After reading this article, the learner will be able to:
1. Discuss the DSM-5 diagnostic criteria for ADHD and explain the importance of obtaining a thorough history in formulating a diagnosis.
2. Describe four ways in which ADHD affects patients with ADHD and those around them.
3. Identify three behavioral approaches to managing ADHD and explain the importance of a patient-centered approach to behavior management.
4. Describe the pharmacologic treatment of ADHD.
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by levels of inattention and disorganization and/or hyperactivity and impulsivity (or some combination of these) that are excessive for a person's age or developmental level.1 People with ADHD are likely to have close relatives with the disorder.1 It is evident in childhood and often persists through adolescence into adulthood. The symptoms of ADHD are evident across multiple settings.1
People with ADHD have difficulty paying attention. Attention is the ability to regulate alertness and sustain focus on a limited set of internal and external stimuli while ignoring everything else (i.e., maintaining task performance while ignoring distractions). Conversely, attention enables us to shift our focus appropriately when performing tasks.2 Attention is also an essential component of the ability to monitor and manage emotional impulses. Some researchers conceptualize ADHD as a disorder of executive function (self-regulation)3 or self-control.4
Taken individually, the symptoms of ADHD may be observed at times in many healthy people without ADHD. ADHD is considered a disorder because the symptoms present as a stable and enduring pattern over time that consistently interferes with normal functioning in daily activities, causes persistent distress, and interferes with the achievement of major social, occupational or other life goals. Children with ADHD are more likely than children without ADHD to have problems with peer relationships, and they have a higher rate of injuries.5 ADHD is associated with mood disorders, substance abuse and, in adults, with an increased risk of suicide.1
In the United States, an estimated 11% of 4- to 17-year-olds5 and 9% of 13- to 18-year-olds have been diagnosed with ADHD. Of these, 1.8% are classified as severe.6 An estimated 4.1% of adults have ADHD, and 41.3% are classified as severe cases.7 An estimated 5.6% of girls and 13.2% of boys have been diagnosed with ADHD.5 Girls are more likely than boys to present with inattentiveness as a primary feature, and to present without hyperactivity.1
ADHD statistics are rough estimates, because the numbers are based on samples of the population identified by a variety of reports and surveys. Rates of diagnosis vary by gender, geography, culture, family income and parents' level of education. ADHD in girls may be undercounted because they present differently from boys.8 ADHD in adults may be undercounted because they are not in school, and they present their symptoms differently from children. The disproportionate percentage of adults with severe ADHD suggests that adults with mild or moderate ADHD are less likely than those with severe ADHD to seek treatment.
Mental disorders are defined by the presence of specific symptoms, the acuity and duration of symptoms, the amount of disruption caused by the symptoms, and by the clustering of symptoms into recognized syndromes.1 Unlike other mental disorders, however, the symptoms of ADHD are manifested over time in more than one setting, and they may not be apparent during a clinical assessment.1 For this reason, ADHD is diagnosed by obtaining a history from people who know the patient well, such as parents, teachers and employers.4
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), ADHD presents as predominantly inattentive, predominantly hyperactive and impulsive, or as a combination of these. The condition may be mild, moderate or severe. The symptoms must have persisted for at least 6 months to a degree that is inconsistent with developmental level, and the symptoms must negatively impact social, academic or occupational activities. Several symptoms must have been present prior to age 12. Symptoms must be present in two or more settings, and are not better explained by another mental disorder. The symptoms listed in the DSM-5 give a clear picture of the behaviors that characterize ADHD:1
To meet the criteria for inattention, 6 or more of the following symptoms (at least 5 symptoms for people 17 years and older) must be present:
• Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities.
• Often has difficulty sustaining attention in tasks or play activities.
• Often does not seem to listen when spoken to directly.
• Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace.
• Often has difficulty organizing tasks and activities.
• Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort.
• Often loses things necessary for tasks or activities.
• Is often easily distracted by extraneous stimuli.
• Is often forgetful in daily activities.
HYPERACTIVITY & IMPULSIVITY
To meet the criteria for hyperactivity and impulsivity, 6 or more of the following symptoms (at least 5 symptoms for people age 17 years and older) must be present:
• Often fidgets with or taps hands or feet or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)
• Often unable to play or engage in leisure activities quietly.
• Is often "on the go," acting as if "driven by a motor".
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has difficulty waiting his or her turn.
• Often interrupts or intrudes on others.
Comorbidities and Differential Diagnoses
Among the most common comorbidities of ADHD in children are learning disorders and developmental coordination disorder. An estimated 4% of children have both ADHD and a learning disorder.9 Swedish researchers estimate that 50% of people with ADHD have developmental coordination disorder.10 Comorbidities of ADHD include depression, conduct disorder, oppositional defiant disorder, and substance abuse.11 These comorbidities should be diagnosed separately from ADHD.1
The differentials to be considered before diagnosing ADHD are conditions that produce similar symptoms. These include conduct disorder, oppositional defiant disorder, substance abuse, depressive disorder, and bipolar disorder. To reach a diagnosis of ADHD, the symptoms of ADHD must be evident in the absence of the symptoms of other mental disorders.1 This is complicated, because depression and substance abuse, for example, are common comorbidities among people with ADHD. In children and adolescents, it is particularly important to distinguish the symptoms of ADHD from developmentally appropriate behavior.1
The Impact of ADHD
People with ADHD have difficulty paying attention. This is particularly true when they have to sit still and listen in a group. It is easier for them to pay attention when participating in direct interpersonal conversation, because conversation requires a give-and-take interaction that engages their attention. Many people with ADHD also find it easier to pay attention when reading because, when their attention drifts, they can go back and pick up where they left off.
People with ADHD generally share the values of their society, and they generally want to meet the expectations of others. Consequently, they often judge themselves negatively. When they internalize these negative judgments, they are vulnerable to poor self-esteem, and they may come to assume that nothing they do will improve their behavior.
The behavior of people with ADHD can be annoying to parents, teachers, employers and peers. When others assume that the person's behavior is intentional, as is commonly the case, their negative feedback can further damage self-esteem.
For most people, paying attention is a natural function. However, unlike vision or hearing impairments, ADHD is not obvious to the observer. In addition, the symptoms of ADHD are manifested intermittently, unlike many other neurological conditions. The symptoms of vision and hearing impairments, for example, are less dependent on circumstances and do not fluctuate as widely as those of ADHD.
Acknowledging the reality of ADHD is the first step in management. This makes it possible to understand the behaviors that are the focus of concern, and it helps validate the person's feelings about the challenges caused by ADHD. This is important because ADHD can have a negative effect on self-esteem; patients are struggling to meet their own expectations and those of others.
As with interventions for other medical and psychiatric conditions, nurses should take a patient-centered approach to behavioral intervention for people with ADHD. This can be done by focusing on the needs of the person (i.e., attempting to support efforts to accomplish specific goals, rather than trying to control behavior). Because ADHD symptoms vary, careful observation of behavior is necessary to identify the specific issues involved. Coaching the person with ADHD to identify specific challenges and note which interventions seem to be effective, and sharing one's own observations, makes it possible to focus on effective interventions and can foster a feeling that at least some aspects of ADHD can be managed.
Many approaches and techniques can help people with ADHD manage their behavior. A few are outlined here, but many more are available using a quick Internet search.
• What looks like poor attention may actually be intense concentration on something else. Gain the person's attention through direct, personal contact. Say the person's name, make eye contact, and touch him or her, if appropriate.
• Give a clear, direct message in terms that are specific and can be operationalized (e.g., "Please open your book to page 73.")
• Avoid criticizing. The person with ADHD may not hear anything you say afterward.
• Avoid saying "I told you." The person with ADHD may not understand that you want her/him to do what you said before.
Self-control is one of the greatest challenges for people whose ADHD includes hyperactivity and impulsivity.4 They are likely to benefit from focused coaching and timely feedback. If the feedback they receive is nonjudgmental, they may come to appreciate and even seek out practical help in learning to manage behavior that frustrates them and annoys others.
Time management allows us to coordinate our activities with those of the people around us. Most people learn from a young age to use time to plan their activities. This learning makes them aware of the passage of time and teaches them to anticipate transitions between activities. People with ADHD need special help with this. The anticipatory cues typically used with children (e.g., "It is time to get ready") benefit people with ADHD throughout their lifespans. Getting into the habit of using alarms to signal the time to transition to a new activity is one time management skill that is likely to improve timeliness.
Four of the DSM-5 diagnostic criteria for impulsivity relate specifically to inadequate social skills. Coaching and nonjudgmental feedback can help people with ADHD moderate their talking and wait their turns in social interactions. Acquiring an awareness of these issues and learning to manage social interactions offers immediate rewards of improved peer relationships and can help mitigate the social isolation that can be one of the sequelae of ADHD.
In addition to social isolation, people with ADHD often experience frustration in meeting their goals and in meeting the expectations of others. This can lead to problems with anger management, depression, anxiety, and substance abuse. These issues should be addressed directly. Anger management skills training and cognitive-behavioral therapy can improve a person's ability to manage the mood dysregulation that may result from ADHD. Family therapy and couples therapy may help improve mutual understanding and relationships with significant others.
With appropriate educational and behavioral accommodations, people with ADHD may be able to achieve their goals and participate in the many educational, occupational and recreational activities that are integral to normal social life. The problem may not be paying attention; it may be sitting still and paying attention. This can be addressed by allowing children to stand up or walk around in class. Other examples of accommodations include allowing extra time to complete work, breaking up large tasks into a series of smaller ones, supplementing oral instructions with instructions in writing, and pausing intermittently during lectures to encourage participants to ask questions or make comments.
The American Academy of Pediatrics (AAP) Clinical Practice Guideline for ADHD recommends both behavioral interventions and medication for the treatment of ADHD.12 For children up to age 5, behavioral interventions are recommended as first-line treatment. For children 6 years and older and for adolescents, the AAP recommends beginning with medication. The guideline recommends continuing behavioral interventions but notes that the quality of the evidence to support the efficacy of behavioral interventions declines through childhood and adolescence.12
Stimulant medications do not appear to affect the risk of developing substance abuse.13 While excessively high doses of stimulant medications may lead to cardiovascular and other complications,13 when prescribed and taken appropriately, stimulant medications are safe and effective for the treatment of ADHD.13,14 According to the AAP, strong evidence shows that using medication to treat ADHD outweighs the risk of adverse effects.12
A recent study demonstrated that using medication to treat ADHD has no effect on the risk of suicidal behavior, while the use of stimulant medications, specifically, may well have a protective effect.15 There is no conclusive evidence that treatment with herbs and vitamins, or that removing sugar, stimulants or food coloring from the diet, will eliminate the symptoms of ADHD.16,17
Medication is used to treat the various physiologic deficits thought to underlie ADHD. These include: inadequate secretion of the neurotransmitters dopamine and norepinephrine, resulting in restlessness and impaired motivation, concentration and motor control; smaller or malformed basal ganglia, resulting in impaired control of learned motor sequences, repetitive behavior and reward-based learning and performance; and frontal and prefrontal lobe dysfunction, resulting in impaired planning, organizing, attention, impulse control, and inhibition of responses to sensory stimulation.18 The variety of symptoms associated with ADHD, and the variety of medications effective in treating ADHD, suggest that people diagnosed with ADHD may have differing physiologic deficits.
Stimulant medications appear to increase central nervous system arousal and alertness by increasing the availability of dopamine and norepinephrine.18 Some evidence suggests that stimulant medications may also help normalize the structural features of the basal ganglia.19 The stimulant medications include: methylphenidate, D-methylphenidate and amphetamines. These are available in short-acting (4 to 6 hours), moderate-acting (6 to 8 hours) and long-acting (8 to 12 hours) formulations.
A variety of nonstimulant medications are effective in managing the symptoms of ADHD, however the AAP guideline notes that the evidence is particularly strong for stimulant medications and sufficient but less strong for atomoxetine, extended-release guanfacine and extended-release clonidine (in that order).12 Among the nonstimulant medications prescribed for ADHD are: atomoxetine, a noradrenergic agent; bupropion, an atypical antidepressant; modafinil, an arousal agent; the tricyclic antidepressants desipramine and nortriptyline; and, for adolescents, the antihypertensives clonidine and guanfacine.
ADHD is a neurodevelopmental disorder that can have serious adverse effects on the lives of those with the condition. People with ADHD are more likely than their peers to perform poorly in school and at work, and they are more likely than their peers to have difficulty with social interactions and relationships. Intervention can be effective, particularly if it employs a patient-centered approach that focuses on specific problems and issues, and if it includes multiple modalities. These include medication, skills training, individual and family therapy, and educational and behavioral accommodations.
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5. Centers for Disease Control and Prevention. Attention-Deficit/Hyperactivity Disorder (ADHD), Data & Statistics: In the United States. http://www.cdc.gov/ncbddd/adhd/data.html
6. National Institute of Mental Health (NIMH). Attention Deficit Hyperactivity Disorder Among Children. http://www.nimh.nih.gov/health/statistics/prevalence/attention-deficit-hyperactivity-disorder-among-children.shtml
7. National Institute of Mental Health (NIMH). Attention-Deficit/Hyperactivity Disorder Among Adults. http://www.nimh.nih.gov/health/statistics/prevalence/attention-deficit-hyperactivity-disorder-among-adults.shtml
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12. American Academy of Pediatrics. ADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654
13. National Institute on Drug Abuse. Drug Facts: Stimulant ADHD Medications: Methylphenidate and Amphetamines. https://www.drugabuse.gov/publications/drugfacts/stimulant-adhd-medications-methylphenidate-amphetamines
14. Wernicke JF, Kratochvil CJ. Safety profile of atomoxetine in the treatment of children and adolescents With ADHD. J Clin Psychiatry. 2002;63(Suppl 12):50.
15. Qi Chen, et al. Drug treatment for attention-deficit/hyperactivity disorder and suicidal behaviour: register based study. BMJ. 2014;348:g3769.
16. Bernard-Bonnin AC. The use of alternative therapies in treating children with attention deficit hyperactivity disorder. Paediatr Child Health. 2002;7(10):710-718.
17. Diet and attention deficit hyperactivity disorder. http://www.health.harvard.edu/newsletter_article/Diet-and-attention-deficit-hyperactivity-disorder
18. Ballard S, et al. The neurological basis of attention deficit hyperactivity disorder. Adolescence. 1997;32(128):855-862.
19. Sobel LJ, et al. Basal Ganglia Surface Morphology and the Effects of Stimulant Medications in Youth with Attention Deficit Hyperactivity Disorder. Amer J Psychiatry. 2010;167:977-986.
Ken Stanton is a staff nurse in the behavioral health services department at Alta Bates-Summit Medical Center in Berkeley, Calif. He has completed a disclosure statement and reports no relationships related to this article.