Attention deficit hyperactivity disorder (ADHD)


Attention deficit hyperactivity disorder (ADHD) similar to hyperkinetic disorder in the ICD10, is a psychiatric disorder of the neurodevelopmental type in which there are significant problems of attention, hyperactivity, or acting impulsively that are not appropriate for a person's age. It is usually not diagnosed before age of 4 year.
ADHD is behavior disorder that is characterized by hyperactivity, impulsiveness, inattention or a combination of those would be expected that are more frequent and severe than would be expected  for the age.
ADHD in the United states have varied from 2 to 20 percent of grade school children. It is more common in boys than girls by a ratio of 2:1 or 4:1 and may occur in as many as 7 to 10 percent of school age children. And about 60 to 70 percent of the case ADHD persist will subsequently meet the criteria for antisocial personality disorder with adults. It affects the home, school, and community life of 3-9% of schoolgoing children worldwide.
One research conducted in Tamil Nadu that's find The prevalence of ADHD among primary school children was found to be 11.32%. Prevalence was found to be Higher among the males (66.7%) as compared to that of females (33.3%). The prevalence among lower socio-economic group was found to be 16.33% and that among middle socio-economic group was 6.84%. The prevalence was highest in the age group 9 and 10 years and higher prevalence among the males than the females.
The study name was Prevalence of Attention Deficit Hyperactivity Disorder in primary school children by Jyothsna Akam Venkata, Anuja S. Panicker
Department of Psychiatry, P. S. G. Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India.
 Genetics: -A large number of parents of hyperactivity children showed signs of hyperactivity during their own childhood.
Siblings of hyperactivity children have about twice the risk of having the disorder as those in the general population.
Children with ADHD are at higher risk of developing conduct disorders and alcohol use disorders and antisocial personality disorder are more common in their parents than in those in the general population.
 Biochemical: - Abnormal levels of dopamine, norepinephrine and serotonin have been implicated as a cause of ADHD. Abnormal level of these neurotransmitters may be associated with the symptoms of inattention, hyperactivity, impulsivity, mood and aggression observed with disorder.
 Perinatal factors: - In this factor implicated with problem pregnancies and difficult deliveries, maternal smoking and use of alcohol or other drug during pregnancy, exposure during pregnancy to environmental toxins.
Psychosocial factors: - A disorganized environment or a disruption in family equilibrium may contribute to ADHD. A high degree of psychosocial stress, maternal mental disorder, paternal criminality, low socioeconomic status and unstable foster care have been shown to increase the risk of ADHD.
1.Attention deficit hyperactivity Inattentive: - Inattention but not enough (at least 6 out of 9 for children less than 18 years old)  symptoms. At least six symptoms of inattention have persisted for at least 6 months. In this sub type of disorder has difficulty paying attention, does not listen when spoken to, difficulty organizing tasks and activities.
2.Attention deficit hyperactivity Impulsive: - In this sub type is used if at least six symptoms of hyperactivity impulsivity ( but fewer than six symptoms of inattention) have persisted for at least six month . In this disorder trouble sitting still, cannot play quietly, talks excessively, blurts answer before question are complete, has difficulty in
3.Attention deficit hyperactivity combined type: - displays a combination of behaviors associated with the above two types. in this disorder six symptoms of both disorder for at least six month. Most of the children and adolescents with the disorder have combined
Clinical feature:-
This must include at least 6 of the following symptoms of inattention that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
1.      Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
2.      Often has difficulty sustaining attention in tasks or play activities
3.      Often does not seem to listen to what is being said
4.      Often does not follow through on and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand insuuctions)
5.      Often has difficulties organizing tasks and activities
6.      Often avoids or strongly dislikes tasks (such as schoolwork or homework) that require sustained mental effort
7.      Often loses things necessary for tasks or activities (school assignments, pencils, books, tools, or toys)
8.      Often is easily distracted by extraneous stimuli
9.      Often forgetful in daily activities
must include at least 4 of the following symptoms of hyperactivity-impulsivity that must have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:
1.      Hyperactivity evidenced by fidgeting with hands or feet, squirming in seat
2.      Hyperactivity evidenced bÿ leaving seat in classroom or in other situations in which remaining seated is expected
3.      Hyperactivity evidenced by running about or climbing excessively in situations where this behavior is inappropriate (in adolescents or adults, this may be limited to subjective feelings of restlessness)
4.      Hyperactivity evidenced by difficulty playing or engaging in leisure activities quietly
5.      Impulsivity evidenced by blurting out answers to questions before the questions have been completed.
6.      Impulsivity evidenced by showing difficulty waiting in lines or awaiting turn in games or group situations
·         Onset is not later than age 7 years.
·         Symptoms must be present in 2 or more situations, such as school, work, or home.
·         The disturbance causes clinically significant distress or impairment in social, academic,  or occupational functioning.
·         Disorder does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and is not better accounted for by mood, anxiety, dissociative, or personality disorder.
Medical management:
CNS Stimulants:-
l. Amphetamines: - Dextroamphetamine sulfate , lisdezamphetamine
2. Amphetamine mixture
Alpha agonists :- Clonidine and Guanfacine
Action: - CNS stimulants increase levels of  neurotransmitters  in the CNS. They produce CNS and respiratory stimulation, dilated pupils, increased motor activity and mental alertness, diminished sense of fatigue and brighter spirits.
Central nervous system stimulants are the first choice of agents in that they have been shown to have the greatest efficacy with generally mild tolerable side effects.
Side effects
 Overstimulation, restlessness, insomnia, Palpitation, tachycardia or bradycardia, Anorexia, weight loss, Tolerance, physical and psychological dependence,Nausea, vomiting, constipation, dry mouth, sedation, Potential for seizures, Liver damage and rebound syndrome
Nursing management: Nursing diagnosis:-
1.Risk for injury related to impulsive and accident prone behaviour and the inability to perceive self-harm
Nursing actions:-
 Ensure that environment is safe
·         Identify and limit behaviors that put child at risk for injury
·         Provide necessary supervision to prevent injury during therapeutic activities
 Nursing diagnosis:-
2.Impaired social interaction related to intrusive and immature behavior
Nursing actions:-
·         Develop a trusting relationship  
·         Discuss with client which behaviors are and are not acceptable
·         Employ consequences for unacceptable behavior
·         Provide group situations for client
Nursing diagnosis:-
3.Low self-esteem related to Dysfunctional family system and negative feedback
Nursing actions:-
·         Ensure that goals are realistic
·         Plan activities that provide opportunity for success
·         Convey unconditional acceptance and positive regard
·         Give positive reinforcement for achievements
Nursing diagnosis:-
4. Noncompliance related to low frustration tolerance and short attention span
Nursing actions:-
·         Reduce environmental distraction
·         Provide simple, concrete instructions
·         Establish goals for completion of tasks in steps, reward each step completion
·         Encourage and reward independent achievement



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item Attention deficit hyperactivity disorder (ADHD)
Attention deficit hyperactivity disorder (ADHD)
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