20 Ray Anne Cook Occupational Therapy private practitioner, Cape Town, South Africa Director, Sensorykidzone, Cape Town, South Africa Attention deficit hyperactive disorder (ADHD) is a common psychiatric disorder in 8–9% of schoolgoing children worldwide. The United States statistics suggest that ADHD appears to be prevalent in approximately 3–6% of the population (Rogers 2005; Timimi & Leo 2009). About 60–63% of these children continue with this disorder into adulthood. Throughout the world, occupational therapists are being confronted by this problem in the paediatric, psychiatric, psychosocial, physical (handwriting) and mental health field. Although in the present time many occupational therapists are treating children and adults with ADHD, there is a dearth of occupational therapy literature on the role of the occupational therapist in the handling and intervention of this disorder for the adult. The disorder manifests throughout the lifespan and needs continual management. There appears to be no actual cure for ADHD, and so the problems persist throughout life. Most research suggests that a combination of medication, behaviour modification and psycho-education achieve the best results (Barkley 2005). The condition is similar across cultures and is classified as a neurodevelopmental disorder which does not have a psychological causation. It has a genetic disposition and is classified as the most inheritable of all psychiatric conditions. Precipitating features such as sensory processing disorders (SPD) and environmental triggers contribute to the disorder causing difficulties in executive functioning (EF). Persons with ADHD are strongly associated with substance abuse, bad vehicle driving and speeding and antisocial behaviour. ADHD is the cause of 40% of teenage pregnancies. 32–40% of children drop out of school and 70–80% are underachievers (Barkley et al. 2008). Researchers differ in their views as to the precise cause of ADHD. Although under investigation, but receiving wide support, the most common factors appear to be a genetic, neurochemical imbalance and/or a neurologically based disorder (Green & Chee, 1997; Kutscher 2005; Rogers 2005). Barkley states that the symptoms seen in ADHD are a result of poor behavioural inhibition, which prevents self-regulation of environmental stimuli, self-organisation and foresight (Barkley 2005). ADHD is often diagnosed because of a person’s behaviour such as inattention, hyperactivity and impulsivity. This behaviour influences the person’s occupational performance, and the occupational therapist has to frequently consider the influence that this disorder has on a person’s life roles and daily activities. Often, only the short-term influence on aspects such as scholastic/work achievement is considered, but the long-term effect on a career, marriage and parenting needs focused attention. There is a growing body of research on the outcomes and intervention of adults with ADHD (Barkley et al. 2008). Occupational science provides a framework for research in this field (see Chapter 2). The Diagnostic Statistical Manual (American Psychiatric Association (APA) 2013) describes ADHD as a condition that is characterised by a pattern of behaviour that is present in multiple settings that results in performance issues in social educational or work settings. The symptoms are divided into two categories of inattention and hyperactivity and impulsivity. These include behaviours that fail to address close attention to details, difficulty in organising activities and tasks, excessive fidgeting, excessive talking or an inability to remain seated in appropriate settings. The Diagnostic Statistical Manual criteria for the DSM-5 (APA 2013) include types of behaviour that children, older adolescents and adults might display. The onset of several of the ADHD symptoms must be present prior to the age of 12 years. The significant change regarding this diagnosis in the DSM-5 (APA 2013) is the inclusion of adults and the acceptance that the ADHD symptoms occur through the lifespan. A lower threshold of five symptoms is sufficient for a reliable diagnosis for adults, while a threshold of six symptoms is needed for children. The DSM-5 includes no exclusion criteria for autism spectrum disorders (ASD) as their symptoms co-occur (APA 2013). The variation in prevalence between males and females is commonly accepted as being 3:1 (Selikowitz 1995; Cooper & Ideus 1996; Furman 2009). Although the interventions are similar for the subtypes, the use of alerting, calming or organising techniques, especially those used from a sensory perspective, differs significantly for the subtypes. Table 20.1 highlights the features of ADHD and how they relate to other co-morbid conditions, especially SPD and difficulties in EF. Table 20.1 Functions related to SPD and EF. This is relevant for children, adolescents and adults. There are varying opinions as to the specific areas of the brain involved in ADHD, including reduced size of the frontal lobes, the basal ganglia, posterior cerebellar vermis and reticular formation (Castellanos & Swanson 2002; Dunn & Bennett 2002). With regard to processing differences, the frontal lobe has been identified as playing a key executive role in screening whether information is appropriate, prioritising and taking future implications into consideration before responding. In a child with ADHD, these steps seem to be omitted, resulting in impulsive responses without going through this executive filtering process (Green & Chee 1997). Some researchers report that ADHD is associated with differences in brain chemistry, hence the term neurobiological disorder (Green & Chee 1997; Silver 1999; Kutscher 2005; Rogers 2005). Attention needs to be given to what this EF problem leads to in the occupational performance of the person in the short and long term and the type of intervention required to improve occupational performance. This also supports the need for Ayres Sensory Integration® (ASI®) intervention, motor skill development and rhythmic training in the intervention protocol. The DSM-5 (APA 2013) particularly relates to the occupational performance of the person in the long term into their adulthood. The genetic theory is supported by similarities in the symptoms experienced by the child with ADHD and close relatives who manifest the condition. Examples of symptoms noted in adults include restlessness, inattention and a low frustration tolerance. Studies on identical twins support the genetic link (Green & Chee 1997; Hunt et al. 2001; Strong & Flanagan 2005). Due to the genetic disposition of this disorder, it is important to include the family in the occupational therapy intervention, as structure and routine in the home will assist EF. The perpetuating cycle of disorganisation needs to be broken to empower the family members. ADHD is a lifelong condition, and at this time, there is no cure, but the condition needs to be managed. It is viewed as a 24/7 condition. It often leads to depression or anxiety or in some cases drug abuse. As yet, there is insufficient preventative intervention. Any intervention should focus on a ‘marriage’ between different therapeutic modalities, the developmental level of the person and an assessment of the EF. The intervention for ADHD should be a combination of medication (prescribed by a medical doctor) and intervention that changes the sensory processing and enhances EF, thus developing self-control. The whole family must be included in the therapeutic process in order to improve occupational performance for the person with ADHD. It is quite often found that the home environment has no structure or routine because one of the parents has ADHD. The person with ADHD should be carefully counselled about the condition to help them understand that it can be treated so that they can reach their true occupational performance potential, as modelled by many successful persons who struggle with the condition. There is a vital need to teach the person with ADHD to take responsibility for his/her condition and not blame the condition for unacceptable behaviour. It is important to remember that due to co-morbid conditions as well as environmental influences, each person requires an individualised plan of intervention, which suits his/her needs and beliefs, culture and values within the family and/or communal setting. The treatment is multidimensional. Treatment by medication is important and differs from country to country. It also differs in the various developmental stages in the lifespan. It must be understood that treatment with stimulants may lead to drug abuse but if the medication is used responsibly, this can be prevented. The person with ADHD who is on medication has less need to use other substances such as alcohol and/or other drugs such as cocaine in order to provide stimulation. A team approach from various professionals is required, and during the various stages of the lifespan of the person with ADHD, different team members will be involved. Team members may include family members, medical practitioners, psychologists, occupational therapists, physiotherapists and social workers. A thorough knowledge of development is necessary so that the intervention is aimed at the age of the person and his/her needs at that stage of his/her life cycle. The main features of ADHD are still present at each stage but differ slightly (Martin 1998). The long-term emotional, social, educational and occupational implications of ADHD through the lifespan are profound and well documented as cited by Cermack (Hahn-Markowitz et al. 2011). Infants are not usually diagnosed with ADHD as such. The developmental history of the person will often reveal the baby was very active or very quiet in utero. They are, however, high-maintenance babies and overly fussy and may have colic, allergies, ear infections or difficulties with eating and sleeping. These babies are often referred to occupational therapy and then diagnosed with sensory integration and self-regulation difficulties (DeGangi 2000; Williamson & Anzalone 2001). Frequently, they are either over-responsive or under-responsive to sensory input and have problems with self-regulation. Rhythmical movement or singing can be very effective. The use of ASI® (Ayres 1972, 2005) and DIR®/Floortime (Greenspan & Wieder 2006) is very valuable. The parents are encouraged to implement an intervention programme and routine that is tailor-made to the family. Many children with ADHD are overlooked at this stage as parents will say that ‘he is just an active, busy little boy’. Some are diagnosed during this stage, especially the hyperactive/impulsive type, as they are always active and in trouble. They are clumsy, crash into anything in their way and have little frustration tolerance. When referred to occupational therapy, it is often for poor drawing skills or task-related difficulties in playschool/preschool. After a comprehensive evaluation, they often present with some type of sensory processing and integration deficit (SPID), and the occupational therapist starts to question the possibility of ADHD. Research has shown a very strong link with SPID and ADHD (Dunn & Bennett 2002), so a differential diagnosis is vital, as the symptoms look similar and the conditions often overlap. The occupational therapist thus needs a thorough knowledge of sensory integration and ADHD. The use of rhythmical strategies relevant to this age, such as swinging and rhythmical games, should be incorporated. Attention should be given to executive functions and behavioural inhibition with the help of adults and in consultation with the occupational therapist. With the increase in school hours and more formal education, there are more demands on children with ADHD. They need to sit still, attend, inhibit behaviours, organise, socialise and cooperate for longer periods of time. They are often identified and referred for ADHD assessment at this age especially for both subtypes. The inattentive type is also now more easily identified, especially if there is an experienced teacher who understands ADHD. Poor handwriting, difficulty working in a group and lack of task completion are some of the most common reasons for referral. An in-depth evaluation is vital here in which all underlying possibilities are taken into consideration and a diagnosis is made. The children begin to participate in sport. There is another set of potential difficulties inherent in sport for the ADHD person to overcome, ranging from forgetting sports clothes to being out of place in the team and not focusing on the game. Homework can become a nightmare for the parent, especially when children know their spelling very well the night before but fail the spelling test the following day. Disorganisation, fluctuating abilities and social rejection then lead to low self-esteem. ASI® therapy (Ayres, 1972, 2005) is frequently used by the occupational therapist at this stage. It is important for the occupational therapist to put attention on the rhythmical training, EF and occupational group therapy (combination of the Alert Programme (Williams & Shellenberg 1996) and social skills). Consultation with regard to the particular sport is also necessary. A change of schools can be a major hurdle for the child with ADHD. He/she is required to be even more organised and independent. The typical adolescent at this stage is going through major physiological, cognitive, behavioural and emotional changes. The ADHD interferes with this ‘mastery of adolescence’ and adds much stress, and unpleasant conflicts and non-compliance are common. The evaluation needs to put special emphasis on handling the adolescent ADHD person and his/her occupational performance in the social, home and school environment. If the person is only diagnosed at this age, it often comes as a relief to him/her. The occupational therapist often does more consultation with regard to EF, sensory processing and the optimal band of arousal with adolescents. Rhythmical training is used and then often linked to finding a sport in which the adolescent can participate. Study skills still need to be addressed. Many adults are only diagnosed when they take their child to the paediatrician for an evaluation for ADHD! The adults’ occupational roles have now evolved to include having a job, providing for a family and being a spouse and a parent. These complexities and responsibilities make it so much more difficult for the adult to cope. The adult ADHD person may have now developed co-morbid condition such as anxiety and/or drug abuse, and it is often difficult to recognise the underlying ADHD which was there from the beginning. The evaluation must consider the influence that the ADHD has on the relationships within the family, work and community. It is important to try to get the adult clients to commit to at least six sessions as they tend not to see the therapy through. Barkley et al. (2008) have led two major studies on ADHD in adults and have concluded the following: ADHD has an adverse effect on the life activities of the adult. The most serious areas affected are educational and occupational functioning. Money management, management of daily responsibilities, parenting, vehicle driving and health risks were also ranked among the most important (Barkley et al. 2008). When referring to the aforementioned life stages, symptoms of ADHD can clearly be divided into child symptoms and adult symptoms. Child symptoms of ADHD are shown through their behaviour. Examples are as follows (Serfontein 1990; Green & Chee 1997; Cook 2013): Adult symptoms of ADHD constitute a lack of EF, namely: The occupational therapist will have important contributions to make in helping the medical practitioner make a diagnosis as a comprehensive and thorough examination is important. Information is required from various environments in which the person functions such as school, home or work. ADHD is diagnosed by the behavioural symptoms. The severity and combination of behaviours vary greatly in individuals, making diagnosis and treatment challenging. More than 50% of individuals diagnosed with ADHD have co-morbid conditions (Green & Chee 1997). Silver (1999) suggests that anxiety, depression and learning disabilities often cause the described behaviours of ADHD. The causes of the presenting behavioural problems need to be identified as not all people with these symptoms have ADHD. The various conditions or behaviours also differ at various stages of life and may resemble ADHD.
Attention Deficit Hyperactive Disorder through a Person’s Lifespan: Occupational Therapy to Enhance Executive and Social Functioning
Introduction
Attention deficit hyperactive disorder criteria (DSM-5)
Inattention
Under-responsive (UR) to sensory input and require more sensory input than others to respond
The sensory craver (SC) seeks the input, and if he/she does not obtain it, he/she is unable to attend to the task at hand
Poor discrimination of senses
Over-responsive (OR) to sensory input and are thus distracted by the extraneous input and not available to attend
Symptoms
Executive functioning
Often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities
UR
Often has difficulty sustaining attention in task or play activities
UR needs external sensory input to increase arousal
SC needs to be given opportunity to get sensory input throughout the day
Praxis
EF working memory
Often does not seem to listen when spoken to directly
UR
Poor hearing
Often does not follow through on instructions and fails to finish schoolwork, chores or duties in the workplace (not due to oppositional behaviour or failure to understand instructions)
Praxis may have difficulty in the motoric output of the task, sequencing of tasks or difficulty in forming an idea of what and how to do the task
EF – memory, plan/organise
Often has difficulty in organising tasks and activities
Poor praxis as explained in the preceding text
EF – plan/organise
Often avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
OR avoids task requiring sensory input such as glue on hands
UR or SC
EF – no interest, repetitive
Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books or tools)
Praxis
EF working memory, inhibition or plan/organise
Is often easily distracted by extraneous stimuli
OR or inhibition
Is often forgetful in daily activities
UR
Praxis sequencing, temporal concepts, EF working memory
Memory
Hyperactivity
SC seeks sensory input at all costs
Poor ideation and praxis abilities make the person appear very busy but actually they do not achieve much
Impulsivity
Poor EF of inhibition.
EF, executive functioning; OR, over-responsive to sensory input; Praxis, includes ideation, motor planning and execution; SC, sensory craver; UR, under-responsive to sensory input.
Symptoms
Executive functioning
Often fidgets with hands or feet or squirms in seat
SC seeks movement or tactile input
The person needs to move to increase their postural tone so they tend to squirm in their seat
Anxiety
Often leaves seat in classroom or in other situations in which remaining seated is expected
SC seeks movement
Postural control
Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
SC seeks movement and proprioceptive input
Poor ideation
Often has difficulty playing or engaging in leisure activities quietly
SC
Is often ‘on the go’ or often acts as if ‘driven by a motor’
Praxis especially ideation, needs help to work out what to do
Often talks excessively
UR uses voice to increase level of arousal
OR to sound uses own voice to drown out other noises
EF poor inhibition of thoughts, talks self through tasks
EF poor inhibition of thoughts, talks self through tasks to energize their body or to decrease anxiety or auditory input
Often blurts out answers before questions have been completed
EF poor inhibition
Often has difficulty awaiting turn
Praxis sequencing
EF poor inhibition
Often interrupts or intrudes on others (e.g. butts into conversations or games)
SC
Praxis (difficulty in planning how to join a game)
EF poor inhibition
ADHD through the lifespan
Infants
Preschool
Primary school
High school/university
Adult
Symptoms of ADHD
Child symptoms
Adults
Differential diagnosis and co-morbid conditions with ADHD in children and adults
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