occupational therapy (OT) for ADHD

What is ADHD and the role of Occupational Therapy in ADHD?

Definition of ADHD (Attention Deficit Hyperactive Disorder)–

According to DSM-IV: ADHD is a disruptive behavioral disorder characterized by a set of chronic and impairing behavior patterns that display abnormal levels of inattention, hyperactivity or their combination.

Symptoms of ADHD –

Children who have symptoms of inattention may:

• Be easily distracted, miss details, forget things, and frequently switch from one activity to another.
• Have difficulty focusing on one thing.
• Become bored with a task after only a few minutes, unless they are doing something enjoyable.
• Have difficulty focusing attention on organizing and completing a task or learning something new.
• Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities.
• Not seem to listen when spoken to.
• Daydream, become easily confused and move slowly.
• Have difficulty processing information as quickly and accurately as others.
• Struggle to follow instructions.

Children who have symptoms of hyperactivity may:

• Fidget and squirm in their seats.
• Talk nonstop.
• Dash around, touching or playing with anything and everything in sight.
• Have trouble sitting still during dinner, school, and story time.
• Be constantly in motion.
• Have difficulty doing quiet tasks or activities.

Children who have symptoms of impulsivity may:

• Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences.
• Have difficulty waiting for things they want or waiting for their turns in games.
• Often interrupt conversations or others’ activities.
• Impatient.

The brain and ADHD – 

Let’s understand the basics of developing brain and what happens to it when affected by ADHD. This is a simplified version of the changes that occur in the brain of a child with ADHD.

One of the major areas of the brain affected by ADHD is the prefrontal cortex. This is the part of the brain that lies in front above our eyes and behind our foreheads. It is the most important part of the brain as it is involved in attention, planning and decision making. It is also involved in judgment and rational decision-making.

The child with ADHD often has difficulties in paying attention and concentration due to this part of the brain being affected. The child with ADHD is also forgetful and shifts from one task to another due to the brain here being affected. The child with ADHD is often accident prone and impulsive i.e. acts without a thought about future consequences of the action he will undertake due to an impaired prefrontal cortex that does not allow him to take rational decisions at times.

The prefrontal cortex is also responsible for executive functions that are impaired in ADHD. Executive function is a function aimed at planning when multiple tasks have to be undertaken for example when writing an exam answer paper or planning a study time table which is affected in ADHD.

At a chemical level, our brain is equipped with a chemical called dopamine that acts a messenger to transfer information from one neuron to another. There are some abnormalities in the dopamine system seen in ADHD whereby dopamine may be more or less in different parts of the brain. The role of medication used in ADHD is to stabilize the dopamine system. Dopamine is an excitatory chemical and keeps the brain active when in excess in certain areas of the brain, accounting for the symptoms of hyperactivity seen in a child with ADHD.

Achieving chemical stability in the brain takes time and hence the medicines prescribed might take 3 to 4 weeks to show the full effect.

Multi-Model Approach in ADHD –

Children with ADHD suffer not because of the core symptoms of lnattention, Hyperactivity and Impulsivity but because these symptoms lead to disruption of normal neuro-developmental processes like learning. This results in impairment in the child’s ability to lead a normal life in the community around it.

The two major areas of dysfunction are academics and social behavior. If unchecked, these lead to further deterioration in self-esteem, motivation, behavior, and mood. These are associated with higher incidence of anxiety, depression, substance abuse and suicidal ideation.

In order to effectively intervene in children with ADHD, the following points must be borne in mind:

The child suffers from problems in a cluster of areas, hence one modality of intervention is unlikely to benefit.

Active participation by parents is a must; active participation includes the ability to effectively understand the concerns.

Academic underachievement is caused by the core symptoms which persist; however, cumulative worsening in academic achievement occurs over a period of time since new learning is based on mastery of the previously learned material. Thus, if a child with ADHD has failed to master Grade 3rd syllabus, it is further difficult for him to connect to Grade 4th syllabus.

Multi Model approach for ADHD kids includes-

The main components of this approach are medications, behavioral therapy, parent education, and occupational therapy.

Behavioral therapy and ADHD-

Behavioral therapy is used to control the undesired behaviors of ADHD child. It may help in children to control his/her impulses and response to emotional stimuli.

Parent Education and ADHD-

Educating parents about the disorder, its feature and most importantly the strategies occupational therapist used during the session. The behavioral strategies, sensory strategies, skills can be learned by the parents for effective intervention planning.

Since changes cannot happen overnight, it is easy to lose track of progress. Recognizing time-bound progress as a necessary component and factoring this into the intervention is crucial.

Finally, none of the above is possible unless one involves a multi-disciplinary team with each professional’s role well laid out. This can be achieved only if the same is documented, so that there is a plan to cross check one’s progress, as well as re-evaluate the latter at regular predetermined intervals. This underlines the necessity to have an Individualized Therapy Program (ITP)or Individulized Educational Program (IEP).

Occupational Therapy (OT) for ADHD children-

Occupational Therapy with Sensory Integration is a vital cog of this wheel with its role, benefits, and limitations well defined.

As its name indicates, Occupational Therapy is a form of rehabilitation; its express role is to enable the child to overcome his/her physical functional deficiencies. Hence, sitting tolerance, hyperactivity, restlessness, impulsivity, distractibility, fine motor control, grip, handwriting (form, shape, orientation and presentation of written material), eye—hand coordination, etc. are the domains which it encompasses.

ADHD kids, preferably refer to an occupational therapist for their attention and hyperactivity issues. The symptoms of ADHD kids restrict them to involve him in a functional and meaningful task. Occupational therapist generally administers sensory integration technique in these kids for a better outcome. By using sensory integration technique, OT helps them to calm down and focus on an activity.

Many children with ADHD will also have sensory processing disorders and this can contribute to their inability to pay attention, focus and concentrate. These children will either withdraw from or seek sensory stimulation like movement, touch, bright light, busy rooms and loud noises and do not engage appropriately in an activity as expected. An Occupational therapist may accompany sensory integration along with the activities, for better results. ADHD kids have many issues in a daily living task like donning and doffing of the shirt, buttoning-unbuttoning, and other fine motor skills.

Occupational therapy Assessment for ADHD kids–

Before applying any sensory strategies, OT assesses all sensory problems and other issues, generally, OT check for these things–

1. Sensory Issues like defensiveness or seeking behavior.
2. Organizational skills or abilities.
3. Distractibility and Impulsivity.
4. Following of command.
5. Difficulty in turn taking.
6. Difficulty in organized group activity.
7. Seating tolerance.
8. Gross motor coordination
9. Fine motor coordination
10. Visual memory and other visual perceptual skills.

Occupational Therapy Intervention for ADHD children–

Some OT exclusively uses only sensory integration technique, and some use functional approach. We would feel better with a multi-model approach.

Sensory Techniques-

These kids have more energy and hyperactivity; the first goal would be to decrease hyperactivity by calming them. It’s very important that they should understand what we are saying and understand the command. If they are hyperactive and impulsive, they won’t listen or follow us.

Sensory integration techniques are useful to calming them and help to channelize the excess amount of energy. Below mentioned activities or techniques are not applicable for all ADHD children, techniques totally depend upon the needs of a child. Let’s have an example of what Occupational therapist do during a therapy session of an ADHD child.

Calming the ADHD child – when the child enters the room OT rolls him/her up in a mat and give him deep pressure with a ball. Next, OT settles him using the light music/ essence of lavender or vanilla and by dimming the lights. OT then put weight cuffs in his hands and put him in a bolster swing where OT give him an activity while giving gentle unidirectional movements. OT make him sit on a chair and do table top activities and writing activities.

Channelizing Energy – As the child enters the room OT give him bouncing on the trampoline, OT can also combine another activity of catching and throwing a ball while bouncing. OT can make climb the children’s gym or ladder. Running or cycling helps him to channelize extra energy.

Teach them organizational skills –

Many parents and teacher think about, how to teach organizational skills to ADHD kids. They are so impulsive and they just throw things here and there.

• Our first approach should be to Encourage and Support them. They are very easily distracted and impatience.
• Give them enough time to think and respond.
• Always ask them to organize things, if they don’t get it, first you have to make them understand by doing yourself. When they see the correct sequencing pattern, they may repeat it successfully.
• Always provide them a demo of a task and your demo should be slowly progressing with minimal verbal cues.  (Too much verbal cues during one task, may distract them, instead use less and more meaningful 2-3 words).

Participation in activities –

• Initially, provide them activities which are simple, just to increase their self-esteem and confidence.
• You may encourage them in participating in sports activities; it will help them to improve self-confidence, self discipline, social skills, motor development and concentration.
• Initially, provide them activities for a short time.
• Encourage the child to finish a task.
• Provide some resting period, e.g. allow the child to stand up and go drink water.

Restructuring of home environment or school setting–

• Minimize visual and auditory stimuli–
• Reduce clutter – in both the rooms and on the desk. No other visually stimulating things like fancy balls.
• Restrict visual fields – It’s better to keep the desk in the corner of a room, facing towards the corner.
• Paint your wall with sober colors.
• Play low calming music, many children’s responds well in this setting but not all.
• Speak or instruct them in a calm voice.
• Sit next to him, provide verbal or physical clues if he needs.

Occupational Therapy Teaching/ Parenting tips for ADHD child-

Children with an Attention Deficit Disorder, with or without Hyperactivity are easily distracted, fidgety and talkative. They may interrupt you while you’re explaining things to the class and have difficulty waiting their turn. And while they are a disruptive influence on the class, they may also need extra help with learning. So as a teacher/ parents, you can do following things-

Teaching Tips / parenting Tips for ADHD child:

• Be predictable. Structured minimal rules/choices are important and work best.
• Establish a positive relationship with ADD/ADHD students/child.
• Encourage hands-on learning. Create learning opportunities where children experience things first-hand.
• Make learning fun: play games, draw pictures, invent funny acronyms to sustain interest.
• Provide visual reminders. Students with ADD/ADHD respond well to visual cues and examples. For instance, leave key points about a topic visible on the board.
• Follow-up directions. Ask the child if he or she understood directions and repeat the directions together.
• Ask questions. Allow a child sufficient time to work out the answer to a question.
• Assign work that suits the student’s skill level. ADD/ADHD students will avoid classwork that is too difficult or too long.
• Help students correct their own mistakes.
• Divide work into smaller units. Break down assignments into smaller, less complex tasks. For example, allow students to complete the first five math problems before presenting them with the remaining five problems, rather than presenting all ten together.
• Prepare for transitions.
• For special events like field trips or other activities, be sure to give plenty of advance notice and reminders.
• Define the appropriate behavior while giving praise. The comments should focus on what the student did right and what part(s) of the student’s behavior was desirable. Rather than praising a student for not disturbing the class, for example, a teacher should praise him/her for quietly completing a math lesson on time. Give praise immediately. The sooner that approval is given regarding appropriate behavior, the more likely the student will repeat it.
• Reward the child with privileges or activities, rather than with food or toys. Change rewards frequently as children with ADD/ADHD get bored if the reward is always the same. Make a chart with points or stars, so the child has a visual reminder of his or her success.
• Consequences – They should be spelled out in advance and occur immediately after the child has misbehaved. Try removal of privileges as a consequence for misbehavior. Remove the child from situations and environments that trigger inappropriate behavior.
• Allow for “escape valve” outlets. Permitting students with ADD/ADHD to leave class for a moment, perhaps on an errand (such as returning a book to the library), can be an effective means of settling them down and allowing them to return to the room ready to concentrate.
• Hurdle helping. Teachers can offer encouragement, support, and assistance to prevent students from becoming frustrated with an assignment. This help can take many forms, from enlisting a peer for support to supplying additional materials or information.
• Proximity control. When talking to a child, move to where the child is standing or sitting. This will help the child to focus and pay attention to what you are saying.
• Seat the child near the teacher.
• Seat the child near a student role model.
• Provide low-distraction work areas.
• Lower noise level.
• Remember that the child isn’t intentionally trying to forget his/her homework or fail a test.
• Having ADD/ADHD can be just as frustrating, if not more, than dealing with someone who has it. Keeping this in mind, it will be a lot easier to respond to the child in positive, supportive ways. As a teacher, one can help the student overcome daily challenges and channelize his or her energy into positive areas.

References –

Jennifer Creek, Lougher (2011). Occupational therapy and mental health. 4^th Ed. Churchill Livingstone publication.

Wagenfeld, Kaldenberg (2005). Foundations of Pediatric practice for the occupational therapy assistant. Slack Incorporated.

Hyche, Maertz (2014). Classroom strategies for children with ADHD, Autism & sensory processing disorders. Pesi publishing & media.