Nursing Field Notes / Mental Health · Psychiatric Care Course
ADD & ADHD ⚡
Attention Deficit (Hyperactivity) Disorder
NG-093Mental HealthADHD-friendly visual edition
Low dopamine & norepinephrine in the brain's reward/focus circuits means the brain can't rank what deserves attention — so it either drifts (inattentive), revs (hyperactive-impulsive), or both (combined type). Treatment lives on a separate page — see ADHD Meds (NG-234).
🧪 2 low chemicalsDopamine & norepinephrine — the "reward vs. risk" & impulse-control messengers.
🎭 3 presentationsInattentive · Hyperactive-Impulsive · Combined — same disorder, different face.
🚨 #1 nursing diagnosisRisk for injury — impulsivity outruns judgment.
🗣️ Teach in 4 stepsEye contact → simple language → repeat back → praise.
🧨
CAUSE
STEP 1 · THE BRAIN CHEMISTRY
One circuit explains the whole picture — the brain's "is this worth my attention" filter runs low on fuel.
🧠 The prefrontal circuit runs low on dopamine & norepinephrine
EXAM TIP Low dopamine & norepinephrine in the prefrontal cortex — the neurotransmitters that help the brain weigh reward vs. risk and control impulsivity & mood. Clients with ADHD are therefore more likely to also carry anxiety and substance use risk — the brain chases whatever raises dopamine fastest.
🧠 "Low fuel, low filter." Dopamine is the brain's reward fuel — without enough, the brain can't decide what's worth focusing on, so it grabs whatever is loudest (impulsivity) or nothing at all (inattention).
⚠️ Risk factors
🧬 Genetic / family history — highly heritable
🤕 History of head trauma — TBI (traumatic brain injury)
🚬 Prenatal exposure — nicotine, alcohol, or substance use in pregnancy
👶 Low birth weight / prematurity
🧠 "Hit head, hooked on risk." A documented head injury is the classic ATI risk-factor trap — kids with a serious TBI are more likely to develop ADHD later.
🔤 Say the terms — ADD vs. ADHD
ADD = Attention Deficit Disorder — inattentive symptoms without the motor hyperactivity
ADHD = Attention Deficit Hyperactivity Disorder — the umbrella term used in current diagnostic criteria (DSM-5-TR), covering all three presentations below
"ADD" is older/lay terminology — on exams, ADHD is the umbrella and the presentation (inattentive / hyperactive-impulsive / combined) is the specifier.
🔎
CLUES
STEP 2 · SPOT THE PRESENTATION
Three faces of the same low-dopamine circuit — know which symptoms build which type.
🎭 Three DSM presentations — same disorder, different symptom mix
🧩 Predominantly Inattentive
Reduced ability to focus, easily distracted, poor follow-through, disorganized, loses items, forgetful in daily activities.
⚡ Predominantly Hyperactive-Impulsive
Restless "always on the go," excessive talking, blurts answers, interrupts, difficulty waiting turn.
🔀 Combined
Meets criteria for both — the most commonly diagnosed presentation, especially in school-age children.
🧠 DSM checklist = "6-6-12-2."6 or more symptoms · lasting more than 6 months · onset before age 12 · present in 2+ settings (home and school). One setting only ≠ ADHD — it might just be that classroom.
😔 Low self-esteem & impaired social skills — from repeated correction/rejection
🧠 "HII-L" — Hyperactive · Inattentive · Impulsive · Low self-esteem. Say it like "hee-ill" — the disorder hurts before it heals.
🚨 Priority nursing diagnosis: Risk for injury
Impulsivity + hyperactivity outrun judgment — a child may run into traffic, climb, or act before thinking. On a HESI/ATI question, "risk for injury" is the nursing diagnosis to pick when ADHD is the stem.
🧠 Aggressive/agitated child? Distract & redirect — e.g., ask them to blow up a balloon. Gives the excess energy somewhere safe to go instead of escalating.
🩺
CARE
STEP 3 · STRUCTURE, SAFETY, COMMUNICATION
Non-drug care is structure and predictability; medication management lives on its own page — see NG-234.
🗣️ Therapeutic communication — 4-step sequence
1
👁️ Get eye contact BEFORE speaking — confirms attention is captured first
2
💬 Use simple, short language — one instruction at a time
3
🔁 Have the child repeat back what was said — confirms it was received
4
🌟 Offer praise upon task completion — reinforces the behavior you want repeated
🧠 "Eye-Say-Say-Yay." Eye contact → Say it simply → child Says it back → Yay (praise). Kaplan's favorite right answer is a hug/praise after the task is completed — not before, and not as a bribe up front.
📋 Structure & scheduling — the #1 classroom/home teaching point
📅 Provide a written or typed daily schedule — predictability lowers anxiety and impulsive behavior
⏱️ Allow regular breaks
👁️ Combine verbal instructions with visual cues
📏 Establish consistent rules — same expectations every day
📉 Do not overload with homework — decrease amount assigned
🧠 On an ATI-style stem — "9-year-old on bedrest with ADD, which action should the nurse prioritize?" — the answer is give a written/typed daily schedule, not medication or restraint.
💊 Where meds fit — cross-reference
Stimulants (methylphenidate, amphetamine salts) and non-stimulants (atomoxetine, guanfacine/clonidine ER) treat the same low-dopamine/norepinephrine circuit covered above. Full mechanism, monitoring, and teaching are on the ADHD Meds page (NG-234) — this page is diagnosis & non-drug care only, so the two pages together are the complete topic.
🔗 See NG-234 — ADHD Meds for: stimulant mechanism, growth/cardiac monitoring, controlled-substance status, drug holidays, and non-stimulant options.