Attention-Deficit Hyperactivity Disorder (ADHD)

Overview

ADHD is a condition characterized by inattention, hyperactivity, and impulsivity. It is most commonly diagnosed in young people, with an estimated 9% of children aged 4-17% with ADHD. An estimated 4.% of adults aged 18-44% have ADHD.(NAMI. (n.d.). ADHD. Retrieved from https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/ADHD))

Recent trends include large increases in ADHD diagnosis and treatment among adults.¹  There has been an increase in ADHD diagnosis and treatment among female children and teens.²  Racially, there have been lower rates of diagnosis and treatment for non-White compared to White populations.³ 

Diagnostic Changes

There has been an increase in case diagnoses for ADHD, some of which may be due to changes in the DSM and American Academy of Pediatrics (AAP) criteria being more broadened. The age criteria for ADHD were broadened in both the DSM and AAP — 4-18 years in 2011 from 6-12 years. DSM-5 requires adolescents and adults to show only five symptoms instead of six. ⁴ 

Causes

ADHD runs in families as there is a genetic risk when passed on from parents. First-degree relatives of those with ADHD are 2-8x more likely than relatives without symptoms to show ADHD. Twins have around 71-90% rates of ADHD. ⁵  Adoption studies also show a strong inherited contribution to ADHD.⁶  ADHD also shows comorbidity with other problems such as lower IQ, intellectual disability, and developmental problems, speech and language problems, motor coordination difficulties, and autism spectrum disorders.^7 8  Although many environmental factor have been associated with ADHD, it has been difficult to identify causation. Potential environmental risks to ADHD include maternal smoking, maternal alcohol and substance abuse, maternal stress, lower birth weight and prematurity, pesticides, lead, nutritional deficiencies or surpluses, family socioeconomic status, parent-child conflict, and severe early deprivation.⁹ 

Symptoms and Terminology

Inattention

• Wandering off task
• Lacking persistence
• Difficulty sustaining focus (attention)
• Being disorganized

Hyperactivity

• Moving about constantly
• Fidgeting, tapping, or talking excessively
• Being restless or wearing others out with excessive activity

Impulsivity

• Making hasty actions without first thinking about them or their consequences
• Desiring immediate awards
• Having difficulty delaying gratification
• Being socially intrusive
• Interrupting others excessively

General Symptoms in Occupations

• Hyperactivity is the most common symptom in preschool.
• For people with ADHD, their behaviors are more severe, and frequent, and interfere with daily functioning.

Inattention Examples

• Overlooking or missing details in school work or work.
• Difficulty sustaining attention for play, conversations, classes, and reading.
• Not seeming to be listening when spoken to.
• Not following through with instructions and failing to finish schoolwork, chores, or duties.
• Getting easily sidetracked on tasks.
• Having problems organizing tasks and activities – sequence, messiness, poor time management, not meeting deadlines.
• Avoiding or disliking tasks that may require sustained mental effort such as schoolwork, reading, completing forms, or reviewing lengthy papers.
• Losing things such as school supplies, wallets, keys, and paperwork.
• Being easily distracted by unrelated thoughts or environmental stimuli.
• Being forgetful in daily activities, chores, errands, and keeping appointments.

Hyperactivity-Impulsivity Examples

• Fidgeting and squirming in seats.
• Leaving seats when expected to stay such as in the classroom or in the office.
• Running, dashing, or climbing in situations when inappropriate.
• Feeling restless (teenagers and adults).
• Being unable to play or engage in leisure quietly.
• Being constantly on the go.
• Talking nonstop.
• Blurting out an answer before a question has been completed.
• Finishing other people’s sentences.
• Speaking out of turn.
• Interrupting others in conversations, games, and activities.¹⁰ 

Outcome Measures

• Observation
• Interview
• Strengths and Limitations Inventory (SLI)
• Perceptual-motor tests
• Perceived Efficacy and Goal Setting System (PEGS)
• School Function Assessment (SFA)
• School Assessment of Motor and Process Skills (School AMPS)
• Sensory Profile
• ADHD Rating Scale¹¹ 

Occupational Therapy Interventions

• Help promote task selection of meaningful tasks at the just-right challenge.
• Provide functional skills training.
• Provide education and training for teachers.
• Provide neurological interventions (sensory integrative therapy, sensory diet, Alert, MORE, Therapeutic Listening) with clear outcome measures.
• Provide direct attention and impulse control training.
• Provide treatment of executive functions.¹² 
• ADHD is covered under Disabilities Education Act (IDEA).
• Educating parents about ADHD and how it may affect the family.
• Helping parents to develop new skills, attitudes, and ways of relating.
• Providing behavioral therapy as a team to teach monitoring of behavior and giving praise or rewards in a desired way.
• Providing positive or negative feedback.
• Establishing clear rules and structures routines.
• Teaching social skills that are appropriate for age level.
• Teaching social skills to read facial expressions, tone of voice, and responding appropriately.
• Use cognitive-behavioral therapy (CBT) combined with mindfulness and meditation to teach thinking before acting or to avoid taking necessary risks.
• Providing classroom management interventions and environmental adaptations.
• Implementing systems and strategies with teachers such as reward programs or point systems with daily report cards for parents.
• Provide stress management and coping techniques.
• Referring to support groups.
• Provide tools to manage routines and to maintain organization, e.g., notebooks, calendars.
• Having a special place for belongings and reducing clutter.¹⁰ 

EBP Interventions

• The Cog-Fun was found to be effective for cognition/executive functioning in two studies.¹³ 
• The Cognitive Orientation to Daily Occupational Performance (CO-OP) was shown to be effective for improving motor performance.¹⁴ 
• Family-centered OT that focused on neurological, psychological, and behavioral domains resulted in behavioral improvements of ADHD symptoms in over half of the participants.¹⁵ 
• Interactive Metronome training appears to facilitate attention, visual-motor control, and selected academic skills in boys with ADHD.¹⁶ 
• Theraplay intervention was found to be effective in decreasing ADHD symptoms.¹⁷ 
• The use of play, video feed-forward and feedback, modeling, and parental involvement is effective for developing social play skills of children aged 5-11 years in a small-scale research study.¹⁸ 
• Weighted vests may improve attention and on-task behavior, but has no impact on impulsivity.¹⁹ 
• Stability balls may help with on-task behavior in children with ADHD.²⁰ 

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