therapy may be beneficial for
school-aged children and adolescents who
have a suboptimal response to
pharmacotherapy or in preschool children who
do not respond to behavioral interventions

48. Treatment Choice
- The treatment strategies for children with ADHD
vary according to age:
1- For preschool children (age 4 through 5 years)
who meet diagnostic criteria for ADHD, we
recommend behavior therapy rather than
medication as initial therapy.

49. 2- For most school-aged children and adolescents
(≥6 years of age) who meet diagnostic criteria for
ADHD & specific criteria for medication, we suggest
initial treatment with stimulant medication
combined with behavioral therapy, to improve core
symptoms & target

50. Nursing Management

51. •Ensure that child has safe environment. Remove
objects from immediate area on which client could
injure self due to hyperactive movement.
•Develop to trusting relationship with the child.
•Ensure client is protected from injury. Keep stimuli
low and environment as quiet as possible to
discourage over stimulation. Avoid over stimulation
places as cinema halls, bus stops, and other crowed
places.

52. •Ensure the child's attention by calling his name and
establishing eye contact, before giving instructions.
•Ask the child to repeat instructions before beginning
a task.
•Encourage child to complete a part of the task,
rewarding each step completion with a break for
physical activity.
•Provide assistance on a one to one basis beginning
with simple instruction.

53. •Give immediate positive feedback for acceptance
behavior.
•Assess parenting skills level, provide information
and materials related to the child's disorder and
effective parenting techniques. Give instructions in
written and verbal form with step-by-step
explanations.

54. •Demonstrate positive parenting technique to
parents or care givers.
•Educate child and family on the use of psycho
stimulants.
•Ensure that parents are aware that the drug should
not be with drawn abruptly.