Attention-deficit/hyperactivity disorder (ADHD) is recognized as the most frequently diagnosed mental health condition affecting children and adolescents, and its effects can persist into adulthood. Young individuals with ADHD may exhibit hyperactivity, struggle with impulse control, or experience difficulties in maintaining focus.

Attention-deficit/hyperactivity disorder (ADHD) represents a neurodevelopmental condition characterized by persistent patterns of inattention and/or hyperactivity-impulsivity. These patterns significantly impede typical development and daily functioning.

Inattention is marked by:

• Difficulty staying on task.

• Lack of persistence in activities.

• Challenges in sustaining concentration.

• Disorganization.

These difficulties are not due to defiance or a failure to understand instructions.

Hyperactivity is characterized by:

• Excessive movement, even in situations where stillness is expected.

• Frequent fidgeting, tapping, or talking.

Impulsivity is defined by:

• Acting hastily without considering potential consequences.

• A strong desire for immediate gratification or an inability to delay rewards.

• Potentially intrusive social behaviors, such as interrupting others excessively.

• Making important decisions without considering long-term repercussions.

This condition is distinguished by a significant disruption in attention, coupled with excessive activity that is more frequent and pronounced compared to what is typical for children of similar developmental stages. ADHD is believed to potentially stem from brain injury during birth. A child with ADHD may be unable to remain still or in one location for extended periods, display constant movement, exhibit a lack of fear of danger, and engage in risky climbing or play with household items. ADHD is observed to be more prevalent in males than females.

Aetiology

Biological Influences

• Genetics: A predisposition to ADHD often runs within families.

• Biochemical Theory: An imbalance in neurotransmitters, specifically a deficiency in dopamine and norepinephrine, is thought to contribute to the hyperactivity observed in ADHD.

Pre, Peri, and Postnatal Factors

• Prenatal Toxic Exposure: Exposure to harmful substances during pregnancy.

• Prematurity: Birth occurring before the full term of pregnancy.

• Fetal Distress: Signs indicating the fetus is under stress during pregnancy or labor.

• Precipitated or Prolonged Labour: Labor that is either unusually rapid or extended.

• Perinatal Asphyxia: Oxygen deprivation to the infant around the time of birth.

• Low Apgar Scores: Lower scores on the Apgar test, assessing a newborn’s health immediately after birth.

• Postnatal Infections: Infections occurring after birth.

• CNS Abnormalities Resulting from Trauma: Damage to the central nervous system caused by injury.

Environmental Influences

• Lead Poisoning: Exposure to lead, a toxic heavy metal.

• Food Additives, Colouring, Preservatives, and Sugars: Certain dietary components.

Psychosocial Factors

• Prolonged Emotional Deprivation: Extended periods without adequate emotional nurturing.

• Stressful Psychic Events: Significant emotionally distressing experiences.

• Disruption of Family Equilibrium: Disturbances in the balance and stability of the family unit.

Risk Factors

• Drug exposure during prenatal development.

• Complications during birth.

• Low birth weight.

• Lead poisoning.

Clinical Features

• Heightened sensitivity to stimuli, easily bothered by bright lights, loud noises, or changes in their surroundings.

• Typically more active and may sleep less than others.

• Short attention span.

• Difficulty completing tasks.

• Impulsivity.

• Difficulties with memory and thinking processes.

• Specific learning disabilities.

In School

• May only answer the initial questions posed and frequently calls out answers before the questions are fully stated.

• Struggles to wait their turn in class and might respond before others have a chance.

• Finds it hard to wait their turn in games or group activities.

• Often misplaces items needed for schoolwork or activities.

Home

• May exhibit explosive or irritable moods.

• Emotionally changeable, shifting rapidly between laughter and tears.

• Unpredictable mood patterns.

• Impulsiveness and difficulty delaying gratification.

• Often talks excessively.

• Frequently participates in physically risky activities without considering potential harm.

Symptoms can also be categorized as follows:

Inattention Symptoms

• Overlooking details or making careless errors in schoolwork or other tasks.

• Difficulty sustaining attention during tasks, play, conversations, lectures, or lengthy reading.

• Appearing not to listen when directly addressed.

• Failing to follow instructions and struggling to finish schoolwork or workplace duties. May start tasks but quickly lose focus and be easily diverted.

• Problems organizing tasks and activities, such as sequencing steps, keeping belongings in order, having disorganized work, poor time management, and missing deadlines.

• Avoiding or disliking tasks that require sustained mental effort, such as schoolwork or homework.

• Losing items needed for tasks or activities, including school supplies, pencils, books, tools, eyeglasses, paperwork, etc.

• Being easily distracted by unrelated thoughts or external stimuli.

• Forgetfulness in daily routines, such as keeping appointments.

Hyperactivity-Impulsivity Symptoms

• Leaving their seat in situations where remaining seated is expected, like classrooms.

• Running or climbing in inappropriate situations, or restlessness in adolescents.

• Inability to play or engage in hobbies quietly.

• Constantly in motion or acting as if “driven by a motor.”

• Talking excessively.

• Blurting out answers before questions are finished, completing others’ sentences, or speaking without waiting for their turn in conversation.

• Difficulty waiting for their turn.

• Interrupting or intruding on others in conversations, games, or activities.

• Frequent fidgeting.

• Acting without thinking.

• Limited or no sense of danger.

MANAGEMENT

Pharmacotherapy

Medications are not a permanent cure for ADHD, but they can assist individuals in improving concentration, reducing impulsivity, promoting calmness, and facilitating the learning of new skills. Medications commonly prescribed for ADHD include:

• Methylphenidate: Typically one tablet daily.

• Lisdexamfetamine: Usually one capsule daily.

• Dexamfetamine: One tablet once or twice a day.

• Atomoxetine: One capsule once or twice a day.

• Guanfacine: One tablet daily.

• Tricyclic antidepressants.

• Antipsychotics.

• Selective serotonin reuptake inhibitors (SSRIs).

Psychological Therapies

Psychotherapy, particularly behavioral therapy, is crucial as it focuses on helping children modify their own behavior. This may involve practical support, such as help with task organization or homework completion, or addressing emotionally challenging experiences.

• Cognitive Behavioral Therapy (CBT): A therapist works to change a child’s thought patterns about situations, which in turn can modify behavior.

• Social Skills Training: Developing skills for interacting effectively in social settings.

• Family Therapy: Involving the family in the therapeutic process.

Nursing Interventions

Children with ADHD require guidance and understanding from parents, families, and educators to achieve their full potential and succeed. For school-aged children, frustration, blame, and anger can impede progress. These children need specialized support to overcome negative feelings and cultivate new skills and attitudes.

• Social Skills Training: Helping children learn appropriate social behaviors and understand how their actions affect others.

• Parenting Skills Training (Behavioral Parent Management Training): Educating parents on techniques to encourage and reward positive behaviors in their children. This includes using reward and consequence systems to modify behavior.

• Stress Management Techniques: Beneficial for parents of children with ADHD, enhancing their ability to manage frustration and respond calmly to their child’s behavior.

• Support Groups: Connecting parents and families with others facing similar challenges and concerns, providing a platform to share experiences, exchange information, and consult with experts.

• Diet: Eliminating sugar, artificial food colors and additives, as well as caffeine, from the patient’s diet as these can worsen hyperactivity.

Strategies to Help Children with ADHD Stay Organized:

• Establish and Maintain a Routine: Follow a consistent daily schedule from wake-up to bedtime, including designated times for homework, outdoor play, and indoor activities. Communicate any schedule changes well in advance.

• Organize Everyday Items: Assign a specific place for everything and ensure items are returned to their designated locations, including clothing, backpacks, and toys.

• Utilize Homework and Notebook Organizers: Emphasize the importance of writing down assignments and bringing necessary materials home.

• Be Clear and Consistent with Rules: Children with ADHD need easily understandable and consistently enforced rules.

• Provide Praise and Rewards: Acknowledge and reward positive behavior, as children with ADHD often experience and expect criticism.

• Develop a Trusting Relationship: Ensure the child feels accepted as an individual, separate from unacceptable behaviors.

• Ensure a Safe Environment: Remove dangerous objects to prevent injury due to impulsive movements.

• Minimize Distractions: Create a distraction-free environment to aid focus on tasks.

• Gain Attention Before Giving Instructions: Call the child’s name and make eye contact before giving directions.

• Request Repetition of Instructions: Ask the child to repeat instructions to ensure understanding.

• Set Achievable Goals: Break down tasks into smaller, manageable steps, rewarding each step completion with a break for physical activity.

• Provide One-on-One Assistance: Begin with simple, concrete instructions when providing help.

• Gradually Reduce Assistance: Decrease the level of support as the child progresses, while assuring them that help is still available if needed.

• Offer Recognition and Reinforcement: Acknowledge successful attempts and positively reinforce effort.

• Provide Supportive Learning Environments: Offer quiet environments, self-contained classrooms, and small group activities when appropriate.

• Teach Social Skills: Help the child learn to take turns, wait in line, and follow rules.

• Provide Education and Resources: Offer information and materials about ADHD and effective parenting techniques.

• Demonstrate Positive Parenting Techniques: Explain and model proactive parenting strategies, such as actively observing the child’s behavior and responding positively.

• Coordinate Treatment Plan: Collaborate with schools, the child, and the family to ensure a comprehensive treatment approach.