Attention Deficit Hyperactivity Disorder (ADHD) is characterized by patterns of inattention, hyperactivity, and impulsivity, affecting 3-5% of school-age children, with a higher prevalence in boys. ADHD has three subtypes: predominantly inattentive, predominantly hyperactive-impulsive, and combined presentation, and can lead to challenges in social and academic functioning. Treatment typically involves a combination of pharmacotherapy, psychotherapy, and behavioral interventions to address symptoms and improve overall functioning.

1. Attention Deficit Hyperactivity
Disorder
Dhrutigna Patel
2nd year M.Sc(N)
MBNC

2. Introduction
• The essential behavior pattern of a child with attention
deficit/hyperactivity disorder (ADHD) is one of inattention and/or
hyperactivity and impulsivity.
• These children are highly distractible and unable to contain their
responses to stimuli. Motor activity is excessive, and movements are
random and impulsive.
• 3-5% prevalence in school age children.
• 3-5 times commoner in boys
• Increase incidence of co-morbid mood disorder, personality disorder,
conduct disorder and oppositional deficient disorder.

3. • In about 60 to 70 percent of the cases, ADHD persists into young
adulthood, and about 25 percent will subsequently meet the criteria for
antisocial personality disorder as adults
• Symptoms are usually present around age 3 or 4
• 68% of children with ADHD have problems as adults
• Boys outnumber girls 4 to 1

4. • ADHD has three subtypes
• Predominantly hyperactive-impulsive
• Most symptoms are in the hyperactivity impulsivity categories
• Fewer than six symptoms of inattention are present, although inattention may
still be present to some degree
• The majority of symptoms are in the inattention category and fewer than six
symptoms of hyperactivity-impulsivity may still be present to some degree
• Children with this subtype are less likely to act out or have difficulties getting
along with other children. They may sit quietly, but they are not paying attention
to what they are doing. Therefore, the child may be overlooked, and parents and
teachers may not notice that he or she has ADHD
• 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

5. •Symptoms of ADHD in children

6. • DSM-IV and DSM-IV-TR symptoms clusters
• Cluster 1- symptoms of inattention
• Cluster 2- symptoms of hyperactivity and impulsivity cluster
• Either cluster 1 or 2 must be present for a diagnosis

7. • Children who have symptoms of inattention may:
• Be easily distracted, miss details, forget things, and frequently switch from one
activity to another
• Have difficulty focusing on one thing
• Become bored with a task after only few minutes, unless they are doing
something enjoyable
• Have difficulty focusing attention on organizing and completing a task or
learning something new
• Have trouble completing or turning in homework assignments, often losing
things needed to complete tasks or activities
• Not seem to listen when spoken to
• Daydream, become easily confused, and move slowly
• Have difficulty processing information as quickly and accurately as others
• Struggle to follow instructions

8. Children who have symptoms of
hyperactivity may
• Fidget and squirm in their seats or often fidgets with hands or feet or
squirms in seat
• Talk nonstop
• Dash around, touching or playing with anything and everything in
sight
• Have trouble sitting still during dinner, school and story time
• Be constantly in motion
• Have difficulty doing quiet tasks or activities

9. • Children who have symptoms of impulsivity may:
• Be very impatient
• Blurt out inappropriate comments, show their emotions without
restraint, and act without regard for consequences
• Have difficulty waiting for things they want or waiting their turns in
games
• Often interrupt conversations or others activities

10. Causes
• Genetic factor ( higher incidence in monozygotic twins than dizygotic
)

11. Biological contributions
• Neurobiological contribution: Brain dysfunction and damage
• Inactivity of the frontal cortex and basal ganglia
• Right hemisphere malfunction
• Abnormal frontal lobe development and functioning
• Maternal smoking increases risk of having a child with ADHD

12. Psychosocial contribution
• Psychosocial factors appear to influence the disorder
• Constant negative feedback from teachers, parents and peers
• Peer rejection and resulting social isolation
• Such factors foster low self image

13. Environmental factors
• Studies suggest a potential link between cigarette smoking and alcohol
use during pregnancy and ADHD in children.
• In addition, pre-schoolers who are exposed to high levels of lead,
which can sometimes be found in plumbing fixtures or paint in old
buildings, may have a higher risk of developing ADHD

14. Brain injuries
• Children who have suffered a brain injury may show some behaviors
similar to those of ADHD. However only a small percentage of
children with ADHD have suffered a traumatic brain injury.
• Prenatal trauma/toxin exposure
• Neurochemical factors
• Neurophysiological factors
• Psychosocial factors

15. Food additives
• Recent british research indicates a possible link between consumption
of certain food additives like artificial colors or preservatives, and an
increase in activity hyperactivity

16. Diagnostic criteria for the 3subtypes
• Persistent pattern of inattention and hyperactivity-impulsivity that is
more frequently displayed and is more severe than is typically
observed in individuals at comparable level of development.
Individual must meet criteria for either 1 or 2
1) Six of the following symptoms of inattention have persisted for at
least six months to a degree that is maladaptive and inconsistent with
developmental level.
2) Six of the following symptoms of hyperactivity impulsivity have
persisted for at least six months to a degree that is maladaptive and
inconsistent with developmental level.
• Some hyperactive impulsive or inattentive symptoms must have been
present before age 7 years
• Some impairment from the symptoms is present in at least two settings

17. • There must be clear evidence of interference with developmentally
appropriate social, academic or occupational functioning.
• The disturbance does not occur exclusively during the course of a pervasive
developmental disorder, schizophrenia, or other psychotic disorders and is not
better accounted for by another mental disorder ( Mood disorder, anxiety
disorder )

18. Diagnostic criteria based on DSM 5
• People with ADHD show a persistent pattern of inattention and
hyperactivity impulsivity that interferes with functioning or
development:
1) inattention: Six or more symptoms of inattention for children up to
age 16, or five or more for adolescents 17 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

19. • Often does not follow through on instructions and fails to finish schoolwork, or
duties in the workplace
• Is often easily distracted
• Is often forgetful in daily activities
2) Hyperactivity and impulsivity: Six or more symptoms of hyperactivity
impulsivity for children up to age 16, or five or more for adolescents 17 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 situation when remaining seated is expected
• Often runs about or climbs in situations where it is not appropriate
• Often unable to play or take part in leisure activities quietly
• Often has trouble waiting his/her turn.

20. Based on types of symptoms, three kinds 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.

21. Treatment
1) Pharmacotherapy: CNS stimulant- methylphenidate is the 1st line
therapy, dextroamphetamine and pemoline, SSRI’s/TCA’s adjunctive
therapy
2) Individual psychotherapy: with more focus on behaviour
modification technique
3) Parental counselling
4) Social group therapy: help patient improve social skills
5) Behavioral and combined treatment of ADHD
6) Behavioral treatment
7) Combined Bio psycho social treatments

22. Nursing Diagnosis
• Based on the data collected during the nursing assessment, possible
nursing diagnoses for the child with ADHD include the following:
• Risk for injury related to impulsive and accident prone behavior and
the inability to perceive self-harm
• Impaired social interaction related to intrusive and immature behavior
• Low self-esteem related to dysfunctional family system and negative
feedback
• Noncompliance with task expectations related to low frustration
tolerance and short attention span

23. Nursing Intervention
• Develop a trusting relationship with the child. Convey acceptance of
the child separate from the unacceptable behavior.
• Ensure that patient has a safe environment. Remove objects from
immediate area in which patient could injure self due to random
hyperactive movements. Identify deliberate behaviors that put the
child at risk for injury. Institute consequences for repetition of this
behavior. Provide supervision for potentially dangerous situations.
• Since there is non-compliance with task expectations, provide an
environment that is as free of distractions as possible.

24. • Ensure the child's attention by calling his name and establishing eye contact,
before giving instructions.
• Ask the patient to repeat instructions before beginning a task.
• Establish goals that allow patient 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 concrete
instructions.
• Gradually decrease the amount of assistance given to task performance,
while assuring the patient that assistance is still available if deemed
necessary.
• Offer recognition of successful attempts and positive reinforcement for
attempts made. Give immediate positive feedback for acceptable behavior.

25. • Provide quiet environment, self-contained classrooms, and small group
activities. Avoid over stimulating places such as cinema halls, bus stops and
other crowded places.
• Assess parenting skill level, considering intellectual, emotional and physical
strengths and limitations. Be sensitive to their needs as there is often exhaustion
of parental resources due to prolonged coping with a disruptive child.
• Provide information and materials related to the child's disorder and effective
parenting techniques. Give instructional materials in written and verbal form
with step-by-step explanations.
• Explain and demonstrate positive parenting techniques to parents or caregivers,
such as time-in for good behavior, or being vigilant in identifying the child's
behavior and responding positively to that behavior.
• Educate child and family on the use of psycho stimulants and anticipated
behavioural response.

26. • Coordinate overall treatment plan with schools, collateral personnel, the child
and the family.