Attention deficit hyperactivity disorder (ADHD)

Attention deficit hyperactivity disorder is a common neurobehavioral developmental disorder of childhood. Core symptoms include:

• Hyperactivity
• Inattention
• Impulsivity.

The terms ‘attention deficit’, ‘attention deficit hyperactivity disorder’, ‘hyperkinetic disorder’ and ‘hyperactivity’ are often used interchangeably by professionals to describe children who are overactive and have difficulty concentrating and controlling their impulses. 

Although hyperactivity, impulsivity and inattention are all attributes of childhood behaviour, they are considered to be features of a disorder when they are severe, developmentally inappropriate, pervasive in nature and cause functional impairment.

Psychosocial, social and biological factors are all likely to contribute to the aetiology. Some important theories and explanations have been put forward.

• Genetics
• Biological factors
• Psychosocial factors.

The core symptoms of ADHD are hyperactivity, impulsivity and inattention. These are further characterised by these symptoms:

Symptoms of hyperactivity

• Present with physical restlessness or fidgeting. This may be misconstrued as evidence of patient anxiety
• Talk excessively throughout assessment
• Describe an inner sense of restlessness
• Struggle to sit still during appointment
• Struggle to be quiet when this is expected.

Symptoms of impulsivity

• Find it difficult to wait their turn within a conversation, often interrupting others
• Struggle to wait their turn. This can be particularly evident within waiting rooms, where service users may not attend their scheduled appointments because of long waiting times
• Increased likelihood of accidental injuries
• Increased likelihood of risky sexual behaviour
• Answering questions within the clinical interview without fully considering a response.

Symptoms of inattention

• Difficulty concentrating for long periods of time
• Making careless mistakes on forms and questionnaires
• Disorganisation, including forgetting important documents and supporting information
• Forgetting

For a diagnosis of ADHD to be made, an individual should present with difficulties within three main areas (National Institute for Health and Care Excellence, 2019):

• Hyperactivity
• Impulsivity
• Inattention.

It is not easy to assess for ADHD but with careful consideration it is possible to detect ADHD, and most importantly what particular aspects of the disorder are impairing for this child. Children with ADHD may present with different types of ADHD: some with executive problem difficulties, some with delay and inhibition difficulties, and some with motivational issues. A full understanding of the difficulties is essential in order to assess the child and tailor treatments to their needs. Therefore, the diagnosing clinician should be a specialist working with children with ADHD who understands these complexities. However, in order to do this effectively they must rely on the reports from the wider community involved with a child to give their views on

Treatment may be with medication or psychological approaches. There are five types of medication licensed for the treatment of ADHD (NHS, 2018):

• Methylphenidate 
• Dexamfetamine
• Lisdexamfetamine
• Atomoxetine
• Guanfacine.

In the UK, atomoxetine, dexamphetamine and methylphenidate are licensed for the treatment of attention deficit hyperactivity disorder. Atomoxetine and methylphenidate can be used for children aged 6 years and older, while dexamphetamine is licensed for use from the age of 3 years. Clonidine, risperidone, imipramine and bupropion are not licensed and are used less frequently, generally only in specialist tertiary centres.

Side Effects 

Rarely stimulants can cause psychotic symptoms or even sensitivity reactions requiring the medication to be stopped. Stimulant medication needs monitoring because of the side effects and length of time that people remain on the treatment (National Institute for Health and Clinical Excellence, 2019). Children receiving long-acting stimulant medication to treat attention deficit hyperactivity disorder are more likely to achieve remission,

Attention must be paid not only to the child's symptoms, side-effects and performance in school, but also to their social and emotional development and their home life. Consider their behaviour over 24 hours and not just at school.

Times of transition need planning and support and should be considered early so that they run smoothly. Consider guidance with organisational and independent living skills early on. Discuss areas of strengths in the child that can be developed.

It is also important to bear in mind the overlap with other developmental disorders as these are common.

It is unusual for a child just to have ADHD. They often have behavioural problems, reading difficulties, speech delay or other delays. A comprehensive assessment is, therefore, required to ascertain the child’s educational and social needs, so that their individual problems may be addressed. 

• Close work with schools and nurseries is essential when managing these children

References

Hosenbocus S, Chahal R. A review of long-acting medications for ADHD in Canada. J Can Acad Child Adolesc Psychiatry. 2009;18(4):331–339

National Institute for Health and Care Excellence. Attention deficit hyperactivity disorder: diagnosis and management. 2019. https://www.nice.org.uk/guidance/ng87/chapter/Context (accessed 8 February 2022)

NHS. Attention deficient hyperactivity disorder - Treatment. 2018. https://www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/treatment/ (accessed 8 February 2022)

Rappley M. Clinical practice. Attention deficit-hyperactivity disorder. N Engl J Med. 2005;352(2):165–73.

Orford E. Attention Deficit Disorder. Practice Nursing. 2014;9(1). https://doi.org/10.12968/pnur.1998.9.1.28

Richardson G. ADD. Early Year Educator. 2001;2(10):44-45. https://doi.org/10.12968/eyed.2001.2.10.15317

Chu S. Attention deficit hyperactivity disorder (ADHD) part two: evaluation and intervention. British Journal of Therapy and Rehabilitation. 2013;10(6):254-263. https://doi.org/10.12968/bjtr.2003.10.6.13534 

Jamdar S, Sathyamoorthy BT. Management of attention-deficit/ hyperactivity disorder. Br J Hosp Med. 2013;68(7):360-366. https://doi.org/10.12968/hmed.2007.68.7.23971 

Nicholson T. A nurse's introduction to attention deficit hyperactivity disorder. Br J Nurs. 2019;28(11):678-680. https://doi.org/10.12968/bjon.2019.28.11.678 

Laver-Bradbury C. Detection, assessment and diagnosis of ADHD. British Journal of School Nursing. 2013;6(9). https://doi.org/10.12968/bjsn.2011.6.9.428 

Ather M, Salmon G. Attention deficit hyperactivity disorder. Br J Hosp Med. 2010;71(11):641-644.