Attention Deficit

Hyperactivity Disorder
Molly Gleason RN, BSN
N530 Advanced Pharmacotherapeutics
 Attention Deficit
Hyperactivity
Disorder
Purpose: To educate students in a beginning pharmacology course on Attention Deficit
Hyperactivity Disorder (ADHD)
Goal: The students will understand the disease process and drug therapy for ADHD

Objectives:
At the end of this lesson, the students will be able to…
● Discuss the disease process of ADHD
● Demonstrate understanding of treatment for ADHD
● Apply the information provided to care for a patient on a stimulant for ADHD
 Teaching Plan #3: Beginning Pharmacology Course
You are a nursing faculty teaching a beginning pharmacology course in a nursing program.
Prepare a classroom-teaching plan on your choice of Neurological/Psychological Disorders.
Be sure and include the following:
▪ Possible causes
▪ Pathophysiology
▪ Diagnostic criteria
▪ Goals of drug therapy
▪ First and second-line therapy
▪ Adverse responses
▪ Monitoring patient response
Background/Introduction
● “ADHD is a highly genetic, brain-based syndrome that has to do with the regulation of a
particular set of brain functions and related behaviors” (Frank, 2016).

● “A cluster of characteristics of behaviors that are related to several heterogeneous

biopsychosocial behaviors and neurodevelopmental processes, which negatively influence
one’s social, occupational, or academic function”
● 11% of children aged 4-17 years are diagnosed with ADHD
○ 60-80% of ADHD patients have symptoms persisting through adulthood

(Arcangelo, Peterson, Wilbur, & Reinhold, 2017

Symptoms
● Inattentiveness
○ Difficulty concentrating
○ Failure to follow through
○ Forgetfulness
○ Distractibility
● Hyperactivity/Impulsivity
○ Inability to remain seated
○ Fidgetiness
○ Excessive running or climbing
○ Trouble awaiting turn
○ Interruption

(Arcangelo et al., 2017).

 NCLEX Question
A school nurse is giving an educational forum on ADHD to the local school board.
Which of the following behaviors is most common in children with ADHD?

a. Short attention span

b. Lethargy

c. Preoccupation with body parts

d. Improved memory

(NCLEX Exam Questions,

2014).
Causes
● No fully validated cause
● Multifactorial
● Evidence suggests...
○ Genetics
○ Dopamine transporter gene (DAT1, SLC6A3) and dopamine 4 receptor gene (DRD4)
○ Perinatal stress
○ Low birth weight
○ Traumatic brain injury
○ Maternal smoking during pregnancy
○ Severe early deprivation
○ Dietary intake of chemicals and sugars

(Arcangelo et al., 2017).

Pathophysiology
● Reduced volume and function of the prefrontal cortex, caudate, and cerebellum
○ These areas are responsible for regulating attention, behavior, emotion, distraction inhibition, and
executive functioning
● Dopamine and norepinephrine imbalance
○ Dopamine - reward, motivation, attention, emotion
○ Norepinephrine - executive function, increases inhibition of thoughts and behavior
○ Too much or too little can hinder this balance, leading to symptoms of ADHD

(Arcangelo et al., 2017).

(St. Louis Neurotherapy
Institute, 2012).
Diagnostic Criteria
● Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5)
● Extensive interview procedures, behavior and symptom rating skills, third party
observations, and a comprehensive history must be taken
● Should be diagnosed by a psychiatrist, psychologist, or psychotherapist specializing
in ADHD (Frank, 2016).
Diagnosis Challenges
● There is an overlap in symptoms of ADHD with mood and anxiety
disorders
● ADHD is comorbid with other psychiatric conditions
○ Anxiety
○ Depression
○ Substance abuse disorders
● Symptoms may be considered “normal” for that developmental age
○ It is when the symptoms occur more frequently and more severely that causes functional impairment
and is inconsistent with developmental level when the diagnosis occurs
■ Example: A child with poor concentration at school under the age of 5 is normal and may resolve
with an intervention. However, if this same child continues to not pay attention and receives
interventions and disciplinary action and the behavior still continues, a diagnosis may then occur
(Arcangelo et al., 2017).
NCLEX Question
A school nurse is assessing a student newly diagnosed with ADHD. Which of the
following are classic symptoms of the disorder? Select all that apply:

a. Constant fidgeting/squirming

b. Excessive fatigue and somatic complaints

c. Difficulty paying attention to details

d. Easily distracted/always talking

(NCLEX Exam Questions,

2014).
Goals of Drug Therapy
● A decline in core ADHD symptoms
● A decline in functional deficits in social, occupational, and academic domains
● Generally happens quickly after drug therapy is initiated
● A balance of resolving the symptoms and minimizing risks and adverse effects is
needed

(Arcangelo et al., 2017).

First Line Drug Therapy
● American Association of Pediatrics (AAP) Guidelines
○ Children 4-18 y/o
■ Behavioral therapy
■ Methylphenidate if symptoms are severe
○ Children 5 -18 y/o
■ Stimulant medication
■ Behavioral interventions
● Stimulants
○ Methylphenidate or amphetamine
■ Works quickly from the first dose
■ Extended release forms are available
■ Easy to titrate
● Therapy should continue as long as clinically effective
● Often started on a short-acting product then transition to long-acting of the same drug
● Medication is prescribed based on experience, patient preference, and patient factors
(Arcangelo et al., 2017).
Second Line Drug Therapy
● Nonstimulant medication
○ First choice: Atomoxetine
■ Used if the patient fails or has contraindications to stimulants
○ Second choice: Guanfacine
■ Less effective than Atomoxetine
○ Third choice: Clonidine
■ Less effective than Atomoxetine

(Arcangelo et al., 2017).

Third Line Drug Therapy
● Atomoxetine
○ When used in addition to a stimulant or with Atomoxetine
● Clonidine
○ When used in addition to a stimulant or with Atomoxetine
● Bupropion
○ Takes weeks to reach therapeutic levels
○ Worsens anxiety
○ Lowers the seizure threshold

(Arcangelo et al., 2017).

Nonpharmacologic Therapy
● Multimodal Treatment Study (MTA)
○ Children who received intensive behavioral management along with medication had better outcomes
than intensive behavioral management alone
● Nonpharmacologic
○ Behavior modification
○ Parent training
○ Family therapy
○ Social skills training
○ Academic skills training
○ Individual psychotherapy
○ Therapeutic recreation

(Arcangelo et al., 2017).

Nonpharmacologic Therapy
● Coaching
○ Identify goals
○ Meet goals
○ Maintain a positive approach
to change
○ Improve productivity while provide a
source of accountability

(Frank, 2016).
Stimulants
Methylphenidate & Amphetamine
● *Drug of choice*
● Drug Names: Ritalin, Concerta, Metadate, Vyvanse, Adderall
● Mechanism of Action: Inhibition of the reuptake of dopamine and norepinephrine, stimulate the release of
dopamine and norepinephrine
○ Immediate release: Beneficial when therapy is only needed at certain times
○ Extended release: Released over 24 hours, convenient once or twice daily dosing
● Dosage: Start low and gradually titrate until benefit is maximized without AEs
● Time Frame for Response: Within the first few days
● Contraindications: Patients with anxiety, tension, agitation, glaucoma, tics, Tourette syndrome, heart disease,
hypertension, hyperthyroidism, and substance abuse
● AEs: Cardiovascular, GI, and neurological symptoms, sleep disturbances/insomnia, appetite suppression,
weight loss, agitation, nervousness, palpitations, tachycardia, elevated BP, heart rhythm disturbances,
cardiomyopathy, nausea, vomiting, headache, seizures
● Patient Teaching: Take medicine with food to avoid side effects, schedule drug free periods (example:
during the summer when not in school) to minimize long-term effects

(Arcangelo et al., 2017).

 NCLEX Question
A 10-year old pediatric male client diagnosed with ADHD has been taking
Methylphenidate over the past two years. The nurse understands the following are all
normal side effects of this therapy except

a. Weight loss

b. Anorexia

c. Dry mouth

d. Bradycardia

(NCLEX Exam Questions,

2014).
 NCLEX Question
A mother calls the clinic to report that her son has recently started medication to
treat ADHD. The mother fears her son is experiencing side effects of the medicine.
Which of the following side effects are typically related to medications used for
ADHD? Select all that apply:

a. Poor appetite

b. Insomnia

c. Lethargy

d. Agitation
(NCLEX Exam Questions,
2014).
Potential for Abuse

● Prescription stimulants are sometimes abused

○ Taken in higher quantities or in a different manner than prescribed
○ Taken by those without a prescription
● Because they suppress appetite, increase wakefulness, and increase focus and
attention, they are frequently abused for purposes of weight loss or performance
enhancement
● Because they may produce euphoria, these drugs are also frequently abused for
recreational purposes
○ Euphoria from stimulants is generally produced when pills are crushed and then snorted or mixed with
water and injected (National Institute of Drug Abuse, 2014).
● Use of extended release products minimizes the risk of abuse
(Arcangelo et al., 2017).
Non-Stimulants
Atomoxetine (Strattera)

● Used when stimulants are contraindicated, or the patient is intolerant or has failed a stimulant drug
● Mechanism of Action: Selective inhibition of the reuptake of norepinephrine, inhibits the presynaptic
norepinephrine transporter, improves function of the prefrontal cortex
● Dosage: 40 mg for patients over 70 kg, increased to 80 mg after 3 days, the maximum dose is 1.8 mg/kg/day
in children and 100 mg in adults, adjust dosage after 2-4 weeks
● Time Frame for Response: Within the first week
● Contraindications: Patients on MAO inhibitors, with uncontrolled hypertension, structural cardiac
abnormalities, cardiomyopathy, heart rhythm abnormalities, or narrow-angle glaucoma
● AEs: Nausea, sedation, increase in BP, increase in HR, urinary retention/hesitation, abdominal pain, vomiting,
decrease in appetite, headache, irritability, dermatitis, hepatotoxicity, suicidal ideation, and increased drug
levels when taking a CYP2D6 inhibitor (paroxetine or fluoxetine)
● Patient Teaching: Not a controlled substance, low risk for substance abuse

(Arcangelo et al., 2017).

Guanfacine (Tenex/Intuniv) & Clonidine
(Catapres/Kapvay)
● Used to treat behavioral symptoms such as aggression, insomnia, and tics
● Mechanism of Action: Postsynaptic alpha2-agonists, regulates subcortical activity in the prefrontal cortex
● Dosage:
○ Guanfacine: 1 mg daily and increase by 1 mg every 7 days until therapeutic (maximum of 7 mg)
○ Clonidine: 0.1 mg at bedtime and increase by 0.1 mg every 7 days until therapeutic (maximum of 0.4
mg)
● Time Frame for Response: 4 weeks-several months
● Contraindications: Hypersensitivity to the drug or drug components, other CNS depressants
● AEs: Fatigue, drowsiness, bradycardia, constipation, dizziness, hypotension, headache
● Patient Teaching: Gradual upward and downward titration is essential to avoid hypertensive crisis

(Arcangelo et al., 2017).

Bupropion (Wellbutrin)

● ADHD is not an approved indication for this drug, off-label use

● Mechanism of Action: Aminoketone antidepressant, inhibits the reuptake of norepinephrine and
dopamine (though not as intensively as stimulant medications)
● Dosage: 150-450 mg daily
● Time Frame for Response: Days-weeks-months
● Contraindications: Patients with seizure disorders, anxiety disorders, who are taking taking
benzodiazepines, CYP2D6 inhibitors or inducers, tricyclic antidepressants, or vortioxetine, or who
consume alcohol
● AEs: Suicidal thinking/behavior, dry mouth, nausea, insomnia, dizziness, anxiety, dyspepsia, sinusitis,
and tremor
● Patient Teaching: Low risk for substance abuse, lowers the seizure threshold

(Arcangelo et al., 2017).

Tricyclic Antidepressants

● No longer used for ADHD

(Arcangelo et al., 2017).

Complementary & Alternative Medications

● Ginkgo biloba
○ Improves memory and concentration
○ Used in addition to stimulant therapy
● Polyunsaturated acids
○ Efficacy not established

(Arcangelo et al., 2017).

Monitoring Patient Response
● Monthly follow-up visits until therapeutic
○ Then every 6-12 months to maintain medication regimen
● Reevaluate with the scale used to diagnose
● Medication should be given at the lowest effective dose

(Arcangelo et al., 2017).

Patient Education
● Take exactly as prescribed
● Contact your healthcare provider with any AEs
● Regular reevaluation by your provider is needed
● Lifestyle Changes
○ No evidence shows the need to limit dyes or preservatives
○ Social skills training
○ Academic skills training
○ Develop and adhere to a schedule
○ Psychotherapy may be used as well as cognitive behavior modification
○ Coaching: Daily encouragement to progress toward set goals

(Arcangelo et al., 2017).

Parent Education
● Parent training
○ Improvement of the patient’s social skills
○ Participate in the child’s social life
○ Use punishment by clear instruction
○ Positive reinforcement for good behavior
○ Ignore some behaviors
○ Use negative reinforcement (time-out)
● Support groups
● Family therapy
● Promote effective problem-solving techniques for the family
● Promote family unity

(Arcangelo et al., 2017).

Resources for Patients
● FDA’s website
○ www.fda.gov
● The National Institute of Mental Health (NIMH)
○ www.nimh.nih.gov → ADHD
○ Provides strategies for parents of young children with ADHD
○ Local providers
○ Clinical research trials
● Children and Adults with Attention Deficit Disorder (CHADD)
○ www.chadd.org
○ Support for parents and patients

(Arcangelo et al., 2017).

Adult ADHD
Manifestations
● Poor time management
● Occupational performance
● Difficulty completing tasks
● Difficulty staying attentive to work-related activities
● Distractibility
● Forgetfulness
● Poor concentration
● Poor professional interpersonal relationships
● Interrupting conversations
● Frequent job changes
● Irritability/quick to anger
● Relationship discord
(Arcangelo et al., 2017).
● Poor driving habits
Diagnosis
● Adult Self-Report Scale (ASRS)
● Conner’s Self-Report Scale

(Arcangelo et al., 2017).

Compensatory Mechanisms
● List-making
● Highly structured daily routine
● Rely on others for reminders or assistance in fulfilling tasks

(Arcangelo et al., 2017).

Treatment
● There is no US guideline for treatment of ADHD in adults
○ It mirrors the American Association of Pediatrics established guidelines
● There is a National Institute for Health and Clinical Excellence guideline from the
British Psychological Society and the Royal College of Psychiatrists for adult
treatment
● Increased risk for AEs and drug abuse with stimulant medication in this population

(Arcangelo et al., 2017).

Post-Test
Post-Test (1-5)
1. _____% of children aged 4-17 years are diagnosed with ADHD.
a. Answer: 11%
2. There is reduced volume and function of the ___________, caudate, and cerebellum
in patients with ADHD.
a. Answer: prefrontal cortex
3. The ____________ is used to diagnose ADHD in children.
a. Answer: Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5)
4. Adderall and Ritalin are examples of _________.
a. Answer: Stimulants
5. Intuniv and Strattera are examples of __________.
a. Answer: Nonstimulants
Post-Test (6-10)
1. _________________ are released over 24 hours, making them convenient for once or
twice daily dosing.
a. Answer: Extended release medications
2. It is recommended that drug free periods are scheduled while on ADHD meds
to(example: during the summer when not in school) to _________________.
a. Answer: minimize long-term effects
3. In addition to medication, ___________ should take place as well.
a. Answer: lifestyle changes
4. Stimulants may produce ________ making these drugs frequently abused for
recreational purposes.
a. Answer: euphoria
5. Wellbutrin lowers the __________.
a. Answer: seizure threshold
References
Arcangelo, V., Peterson, A., Wilbur, W. Reinhold, J. (2017). Pharmacotherapeutics for Advanced Practice: A Practical
Approach. (4th ed.). China: Wolters Kluwer.

Frank, M. (2016). ADHD: The facts. Attention Deficit Disorder Association. Retrieved from
https://add.org/adhd-facts/

National Institute of Drug Abuse. (2014, January). Stimulant ADHD medications: Methylphenidate and amphetamines.

Retrieved from https://www.drugabuse.gov/publications/drugfacts/stimulant-adhd-medication

s-methylphenidate-amphetamines

NLCEX Exam Questions. (2014, May 19). RN Practice Test. Retrieved from

https://www.nclexexamquestions.com/rn-practice-test-1.html

St. Louis Neurotherapy Institute. (2012). Brainmapping: A window into an ADHD brain. Retrieved from

http://www.stlneurotherapy.com/brainmapping-a-window-into-an-adhd-brain/