Attention-Deficit Hyperactivity Disorder (ADHD) in Children

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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


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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
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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
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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

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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

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TYPES:
Class I: Inattention +Hyperactivity +Impulsiveness.
Class Ii: Hyperactivity +Impulsiveness
Class Iii: Inattention

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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

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Symptoms of inattention:-
Symptoms of inattention
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Symptoms of Hyperactivity:-
Symptoms of Hyperactivity
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Symptoms of Impassivity:-
Symptoms of Impassivity

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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.
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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.
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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
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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

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Attention-Deficit Hyperactivity Disorder (ADHD) in Children
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