Attention-Deficit Hyperactivity Disorder (ADHD) in Children

Attention –deficit hyperactivity disorder (ADHD) is a syndrome characterized by persistent and developmentally inappropriate levels of  Inattention and/or  hyperactivity and impulsivity

Symptom Class	Specific Symptoms
Inattention	•             Does not pay attention to details •             Has difficulty sustaining attention at school •             Does not seem to listen when spoken to •             Does not follow through on instructions or finish tasks •             Has difficulty organizing tasks and activities •             Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort •             Often loses things •             Is easily distracted Is forgetful
Hyperactivity	•             Often fidgets with hands or feet or squirms •             Often leaves seat in classroom or elsewhere •             Often runs about or climbs excessively •             Has difficulty playing quietly •             Often on the go, acting as if driven by a motor •             Often talks excessively
Impulsivity	•             Often blurts out answers before questions are completed •             Often has difficulty awaiting turn Often interrupts or intrudes on others

 [next]

Etiology-

•       Unknown

•       Genetic Factors

•       Biochemical Theory

•       Pre, Peri and Postnatal

            Factors

•       Environmental Influences

•       Psychosocial Factors

Prevalence

3–7% of school-age children

3–4 times more common in males than females

Females more likely to have inattentive type

Course-

50-80% continue to demonstrate symptoms in adolescence

Significant number of children carry the symptoms in adulthood

  [next]

RISK FACTORS

•       Drug exposure in utero.

•       Genetic factors

•       Family history

•       Chromosomal- fragile X

•       Turner’s syndrome

•       Klinefelter syndrome

•       Exposure to toxins

•       Perinatal complications

•       Drug exposure in utero

•       Head trauma

•       Neurologic infection

•       Birth complications.

•       Low birth weight.

•       Lead poisoning.

•       Dysfunctional family (poverty, substance abuse)

•       Family history of substance abuse ,Conduct disorders

•       Learning disorder

•       Antisocial personality disorder

  [next]

DIAGNOSIS

•       Complete medical evaluation.

•       A psychiatric evaluation.

•       Detailed prenatal history and early developmental history.

•       Direct observation, teacher’s school report, parent’s report.

DSM-IV criteria for diagnosis:

·         At least 6 of 9 behaviours in inattention and/or hyperactivity/impulsivity

·         Persisting for at least 6 months that is maladaptive and inconsistent with developmental level

·         Some symptoms present before age 7 years

·         Impairment from symptoms present in 2 or more settings

·         Clear evidence of clinically significant impairment in social, academic, or occupational functioning

 [next]

CLINICAL FEATURES

•       Sensitive to stimuli, easily upset by noise, light, temperature and other environmental changes.

•       At times, the reverse occurs and the children are flaccid and limp, sleep more and the growth and development is slow in the first month of life.

•       General coordination deficit.

•       Short attention span, easily distractible.

•       Selective attention

•       Speech and Learning difficulty

•       Failure to finish tasks

•       Impulsivity.

•       Memory and thinking deficits.

•       Specific learning disabilities.

•       Risk for conduct , mood and anxiety disorder

•       Impairment in cognitive and behavioural function

 [next]

TYPES:

Class I: Inattention +Hyperactivity +Impulsiveness.

Class Ii: Hyperactivity +Impulsiveness

Class Iii: Inattention

  [next]

Classification:-

1.    Combined type-

•      ≥ 6 symptoms of inattention,

•      ≥ 6 symptoms of hyperactivity ,impulsivity

•      Should last ≥6 months

2.    Predominantly hyperactive-impulsive type-

•      ≥6 symptoms of hyperactivity – impulsivity

•      < 6 symptoms of inattention

•      Should last ≥6 months

3.    Predominantly inattention type-

•      ≥ 6 symptoms of inattention

•      < 6 symptoms of hyperactivity

•      Should last ≥6 months

 [next]

Symptoms of inattention:-

Symptoms of inattention

 [next]

Symptoms of Hyperactivity:-

Symptoms of Hyperactivity

 [next]

Symptoms of Impassivity:-

Symptoms of Impassivity

 [next]

Diagnosis-

Complete medical evaluation:

Vision,hearing screening

Neurological examination

Psychiatry Problems Ruling Out-

•      Projective tests to determine visual –perceptual difficulties.

•      Behavioral checklists,

•      Adaptive scales to measure social adaptive functioning

•      Computer screening to measure body movement and attention

•      Detailed perinatal and early developmental history,

•      Direct observation, tally school and parent’s report

•      Therapeutic management:

•      Proper classroom placement

•      Environmental manipulation

•      Behaviour therapy and psychotherapy

•      Help family to identify appropriate reward system to meet child’s developmental skills

•      Positive reinforcement

•      Rewarding desired behaviours and age appropriate consequences (eg – time out)

•      Collaboration with parents to learn the techniques to help the child

•      Organization charts for completing self care activities and using a word processor instead of manually writing out assignments.

  [next]

TREATMENT

Pharmacotherapy-

•      Psychostimulants- Methylphenidate hydrochloride (Ritalin, Concerta) or methylphenidate patch (Daytrana)

•      Amphetamines, such as dextroamphetamine sulfate and amphetamine (Adderall)

•      Nonstimulants, such as atomoxetine hydrochloride (Strattera)

•      TCA’s –Imipramine,desipramine etc

•      SSRI’s - Atomoxetine (Strattera)

•      Antidepressants such as bupropion

•      Guanfacine

•      Clonidine

Non Pharmacologic

•      Psychologic Therapies

•       Cognitive Behavior Therapy

•       Biofeedback

•       Behavior therapy- Teachers and parents can learn behavior-changing strategies, such as token reward systems and timeouts, for dealing with difficult situations.

•       Psychotherapy- This allows older children with ADHD to talk about issues that bother them, explore negative behavioral patterns and learn ways to deal with their symptoms.

•       Parenting skills training -This can help parents develop ways to understand and guide their child's behavior.

•       Family therapy -Family therapy can help parents and siblings deal with the stress of living with someone who has ADHD.

•       Social skills training- This can help children learn appropriate social behaviors.

 [next]

NURSING INTERVENTION

Nursing Diagnoses:

•      Compromised family coping

•      Impaired social interaction

•      Ineffective family health management

•      Ineffective impulse control

•      Interrupted family processes

•      Risk for injury

Expected Outcomes

The child and family will:

•      Seek support systems and exhibit adequate coping behaviors

•      Demonstrate effective social interaction skills in one-on-one and group settings

•      Report improvement in family and social interactions

•      Remain free from injury.

Nursing Interventions

•      Set realistic expectations and limits to avoid frustrating the child.

•      Maintain a calm, consistent manner.

•      Ensure a safe environment.

 Develop a trusting relationship with the child.

•       Ensure safe environment.

•       Offer recognition for successful attempts and positive reinforcement.

•       Provide information and materials related to the child’s disorder and effective parenting techniques. 

•       Explain and demonstrate positive parenting techniques

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

•      Keep all instructions short and simple; make one-step requests.

•      Provide praise, rewards, and positive feedback whenever possible.

•      Provide diversional activities suited to a short attention span.

•      Administer medications as prescribed; give short-acting methylphenidate in the morning, at noon, and at 4 p.m.; give long-acting forms once daily in the morning; give dextroamphetamine and amphetamine extended-release once daily in the morning; give atomoxetine in the morning.

•      Apply a methylphenidate patch to the hip for up to 9 hours daily; anticipate the dosage to be titrated upward every week as needed.

Monitoring

•      Behavior and activity level

•      Nutritional status

•      Ability to sleep

•      Compliance with medication regimen

•      Adverse drug reactions

•      Response to treatment

•      Cardiovascular and liver function

•      Suicidal ideation with use of atomoxetine

 [next]

Patient and Family Teaching
General:
Be sure to include the child's family or caregiver in your teaching, when appropriate. Be sure to cover:
importance of behavior therapy and use of limits and positive feedback
examples of rewards and positive reinforcements of good behavior
need to develop realistic expectations
medication regimen, including drugs, dosages, frequency, schedule for administration, and proper technique for applying a patch, if ordered
intended effects of medication therapy and possible adverse reactions, including signs and symptoms that warrant notifying the practitioner
possible periodic drug cessation to determine the continued need for medication
effects of medications on sleeping and measures to promote sleep
effects of medications on appetite and appropriate suggestions for sound nutritional choices, including small, frequent meals
importance of continued follow-up and ongoing evaluation to determine the effectiveness of therapy and to evaluate growth and development.

Mnemonics:

Attention Deficit Hyperactivity Disorder (ADHD) symptoms

ADHD

·         Attention impaired – short attention span

·         Distractibility

·         Hyperactive – over activity

·         Devil-may-care attitude – impulsivity

Or,

in keeping with the 3 core symptoms:

1.      Attention Deficit

2.      Hyperactivity

3.      Devil-may-care attitude – impulsivity