Liceo de Cagayan University

R.N. pelaez blvd., kauswagan, Cagayan de oro city

College of nursing

As partial requirement for NCM501203

ATTENTION DEFICIT HYPERACTIVITY

DISORDER
Submitted by:
Bayhon, Iris
Dagasuhan, Dario
Gerozaga, Randolph
Ontolan, Michelle Pia
Pagador, Fatima Anne
Pontillas, Kath Lynn
Robas, Paulie Kathleen
Tacna, Jackie Lou
Tumapon, Fritz Regis
Zaportiza, Hazzel Mae

Submitted to:
Mrs. Louvella Cubillo
Clinical Instructor
Attention-Deficit Hyperactivity Disorder (ADHD or AD/HD or ADD) is a
neurobehavioral developmental disorder. It is primarily characterized by "the co-
existence of attention problems and hyperactivity, with each behavior occurring
infrequently alone" and symptoms starting before seven years of age.

ADHD is the most commonly studied and diagnosed psychiatric disorder in

children, affecting about 3% to 5% of children globally and diagnosed in about 2% to
16% of school aged children. [6] It is a chronic disorder with 30% to 50% of those
individuals diagnosed in childhood continuing to have symptoms into
adulthood. Adolescents and adults with ADHD tend to develop coping mechanisms to
compensate for some or all of their impairments. 4.7 percent of American adults are
estimated to live with ADHD.

ADHD is diagnosed two to four times as frequently in boys as in girls, [12] though

studies suggest this discrepancy may be due to subjective bias of referring teachers.
ADHD management usually involves some combination of medications, behavior
modifications, lifestyle changes, and counseling. Its symptoms can be difficult to
differentiate from other disorders, increasing the likelihood that the diagnosis of ADHD
will be missed. Additionally, most clinicians have not received formal training in the
assessment and treatment of ADHD, particularly in adult patients.

ADHD and its diagnosis and treatment have been considered controversial since

the 1970s. The controversies have involved clinicians, teachers, policymakers, parents
and the media. Topics include the actuality of the disorder, its causes, and the use of
stimulant medications in its treatment. Most healthcare providers accept that ADHD is a
genuine disorder with debate in the scientific community centering mainly on how it is
diagnosed and treated. The American Medical Association concluded in 1998 that the
diagnostic criteria for ADHD are based on extensive research and, if applied
appropriately, lead to the diagnosis with high reliability.

Subtypes
ADHD has three subtypes:

 Predominantly hyperactive-impulsive
o Most symptoms (six or more) are in the hyperactivity-impulsivity
categories.
o Fewer than six symptoms of inattention are present, although inattention
may still be present to some degree.
 Predominantly inattentive
o The majority of symptoms (six or more) are in the inattention category and
fewer than six symptoms of hyperactivity-impulsivity are present, although
hyperactivity-impulsivity may still be present to some degree.
o 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 symptoms of ADHD.
 Combined hyperactive-impulsive and inattentive
o Six or more symptoms of inattention and six or more symptoms of
hyperactivity-impulsivity are present.
o Most children with ADHD have the combined type.

SYMPTOMS

The symptom categories of ADHD in children yield three potential classifications of

ADHD—predominantly inattentive type, predominantly hyperactive-impulsive type, or combined
type if criteria for both subtypes are met:

Predominantly inattentive type symptoms may include:

 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 a few minutes, unless 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 (e.g.,
pencils, toys, assignments) 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.

Predominantly hyperactive-impulsive type symptoms may include:

 Fidget and squirm in their seats

 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.

and also these manifestations primarily of impulsivity:

 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

Causes/Etiology

A specific cause of ADHD is not known. There are, however, a number of factors that may
contribute to, or exacerbate ADHD. They include genetics, diet and social and physical
environments.

Genetics
Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about
75% of ADHD cases. Hyperactivity also seems to be primarily a genetic condition; however,
other causes do have an effect.

Researchers believe that a large majority of ADHD cases arise from a combination of various
genes, many of which affect dopamine transporters. Candidate genes include α2A adrenergic
receptor, dopamine transporter, dopamine receptors / , dopamine beta-hydroxylase
D2 D3

monoamine oxidase A, catecholamine-methyl transferase, serotonin transporter promoter

(SLC6A4), 5HT2A receptor, 5HT1B receptor, the 10-repeat allele of the DAT1 gene, the 7-repeat
allele of the DRD4 gene, and the dopamine beta hydroxylase gene (DBH TaqI).

The broad selection of targets indicates that ADHD does not follow the traditional model of "a
genetic disease" and should therefore be viewed as a complex interaction among genetic and
environmental factors. Even though all these genes might play a role, to date no single gene
has been shown to make a major contribution to ADHD.

Evolutionary theories

The hunter vs. farmer theory is a hypothesis proposed by author Thom Hartmann about the
origins of ADHD. The theory proposes that hyperactivity may be an adaptive behavior in pre
modern humans and that those with ADHD retain some of the older "hunter" characteristics
associated with early pre-agricultural human society. According to this theory, individuals with
ADHD may be more adept at searching and seeking and less adept at staying put and
managing complex tasks over time. Further evidence showing hyperactivity may be
evolutionarily beneficial was put forth in 2006 in a study which found it may carry specific
benefits for certain forms of ancient society. In these societies, those with ADHD are
hypothesized to have been more proficient in tasks involving risk or competition (i.e. hunting,
mating rituals, etc.).

Environmental
Twin studies to date have suggested that approximately 9% to 20% of the variance in
hyperactive-impulsive-inattentive behavior or ADHD symptoms can be attributed to nonshared
environmental (nongenetic) factors. Environmental factors implicated include alcohol and
tobacco smoke exposure during pregnancy and environmental exposure to lead in very early
life. The relation of smoking to ADHD could be due to nicotine causing hypoxia (lack of oxygen)
to the fetus in utero. It could also be that women with ADHD are more likely to smoke and
therefore, due to the strong genetic component of ADHD, are more likely to have children with
ADHD. Complications during pregnancy and birth—including premature birth—might also play a
role. ADHD patients have been observed to have higher than average rates of head injuries;
however, current evidence does not indicate that head injuries are the cause of ADHD in the
patients observed. Infections during pregnancy, at birth, and in early childhood are linked to an
increased risk of developing ADHD. These include various viruses (measles, varicella, rubella,
enterovirus 71) and streptococcal bacterial infection.

A 2007 study linked the organophosphate insecticide chlorpyrifos, which is used on some fruits
and vegetables, with delays in learning rates, reduced physical coordination, and behavioral
problems in children, especially ADHD.

A 2010 study found that pesticide exposure is strongly associated with an increased risk of
ADHD in children. Researchers analyzed the levels of organophosphate residues in the urine of
more than 1,100 children aged 8 to 15 years old, and found that those with the highest levels of
dialkyl phosphates, which are the breakdown products of organophosphate pesticides, also had
the highest incidence of ADHD. Overall, they found a 35% increase in the odds of developing
ADHD with every 10-fold increase in urinary concentration of the pesticide residues. The effect
was seen even at the low end of exposure: children who had any detectable, above-average
level of pesticide metabolite in their urine were twice as likely as those with undetectable levels
to record symptoms of ADHD.

Diet

A study conducted by researchers at Southampton University in the United Kingdom and

published in The Lancet on November 3, 2007 found a link between children’s ingestion of
many commonly used artificial food colors, the preservative sodium benzoate and hyperactivity.
In response to these findings, the British government took prompt action. According to the Food
Standards Agency, the food regulatory agency in the UK, food manufacturers are being
encouraged to voluntarily phase out the use of most artificial food colors by the end of 2009.
Following the FSA’s actions, the European Commission ruled that any food products containing
the “Southampton Six” (The contentious colourings are: sunset yellow FCF (E110), quinoline
yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124))
must display warning labels on their packaging by 2010. In the US, little has been done to curb
food manufacturer’s use of specific food colors, despite the new evidence presented by the
Southampton study. However, the existing US Food Drug and Cosmetic Act had already
required that artificial food colors be approved for use, that they must be given FD&C numbers
by the FDA, and the use of these colors must be indicated on the package. This is why food
packaging in the USA may state something like: "Contains FD&C Red #40."

Social

The World Health Organization states that the diagnosis of ADHD can represent family
dysfunction or inadequacies in the educational system rather than individual psychopathology.
Other researchers believe that relationships with caregivers have a profound effect on
attentional and self-regulatory abilities. A study of foster children found that a high number of
them had symptoms closely resembling ADHD. Researchers have found behavior typical of
ADHD in children who have suffered violence and emotional abuse. Furthermore, Complex Post
Traumatic Stress Disorder can result in attention problems that can look like ADHD. ADHD is
also considered to be related to sensory integration dysfunction.

A 2010 article by CNN suggests that there is an increased risk for internationally adopted
children to develop mental health disorders, such as ADHD and ODD. The risk may be related
to the length of time the children spent in an orphanage, especially if they were neglected or
abused. Many of these families who adopted the affected children feel overwhelmed and
frustrated, since managing their children may entail more responsibilities than originally
anticipated. The adoption agencies may be aware of the child's behavioral history, but decide to
withhold the information prior to the adoption. This in turn has resulted in some parents suing
adoption agencies, the abuse of children, and even the relinquishment of the child.

Neuro-diversity

Proponents of the neurodiversity theory assert that atypical (neurodivergent) neurological

development is a normal human difference that is to be tolerated and respected just like any
other human difference. Social critics argue that while biological factors may play a large role in
difficulties with sitting still in class and/or concentrating on schoolwork in some children, these
children could have failed to integrate others' social expectations of their behavior for a variety
of other reasons. It has been said that ADHD has a link with creativity. As genetic research into
ADHD proceeds, it may become possible to integrate this information with the neurobiology in
order to distinguish disability from varieties of normal or even exceptional functioning in people
along the same spectrum of attention differences.

Social construct theory of ADHD

Social construction theory states that it is societies that determine where the line between
normal and abnormal behavior is drawn. Thus society members including physicians, parents,
teachers, and others are the ones who determine which diagnostic criteria are applied and thus
determine the number of people affected. This is exemplified in the fact that the DSM IV arrives
at levels of ADHD three to four times higher than those obtained with use of the ICD 10.
Thomas Szasz, an extreme proponent of this theory, has gone so far as to state that ADHD was
"invented and not discovered."

Low arousal theory

According to the low arousal theory, people with ADHD need excessive activity as self-
stimulation because of their state of abnormally low arousal. The theory states that those with
ADHD cannot self-moderate, and their attention can only be gained by means of environmental
stimuli, which in turn results in disruption of attention capacity and an increase in hyperactive
behaviour.

Without enough stimulation coming from the environment, an ADHD child will create it him or
herself by walking around, fidgeting, talking, etc. This theory also explains why stimulant
medications have high success rates and can induce a calming effect at therapeutic dosages
among children with ADHD. It establishes a strong link with scientific data that ADHD is
connected to abnormalities with the neurochemical dopamine and a powerful link with low-
stimulation PET scan results in ADHD subjects

Laboratory Exam
There are no lab-tests that can determine or exclude ADHD. But it might be important to
rule out some other relevant causes of hyperactivity or attention problems. So the
doctor will do a physical and basic neurological clinical examination of the patient. Using
his eyes and ears and doing some basic tests of reflexes, motor functions, coordination
and testing the senses of the patient will give a lot of important information.

Then a blood test of the thyroid functions (TSH and maybe thyroid hormones T3, T4)
should be considered. This will normally be done within a routine check of the patient.

If the patient (or family) has a history of seizure the doctor will do an EEG. This will not
show specific signs of ADHD but might exclude specific forms of seizures. If the doctor
and you decide to use psychopharmacological treatment an EKG should exclude
significant heart problems.

A scull X-ray (Computer tomography, NMR) can be useful to exclude rare other causes
of attention problems (like malformations of blood vessels, tumour, hydrocephalus). But
these are very rare conditions!

Some parents think very specific diagnosis of functional imaging (SPECT, PET) will
show specific signs of ADHD. At the moment these diagnostic tools are mainly used for
research. You have to consider possible side effects of nuclear medicine especially for
children. So these diagnostic tools cannot be recommended for a routine diagnosis of
ADHD.

Nursing Management

 Assess mental status

 Looking for changes in mood
 Reported when noted
 Protect from injury
 Prone to accidents; they are impulsive
 Keep stimuli low
 Teach parents they need a quiet environment
 To determine the effectiveness of the drugs
 Usually don’t take on weekends or summer holidays
 Avoid OTC medications especially cold medications
 Can interact with drug and cause toxic effect
 Need to let doctor know that child is on Ritalin before he prescribes any
medications
 Weigh regularly

 Monitor for anorexia

 Weighed on weekly basis
  Give after meals
 Decreases their appetite
 Teach parents about Cylert
 May take 2-3 weeks to take affect
 Don’t withdraw abruptly
 Do not give at hour of sleep
 Stimulant – can cause insomnia
 Sustained Release can be given early in the morning

Diagnosis

ADHD is diagnosed via a psychiatric assessment; to rule out other potential causes or
comorbidities, physical examination, radiological imaging, and laboratory tests may be used.

In North America, the DSM-IV criteria are often the basis for a diagnosis, while European
countries usually use the ICD-10. If the DSM-IV criteria are used, rather than the ICD-10, a
diagnosis of ADHD is 3–4 times more likely.[13] Factors other than those within the DSM or ICD
however have been found to affect the diagnosis in clinical practice. A child's social and school
environment as well as academic pressures at school are likely to be of influence.[113]

Many of the symptoms of ADHD occur from time to time in everyone; in patients with ADHD, the
frequency of these symptoms is greater and patients' lives are significantly impaired.
Impairment must occur in multiple settings to be classified as ADHD.[33] As with many other
psychiatric and medical disorders, the formal diagnosis is made by a qualified professional in
the field based on a set number of criteria. In the USA these criteria are laid down by the
American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV), 4th edition. Based on the DSM-IV criteria listed below, three types of ADHD are
classified:

1. ADHD, Combined Type: if both criteria 1A and 1B are met for the past 6 months
2. ADHD Predominantly Inattentive Type: if criterion 1A is met but criterion 1B is not met
for the past six months
3. ADHD, Predominantly Hyperactive-Impulsive Type: if criterion 1B is met but criterion 1A
is not met for the past six months.
The previously used term ADD expired with the most recent revision of the DSM. Consequently,
ADHD is the current nomenclature used to describe the disorder as one distinct disorder which
can manifest itself as being a primary deficit resulting in hyperactivity/impulsivity (ADHD,
predominately hyperactive-impulsive type) or inattention (ADHD predominately inattentive type)
or both (ADHD combined type).

DSM-IV criteria

IA. Six or more of the following signs of inattention have been present for at least 6 months to a
point that is disruptive and inappropriate for developmental level:

 Inattention:

1. Often does not give close attention to details or makes careless mistakes in
schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow instructions and fails to finish schoolwork, chores, or duties
in the workplace (not due to oppositional behavior or failure to understand
instructions).
5. Often has a trouble organizing activity.
6. Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort
for a long period of time (such as schoolwork or homework).
7. Often loses things needed for tasks and activities (such as toys, school
assignments, pencils, books, or tools).
8. Is often easily distracted.
9. Often forgetful in daily activities.

IB. Six or more of the following signs of hyperactivity-impulsivity have been present for at least 6
months to an extent that is disruptive and inappropriate for developmental level:

 Hyperactivity:

1. Often fidgets with hands or feet or squirms in seat.

2. Often gets up from seat when remaining in seat is expected.
 3. Often runs about or climbs when and where it is not appropriate (adolescents or
adults may feel very restless).
4. Often has trouble playing or enjoying leisure activities quietly.
5. Is often "on the go" or often acts as if "driven by a motor".
6. Often talks excessively.

 Impulsiveness:

1. Often blurts out answers before questions have been finished.

2. Often has trouble waiting one's turn.
3. Often interrupts or intrudes on others (example: butts into conversations or
games).

II. Some signs that cause impairment were present before age 7 years.

III. Some impairment from the signs is present in two or more settings (such as at school/work
and at home).

IV. There must be clear evidence of significant impairment in social, school, or work functioning.

V. The signs do not happen only during the course of a Pervasive Developmental Disorder,
Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another
mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or a
Personality Disorder).

Medical Management

Ritalin (methylphenidate) 10 mg tablets

Management with medication was shown to be the most cost-effective, followed by behavioral
treatment and combined treatment in a 14 month follow-up study. However, a follow-up study
found that stimulant medication offered no benefits over behavioral therapy in children after their
respective treatments allocations had been discontinued for two years. Stimulant medication or
non-stimulant medication may be prescribed. A 2007 drug class review found that there are no
good studies of comparative effectiveness between various drugs for ADHD and that there is a
lack of quality evidence on their effects on overall academic performance and social behaviors.
ADHD medications are not recommended for preschool children as their long term effects in
such young people are unknown. There is very little data on the long-term adverse effects or
benefits of stimulants for ADHD.

Children diagnosed with ADHD have significant difficulties in adolescence, regardless of

treatment. In the United States, 37% of those with ADHD do not get a high school diploma even
though many of them will receive special education services. A 1995 briefing citing a 1994 book
review says the combined outcomes of the expulsion and dropout rates indicate that almost half
of all ADHD students never finish high school. Also in the US, less than 5% of individuals with
ADHD get a college degree compared to 28% of the general population. Those with ADHD as
children are at increased risk of a number of adverse life outcomes once they become
teenagers. These include a greater risk of auto crashes, injury and higher medical expenses,
earlier sexual activity, and teen pregnancy. Russell Barkley states that adult ADHD impairments
affect "education, occupation, social relationships, sexual activities, dating and marriage,
parenting and offspring psychological morbidity, crime and drug abuse, health and related
lifestyles, financial management, or driving. ADHD can be found to produce diverse and serious
impairments". The proportion of children meeting the diagnostic criteria for ADHD drops by
about 50% over three years after the diagnosis. This occurs regardless of the treatments used
and also occurs in untreated children with ADHD. ADHD persists into adulthood in about 30-
50% of cases. Those affected are likely to develop coping mechanisms as they mature, thus
compensating for their previous ADHD

Stimulant medication

Stimulants are the most commonly prescribed medications for ADHD. The most
common stimulant medications are the chain subsitituted
amphetaminemethylphenidate (Ritalin, Metadate, Concerta), dextroamphetamine (Dexe
drine), mixed amphetamine salts (Adderall), dextromethamphetamine(Desoxyn)
and lisdexamfetamine (Vyvanse). However, caution needs to be used when prescribing
medications that increase levels of "feel-good” neurotransmitters like dopamine,
because they can be addictive (see article: amphetamine dependence). According to
several studies, use of stimulants (e.g. methylphenidate) can lead to development
of drug tolerance to therapeutic doses; tolerance also occurs among high dose abusers
of methylphenidate.
Stimulants used to treat ADHD raise the extracellular concentrations of
the neurotransmitters dopamine and norepinephrine which causes an increase in
neurotransmission. The therapeutic benefits are due to noradrenergic effects at
the locus coeruleus and the prefrontal cortex and dopaminergic effects at the nucleus.

Both children with and without ADHD abuse stimulants, with ADHD individuals being at
the highest risk of abusing or diverting their stimulant prescriptions. Between 16 and 29
percent of students who are prescribed stimulants report diverting their prescriptions.
Between 5 and 9 percent of grade/primary and high school children and between 5 and
35 percent of college students have used nonprescribed stimulants. Most often their
motivation is to concentrate, improve alertness, "get high," or to experiment.

The use of stimulant therapy for ADHD does not increase the risk of subsequent
substance abuse and may be protective against it when treatment is started in
childhood. However, when stimulant therapy is started during adolescence or
adulthood, there is an increased risk of subsequent substance abuse.

 Weight gain, diabetes, lactation,gynecomastia, drooling, dysphoria, anhedonia (inability
to experience pleasure), fatigue, sexual dysfunction, heart rhythm problems and the
possibility of tardive dyskinesia, an irreversible movement disorder, are among the
adverse events associated with antipsychotic drugs.

Other non-stimulant medications

Atomoxetine (Strattera) and Guanfacine (Intuniv) are the only non-stimulant drug

approved for the treatment of ADHD. Other medications which may be prescribedoff-
label include α2A adrenergic receptor agonists such as clonidine,
certain antidepressants such as tricyclic antidepressants, SNRIs or MAOIs.

Prognosis
Children diagnosed with ADHD have significant difficulties in adolescence, regardless of
treatment. In the United States, 37% of those with ADHD do not get a high school
diploma even though many of them will receive special education services. A 1995
briefing citing a 1994 book review says the combined outcomes of the expulsion and
dropout rates indicate that almost half of all ADHD students never finish high
school. Also in the US, less than 5% of individuals with ADHD get a college
degree] compared to 28% of the general population. Those with ADHD as children are
at increased risk of a number of adverse life outcomes once they become teenagers.
These include a greater risk of auto crashes, injury and higher medical expenses,
earlier sexual activity, and teen pregnancy. Russell Barkley states that adult ADHD
impairments affect "education, occupation, social relationships, sexual activities, dating
and marriage, parenting and offspring psychological morbidity, crime and drug abuse,
health and related lifestyles, financial management, or driving. ADHD can be found to
produce diverse and serious impairments". The proportion of children meeting the
diagnostic criteria for ADHD drops by about 50% over three years after the diagnosis.
This occurs regardless of the treatments used and also occurs in untreated children with
ADHD. ADHD persists into adulthood in about 30-50% of cases. Those affected are
likely to develop coping mechanisms as they mature, thus compensating for their
previous ADHD.

Webliography:
 http://en.wikipedia.org/wiki/Attention-deficit_hyperactivity_disorder
 http://www.scribd.com/doc/23193194/ADHD
 http://www.webmd.com/add-adhd/default.htm
 www.webmd.com/add-adhd/guide/adhd-guide-symptoms-types