CLINICAL

REVIEW
Authors
Amy Lombara, PT, DPT
Ellenore Palmer, BScPT, MSc
Cinahl Information Systems, Glendale, CA
Reviewers
Diane Matlick, PT
Cinahl Information Systems, Glendale, CA
Andrea Callanen, MPT
Cinahl Information Systems, Glendale, CA
Rehabilitation Operations Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Sharon Richman, MSPT
Cinahl Information Systems, Glendale, CA
June 27, 2014
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright2014, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Attention Deficit Hyperactivity Disorder (ADHD) in
Children
Indexing Metadata/Description
Title/condition: Attention Deficit Hyperactivity Disorder (ADHD) in Children
Synonyms: ADHD; hyperkinetic syndrome; attention deficit disorder; ADD; minimal
brain dysfunction; brain dysfunction, minimal
Anatomical location/body part affected: Attention deficit hyperactivity disorder
(ADHD) affects the entire individual
Area(s) of specialty: Neurological rehabilitation, pediatric rehabilitation
Description
General overview of ADHD

Most common neurobehavioral disorder in children

(47,48)
ADHD is a common neurobiologic disorder characterized by developmentally
inappropriate levels of inattention, hyperactivity, and impulsivity
(2)

Viewed as a chronic condition;

(3)
more than 60% of children diagnosed will have
symptoms as adults
(1)
ADHD is associated with the following conditions:
-
Developmental coordination disorder
(4)
- Defined as a marked impairment in the development of motor coordination that
significantly interferes with academic achievement or activities of daily living
- Developmental coordination disorder may coexist in as many as 50% of cases of
ADHD
-
Conduct disorder
(5)
-
Anxiety
(5)
-
Depression
(5)
-
Sleep disorders
(6)
-
Learning disabilities
(7)
-
Mood disorders
(7)
-
Sensory processing disorders
(8)
-
Substance abuse (in adolescents)
(9)

There are 3 presentations of ADHD

(17)
- Predominately inattentive
- Predominantly inattentive is sometimes referred to as attention deficit disorder
(ADD) because the hyperactivity and impulsivity criteria are not met; however, it
is generally considered a variant presentation of the same disorder, not a distinct
disorder
- Hyperactive-impulsive
- Combined (most common presentation)
ICD-9 codes
314.0 attention deficit disorder of childhood
314.00 attention deficit disorder of childhood without mention of hyperactivity
314.01 attention deficit disorder of childhood with hyperactivity
314.1 hyperkinesis of childhood with developmental delay
314.2 hyperkinetic conduct disorder of childhood
314.8 other specified manifestations of hyperkinetic syndrome of childhood
314.9 unspecified hyperkinetic syndrome of childhood
ICD-10 codes
F90.0 disturbance of activity and attention
F90.1 hyperkinetic conduct disorder
F90.8 other hyperkinetic disorders
F90.9 hyperkinetic disorder, unspecified
F98.8 other specified behavioural and emotional disorders with onset usually occurring in childhood and adolescence [used
for attention deficit disorder without hyperactivity]
Reimbursement: No specific issues or information regarding reimbursement have been identified
Presentation/signs and symptoms
Prevalence
In the U.S., the prevalence of ADHD in children is reported to be 5% to 9.5%
(3)
~ 7% of children in U.S. aged 611 years have a diagnosis of ADHD; ~ 75% are males
(10)
Signs and symptoms
Impulsivity
(11)
Decreased ability to focus attention
(11)
Hyperactivity
(11)
Decreased coordination
(11)
Low frustration threshold
(11)
Difficulties with organization
(1)
Daydreaming
(11)
Changing activities often
(11)
Underachievement in school
(5)
Low self-esteem
(5)
Compared to peers without ADHD, adolescent females with ADHD were more prone to symptoms of:
(12)
- Depression
- Eating disorders
- Substance abuse
Causes, Pathogenesis, & Risk Factors
Causes
Largely unknown
(3)
Neurochemical, neurophysiological, genetic, and psychosocial components are proposed
(48)
Pathogenesis
Anatomic findings/reported insights into pathogenesis
Cortical brain size in patients with ADHD was found to be reduced in inferior portions of dorsal prefrontal cortices and
anterior temporal cortices bilaterally, and increased in posterior temporal and inferior parietal cortices bilaterally
(13)
- Based on MRI study of 27 children and adolescents with ADHD and 46 matched controls
Certain areas in the brain, including the frontal cortex and basal ganglion, have a decreased rate of glucose metabolism
(5)
Risk factors
Maternal smoking during pregnancy
(2)
High lead exposure
(14)
Genetics/family history
(2,14,48)
Fetal alcohol exposure
(15)
Low-birth weight
(15)
Psychosocial adversity
(15)
Low APGAR score at 5 minutes after birth
(16)
Sex: 4:1 male-to-female ratio
(48)
Overall Contraindications/Precautions
Therapeutic interventions should be implemented in a gradual manner and arousal level should be carefully monitored,
particularly in the situations where the child has a history of becoming agitated or for demonstrating negative behaviors upon
overstimulation
Obtain the necessary parental consent forms according to the facilitys protocols
See specific Contraindications/precautions under Assessment/Plan of Care
Examination
History
History of present illness/injury
General inquiry/etiology of illness
- What is the reason for evaluation/treatment?
- At what age was the child diagnosed with ADHD?
- Who comprises the childs medical team?
- What evaluations has the child undergone to date?
- What were the initial symptoms/signs of ADHD?
- What formalized testing has the child undergone, if any?
- Any recent hospital admissions?
Course of treatment
- Medical management: May include recommendations for medication, counseling/behavioral therapy, and school-based
interventions
(2)
- Medications for current illness/injury
- Determine what medications clinician has prescribed; are they being taken? Does the family feel the medications are
effectively controlling the patients symptoms?
- Stimulants, including methylphenidate and amphetamines, are typically prescribed
(14)
- Methylphenidate
(10)
- Ritalin is a formulation of methylphenidate
- Most widely used intervention for individuals with ADHD
- ~ 3% of children in U.S. are prescribed methylphenidate for ADHD
- Tremendous controversy exists over the use of methylphenidate in the treatment of ADHD; controversy involves
the ethics of prescribing methylphenidate to a child and ADHDs sometimes indistinct symptoms
- Parents may be reluctant to pursue stimulant medication management, especially for young children, due to
tolerability, side effects such as trouble sleeping and decreased growth rate, and debate regarding cardiovascular
risk
(49)
- If there is an inadequate or undesired response to stimulants, other medications may be tried, including:
(14)
- Atomoxetine
- Classified as a norepinephrine reuptake inhibitor
- Rare but serious adverse effects include suicidal ideation and liver toxicity
- Antidepressants and alpha-adrenergic agents may be prescribed
- Adverse cardiovascular events, including sudden death, have occurred in children taking tricyclic antidepressants
- Diagnostic tests completed
- No biological marker is diagnostic for ADHD
(17)
- Diagnosis of ADHD based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
criteria requires that the child display a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes
with functioning or development.
(17)
The presence of 6 or more symptoms of inattention and/or 6 or more symptoms of
hyperactivity-impulsiveness that have persisted for at least 6 months to a degree inconsistent with developmental level
and that negatively affect social and academic/occupational activities is required
(17)
- Examples of symptoms of inattentioninclude the following:
(17)
- Careless mistakes in school work
- Difficulty sustaining attention in tasks or activities
- Does not seem to listen when spoken to directly
- Does not follow through on instructions
- Difficulty organizing tasks or activities
- Often loses things necessary for tasks or activities
- Easily distracted by extraneous stimuli
- Examples of symptoms of hyperactivity and impulsivity include:
(17)
- Often fidgets with or taps hands or feet or squirms in seat
- Often leaves seat in situations where remaining seated is expected
- Often runs about or climbs in situations where it is inappropriate
- Often talks excessively
- Often has difficulty waiting his or her turn
- Home remedies/alternative therapies: Document any use of home remedies or alternative therapies (e.g., acupuncture)
and whether or not they help
- Previous therapy: Document whether patient has had occupational, physical, or speech therapy for this or other
conditions and what specific treatments were helpful or not helpful
Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased)
Nature of symptoms: Document nature of symptoms
Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.,
night); also document changes in symptoms due other external variables
Sleep disturbance: Document number of wakings/night, if any. Research indicates that children with ADHD are at
increased risk for sleep disturbance (e.g., insomnia, daytime sleepiness, restless leg syndrome, periodic limb movement
disorder, sleep-disordered breathing)
(18,19)
Other symptoms: Document other symptoms patient may be experiencing that could be indicative of a need to refer to
physician (e.g., dizziness, bowel/bladder dysfunction)
Psychosocial status
Obtain results of neuropsychological testing performed by other disciplines where available
Document education and employment history, family interactions and resources, legal issues, and cultural issues where
relevant
- Adolescents with ADHD and their parents are reported to engage in further elevated conflict, exhibiting more intense
arguments, less effective communication skills, and fewer positive statements during discussions than age-matched
adolescents without ADHD and their parents
(50)
A study in Israel involving 308 children attending a high school geared for children requiring special education services
(due to a diagnosis of ADHD with learning disabilities) reported on the childrens self-perception. The authors attempted
to create a profile for children with ADHD and learning disabilities
(5)
- Children were aged 1218 years
- Findings
- 25% were taking Ritalin
- 94% had a coexisting learning disability
- 34% stated they were severely stressed while sitting in class
- Over 50% had outbursts when faced with even a nominal stressor
- Watched an average of 3.2 1.0 hrs of TV/day
- ~ 58% participated in sports
- ~ 50% had pets at home
- ~ 22% drank alcohol
- ~ 27% smoked
- ~ 21% have been offered or taken drugs
- Childrens complaints included:
- Fatigue; need for more sleep
- Regular arguing with friends
- Feeling different from others their age
- Low self-esteem
- Lack of parent understanding
Barriers to learning
- Are there any barriers to learning? Yes__ No__
- A child typically does not meet the criteria for diagnosis of ADHD if there are no barriers to learning(see diagnostic
criteria above)
Medical history
Past medical history
- Comorbid diagnoses:Comorbidity is common in childhood ADHD.
(1)
Only 30% of children with ADHD have the
disorder alone. Up to 60% of children with ADHD have learning disorders. Thirty percent to 40% have oppositional
defiant disorder or conduct disorder,and 30% have an anxiety disorder.
(1)
Ask patient/caregivers about other problems,
including sensory processing disorder, diabetes, cancer, heart disease, psychiatric disorders, orthopedic disorders,
asthma, etc. Where relevant, inquire about substance abuse. Guidelines of the American Academy of Pediatricians
(AAP) state that adolescents with newly diagnosed ADHD should be assessed for substance abuse and if substance
abuse is present it should be treated before initiating treatment for ADHD
(47)
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counter drugs)
- Other symptoms: Ask patient about other symptoms he/she may be experiencing
Social/occupational history
Patients goals: Document what the patient hopes to accomplish with therapy and in general
General inquiry
- At what age were developmental milestones reached?
- How is the child able to negotiate the school/home environment?
- Does the child have any siblings?
- What ADLs can the child perform?
- Is the child involved in any sports?
- Does the family feel they have necessary support in place?
- Is the child involved in any leisure activities?
- How much daily screen time does the child partake in?
Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting.) Listed below is a sample of available general
assessment tools as well as assessment considerations specific to ADHD
Arousal, attention, cognition (including memory, problem solving): Document patients level of cooperation. Note any
signs of restlessness or inattention during assessment
Balance: Assess static and dynamic balance using the Peabody Developmental Motor Scales (PDMS-2) or
Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2) balance sections. If time is limited, single-leg
stance and double-leg stance with eyes open and closed can be assessed
Cardiorespiratory function and endurance: Monitor vital signs as appropriate. Stimulant medication may increase a
childs heart rate
(20)
and blood pressure.
(48)
Endurance may be assessed using the 6-minute walk for distance test (6MWT)
Gait assessment: Assess for abnormalities
Neuromotor development
(21)
Bayley Scales of Infant Motor Development-II
- Comprehensive assessment tool
- Evaluates pediatric development
- May be used up to 42 months of age
- Comprised of three subscales: Mental, Motor, and Behavior
BOT-2
- May be used from 4.5 to 14.5 years of age
- Evaluates various components of functional development
Early Intervention Developmental Profile (EIDP)
- May be used from birth to age 3 years
- Evaluates development and identifies areas of delay
PDMS-2
- May be used from 1 to 83 months of age
- Comprised of thorough gross and fine motor scales
Pediatric Evaluation of Disability Inventory (PEDI)
- May be used from ages 6 months to 7.5 years
- Comprised of functional skill, mobility, and social function scales
Movement Assessment Battery for ChildrenSecond Edition (MABC-2)
- Designed to identify and describe impairments in motor performance of children and adolescents 3 through 16 years of
age
Motor function (motor control/tone/learning)
Assess for abnormal trunk and bilateral upper and lower extremity muscle tone and motor coordinationusing Bilateral
Coordination subscale of BOT-2
A comparative study in Sweden that evaluated the ability of children with ADHD to program and execute upper extremity
movements reported impaired movement control during the computerized tasks
(22)
- The study involved 25 children with ADHD and 25 age-matched, typically developing peers (control subjects)
- The subjects were asked to move a cursor on a computer screen by manipulating a handheld device; trials were
completed with and without visual feedback
- Reported results for the children with ADHD (in contrast to control group) included:
- Decreased movement control; reduced control became even more evident during the trials without visual feedback
- Reduced motor programming evidenced by significant end-point errors and protracted movement durations when
visual feedback was not provided
- Reduced ability to select appropriate movement speeds that match demands of task; overall uncoordinated (jerky)
movements
Impaired timing perception and poor motor coordination have been reported in children with ADHD
- Based on a study conducted in Taiwan comparing 10 children with ADHD and 10 children without ADHD rope jumping
at different rates
(51)
- The group with ADHD showed greater variation in time between tasks. The children without ADHD were able to
modify their pace and respond to the target speed, while the ADHD group could not
- Impaired timing perception and poor hand-foot coordination lead to less accurate performance and poor control of
simultaneous movements of the upper and lower limbs while rope jumping
Strength: Assess bilateral upper and lower extremity and core strength with manual muscle testing(MMT) or through
functional activities such as sit-ups, push-ups, or strength section of the BOT-2
Self-care/activities of daily living (objective testing)
In a school setting, an observation of the child in his or her classroom should be completed by the evaluating OT, focusing
on:
(23)
- Factors that may be taxing the childs sensory system
- Coping ability when faced with classroom stressors
- If current setting is appropriate and meeting the childs needs
The clinician should evaluate ADLs in the home setting as indicated
Use Sensory Profile Questionnaire or PEDI to assess ADLs
Sensory testing: Assess light touch, proprioception, and vibration
Special tests specific to diagnosis
Assessment of Motor and Process Skills (AMPS)
(24,25)
- Standardized observational evaluation tool (requires trained therapist to administer) created to assess occupational
abilities
- Appropriate for children aged 2 years and older
- Tasks or ADLs are partitioned into 13 key groups and individuals must choose and complete 2 or 3 during observation
- There are 16 motor and 20 process skill items with a 4-point rating scale within each task
- Clinician assesses the individuals
- effort
- efficiency
- safety
- independence
- Requires ~ 3040 minutes to complete assessment
Developmental Test of Visual-Motor Integration (VMI)
- The VMI identifies problems in integrating or coordinating visual perceptual and motor abilities (finger and hand
movement)
- Geometric figures (not numbers or letters) are copied, making the test culture-independent
- Norms exist for ages 2 through 100 years
Assessment/Plan of Care
Contraindications/precautions
Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patients physician. The summary
presented below is meant to serve as a guide, not to replace orders from a physician or a clinics specific protocols
Diagnosis/need for treatment
~ 50% of children with ADHD will have some motor impairment; this is especially true in the area of fine motor skills
(22)
OTs play a vital role in the evaluation and treatment of individuals with ADHD, with particular emphasis on ability to
complete ADLs, fine motor skills, and any sensory components of the disorder
Rule out/potential coexisting conditions: (the complete list is extensive; the following is a sample of the conditions the
physician should consider)
Oppositional defiant disorder
(15)
Conduct disorder
(15)
Depression
(15)
Mania
(15)
Anxiety disorder
(15)
Learning disabilities
(15)
Tic disorders
(1)
Substance abuse
(15)
Autism spectrum disorder
(2)
Developmental coordination disorder
Stress in the home
(2)
Inadequate sleep
(2)
Sensory impairment
(2)
Seizure disorder
(2)
Inappropriate school placement
(2)
Unrealistic expectations
(2)
Prognosis: For most children, ADHD will persist into adulthood
(15)
Referral to other disciplines
Team may include physician, counselor/therapist, occupational therapist (OT), teacher, physical therapist (PT),
speech-language pathologist (SLP), social worker, parent/caregiver, neuropsychologist, clinical psychologist, special
education teacher/resource specialist
Referral for physical therapy may be appropriate to address any gross motor impairments, difficulties with bilateral
coordination, muscle weakness, or reduced cardiorespiratory endurance
The authors of a survey of children with ADHD and their parents reported the greater part of those surveyed described
improvement in some facet of life after the initiation of some form of treatment
(26)
268 parents and 265 teenagers were surveyed
Treatment participants had undergone counseling, behavior therapy, medication, and school services
Reported benefits
- 56% earned better grades
- Improvement in capacity to feel happy/good
- Improvement in friendships
Other considerations
There is insufficient evidence to support the implementation of the following treatments
Elimination of certain substances (e.g., food dyes and preservatives)
(15,27)
Herbs, homeopathy, and vitamins
(28)
Mindfulness training
(29)
There is insufficient evidence to evaluate the effectiveness of meditation therapies in the treatment of ADHD
(30)
Based on a Cochrane systematic review
Review included 4 randomized trials evaluating meditation in 83 children and adults with ADHD
Of the 4 trials, data were sufficient for analysis in only 1 trial
HeartMath self-regulation skills and coherence training may improve some aspects of cognitive functioning in children
with ADHD
(31)
Based on a randomized crossover trial conducted in the United Kingdom involving 38 children with ADHD in grades 68
Children were randomized to the HeartMath self-regulation skills and coherence training intervention or active placebo
for 6 weeks, followed by the other intervention (14 children received only the intervention under investigation)
The HeartMath self-regulation skills and coherence training program included skills learning supported with heart
rhythm coherence monitoring and feedback technology designed to facilitate self-induced shifts in cardiac coherence
(31)
The HeartMath self-regulation skills and coherence training program was associated with significantly greater
improvement in word recognition sensitivity and a trend toward improvement in quality of verbal episodic memory
Neurofeedback may improve symptoms (i.e., inattention and impulsivity) associated with ADHD
(32,33)
Clinical guidelines of the AAP and the American Academy of Child and Adolescent Psychiatry advise that initial treatment
for preschoolers with ADHD be behavioral modification, followed by pharmacotherapy with the first-line medication
methylphenidate when behavioral modification is unsuccessful
(52)
Data from a survey of 560 board-certified pediatric subspecialists, including developmental-behavioral pediatricians,
child psychiatrists, and child neurologists, showedthat more than 90% of pediatric subspecialists who diagnose and
manage ADHD in young children do not comply with the current clinical guidelines
(52)
- Many prescribed medication as initial treatment
(52)
- Among those who prescribed medication, more than one third prescribed something other than methylphenidate as first
line
(52)
- It is unclear why so many clinicians who specialize in the management of ADHD do not follow treatment guidelines
Treatment summary
Physical therapy
Intensive physical therapy intervention may improve motor performance in children with both ADHD and developmental
coordination disorder
(4)
- Based on a randomized controlled trial in Israel involving 28 children with both disorders
- Treatment group
- Physical therapy for 4 wks, 2x/wk for 1 hour
- Interventions included perceptual motor training, kinesthesia training, sensory integration training, and
neurodevelopmental training
- Prescribed a daily home exercise program that included stretching, strengthening, and balance activities
- Control group no intervention
- Outcome measure was the Movement Assessment Battery for Children
- Statistically significant improvements were seen in the treatment group when compared to the control group
Physical activity is associated with higher executive functioning in children with ADHD
(34)
Based on a research study involving 18 boys with ADHD
A single bout of moderately intense aerobic exercise may lead to improved neurocognitive function and inhibitory control
in children with ADHD
(53)
Based on a study conducted in the United States
- Participants were 20 children aged 8 to 10 years who had diagnosed or suspected ADHD and no comorbid diagnoses
and 20 healthy age-matched controls
- Outcome measures taken at baseline and after intervention included an inhibitory control task (Eriksoen flanker task),
neuroelectric assessment to obtainevent-related brain potentials, and an academic performance assessment
- On 2 separate days, participants spent 20 minutes either sitting and reading or working out on a treadmill and then were
reassessed
- Children in both the ADHD group and the control group performed better on tests of reading comprehension
and arithmetic after exercising than after sitting and reading. Both groups showed better response accuracy and
stimulus-related processing after exercise
- After the single 20-minute session of exercise, children in the ADHD group showed selective enhancements in
regulatory processes compared to after sitting
Sustained involvement in structured physical activity may provide benefits in motor, cognitive, social, and behavioral
functioning in children with ADHD symptoms
(49)
Based on a pilot study of a before-school physical activity program conducted in the United States
- 17 children, mean age 6.7 years of age at entry, participated
- Children completed about 26 minutes of continuous moderate-to-vigorous physical activity daily over 8 school weeks
- Cognitive, motor, social, and behavioral measures were administered pre and post program. Response inhibition was
assessed weekly
- Most participants showed overall improvement based on parent, teacher, and program staff ratings
- This was a pilot study with no control condition and no comparison groups of typically developing peers; however,
observable changes were detected, changes were in a positive (adaptive) direction, and participant adherence was high.
This suggests that further research is warranted
Sports-based group therapy
(35)
Sports-based group therapy may improve symptoms associated with ADHD
- Based on a study conductedin Israel involving 32 boys aged 813.5 years who participated in a program that consisted
of:
- Approximately 30 minutes each of psychologist-led group therapy, individual sports (e.g., running), and team sports
- Approximately 10 minutes of discussion about the session
Functional training
Social skills training in children with ADHD may improve ADLs
(24)
- Based on a randomized controlled trial conducted in Israel
- 27 children with ADHD and 24 children without ADHD were included in the 2-part study
- Children were assessed via the AMPS and abilities were compared
- 9/27 children with ADHD were randomly selected to participate in the social skills training intervention
- 10/24 children without ADHD were randomly selected and evaluated in a time frame similar to their peers with ADHD
- Social skills group
- Centered on communication, occupation, and interaction skills
- Training included relaxation exercises, specific activity, then group clean-up
- Children were evaluated, completed ten 1-hour sessions, and were then reevaluated
- Prior to intervention the children without ADHD had significantly higher AMPS process scores and coordination motor
subtest scores than the children with ADHD
- However, post treatment the children with ADHD no longer differed significantly in AMPS test results
Behavioral and social skills program may improve behavioral management at home
(36)
- Based on a randomized controlled trialconducted in the United States
- 100 children aged 512 years recently diagnosed with ADHD and treated with stimulants were randomized to
intervention group or control group
- Intervention consisted of eight 50-minute group sessions over 8 weeks
- Results
- Significantly decreased symptoms of ADHD (parent rated) in home setting
- Parents of the children in the intervention group used behavior modification strategies more consistently
- No differences observed in the school setting
Play-based therapy may improve social skills in children with ADHD
(37)
- Based on an Australian randomized controlled trial involving 14 children with ADHD and 14 typically developing
age-matched children
- The children participated in 7 weekly play sessions that were recorded
- The treating therapist provided feedback and modeling
Computer-based neuropsychological training has been reported to improve symptoms of inattention and other training
parameters; however, there was no generalization of training effects as measured by parent and teacher ratings
(54)
- Based on a within subject control designed study conducted in Germany
- 30 children aged 613 years with a diagnosis of ADHD and no comorbidities participated
- A computer-based program consisting of 8 different modules for practicing specific neuropsychological functions was
used
Environmental modifications
Color stimulation may improve graphomotor control in children with a diagnosis of ADHD
(23)
- Based on a nonrandomized controlled trialconducted in Germany
- 66 subjects with a diagnosis of ADHD and 254 control subjects participated in the study
- Of the children with ADHD, 28 had coexisting speech disorders and 19 had coexisting learning disabilities
- Children were asked to complete a copying task on white and colored paper
- Significant improvements were noted in letter alignment, formation, and neatness when written on colored paper
- Theory underlying use of intervention children with ADHD often operate under reduced cortical activation, therefore
increased stimulation is needed to obtain the ideal arousal state
Prescription, application of devices and equipment
Interactive Metronome program
- The first established musical metronome was created for artists, to bolster their precision and timing
(38)
- A computerized program designed to progress timing responses and sense of rhythm when it comes to preparing for and
executing an assortment of tasks
(38,39)
- Child hears the musical beat from the computer
- Child is instructed to tap hand or foot or combination on top of a computer trigger to the metronome beat
- Sounds from the computer provide feedback on performance if clinician desires
- Computer can analyze timing error
- Theory underlying use of intervention Motor planning processes of organizing and sequencing are based on an
internal sense of rhythmicity
(39)
Interactive Metronome training may improve attention, language processing, reading, motor control, and ability to
regulate aggression in children with a diagnosis of ADHD
(40)
- Based on a randomized controlled trial involving 56 male participantsin the United States
- All subjects had a diagnosis of ADHD
- The study was comprised of 3 groups
- The Interactive Metronome training group
- 15 hrs in total; 1-hour sessions, over 35 weeks
- Included 48 exercises prescribed by the guide during each session
- Exercises completed at pace of 54 repetitions/min
- 200 repetitions for every exercise occurred during first session to 2,000 repetitions for every exercise during the ninth
session
- A video game (placebo) group
- 15 hrs in total; 1-hour sessions, over 35 weeks
- A control group no treatment
- The Interactive Metronome training group demonstrated significant improvement in 53/58 test scores compared to 40/58
for the video game group
- The parents of the children in the Interactive Metronome training group ranked their kids as significantly less aggressive
post treatment (this finding only occurred in this treatment group)
A small crossover trial in the United States investigated the impact of donning a weighted vest during classroom activities
in children with ADHD and reported significant behavioral changes
(41)
- 4 participants (serving as their own controls)
- The weighted vests were designed to weigh 5% of the childs weight
- All participants wore the vest for six 15-minute observation periods and six 15-minute periods without the vest
- The participants behavior with/without the vest was observed during a fine motor activity
- Each participant had an increase in on-task behavior of 1825%
- Theory behind use of weighted vest method of providing deep pressure to the child with the goal of reducing an
overactive arousal state and improving the childs attention to desired task
The authors of a case series in the United States evaluated the efficacy of replacing standard classroom chairs with
therapy balls in children with ADHD and reported improved legible word productivity and in-seat behavior
(42)
- 3 subjects with ADHD were evaluated; the entire classroom trialed the balls
- Other reported improvements were overall child and teacher satisfaction with the therapy balls evidenced by feelings of
work facilitation and improved attention
Use of Disc O Sit cushion is associated with improved classroom attention in second graders with attention
difficulties
(43)
- Based on a randomized trial in the United States
- Disc O Sit is an inflatable dynamic air cushion
- 63 second grade students with attention difficulties were randomized to Disc O Sit cushion use throughout school day
for 2 weeks vs. control (standard classroom chairs without a cushion)
- Disc O Sit group had significant improvement in attention to task compared to control group
Manual therapy
Massage therapy may improve mood and behavior in children with ADHD
(7)
- Based on a randomized controlled trial conducted in the United States involving 30 children
- Subjects were randomly assigned to massage treatment group or a wait list control group
- Treatment consisted of:
- 20 minutes of massage therapy, 2x/wk, for 9 sessions over 1 month
- Moderate pressure stroking, gentle rocking, stretching of Achilles tendon and lumbar area
- Significant positive changes were noted for the treatment group in immediate mood state and longer term classroom
behavior
Electrotherapeutic modalities
Electroacupuncture combined with behavior therapy may improve symptoms associated with ADHD
(44)
- Based on a Chinese randomized controlled trial involving 180 preschool-aged children who were assigned to a
experimental group (electroacupuncture and behavior therapy) or a control group (sham electroacupuncture and
behavior therapy)
- The experimental group had a greater improvement in symptoms than the control group
Transcutaneous electrical nerve stimulation (TENS) may improve cognition, rest-activity rhythm, and behavior in
children with ADHD
(6)
- Theory behind intervention
- TENS is a method of central nervous system stimulation without the use of medication
- In patients with Alzheimers disease, significant impact of TENS has been documented in the above-mentioned areas
- Current study
- Pilot study with no control groupconducted in Iceland
- Study involved 22 children
- TENS was administered by a parent 2x daily, 30 minutes each time, for 6 weeks
- Authors called for more research, with a control group, in an effort to support findings
.
Problem Goal Intervention Expected Progression Home Program
Decreased parental
and teacher knowledge
regarding ADHD
Improved parental and
teacher knowledge
regarding ADHD
Parent Education
_
Behavioral
management programs
may improve parental
and teacher knowledge
regarding ADHD
(45)
_
_
Parent training
programs may improve
behavior in children
with ADHD
(46)
Progress as indicated
and appropriate
Provide parents with
written information
Impaired coordination,
strength, and motor
control
Improve coordination,
strength, and motor
control
Therapeutic strategies
_
Implement
occupational/physical
therapy interventions
based on the needs
of the child and
goals of the family.
Ongoing and open
communication with
the family is crucial
as progression and
treatment strategies are
modified. Please see
Treatment summary,
above, for best
available research on
certain therapeutic
interventions
Progress each child
as indicated and
appropriate
Implement a home
program based on
specific needs of child
Impulsivity Reduce impulsivity Therapeutic strategies
_
Implement
occupational/physical
therapy interventions
based on the needs
of the child and
goals of the family.
Ongoing and open
communication with
the family is crucial
as progression and
treatment strategies are
modified. Please see
Treatment summary,
above, for best
available research on
certain therapeutic
interventions
Progress each child
as indicated and
appropriate
Implement a home
program based on
specific needs of child
Delayed achievement
of developmental
milestones
Improve achievement
of developmental
milestones
Therapeutic strategies
_
Implement
occupational/physical
therapy interventions
based on the needs
of the child and
goals of the family.
Ongoing and open
communication with
the family is crucial
as progression and
treatment strategies are
modified. Please see
Treatment summary,
above, for best
available research on
certain therapeutic
interventions
Progress each child
as indicated and
appropriate
Implement a home
program based on
specific needs of child
Sensory processing
disorder
Improve sensory self-
regulation
Therapeutic strategies
_
Implement
occupational/physical
therapy interventions
based on the needs
of the child and
goals of the family.
Ongoing and open
communication with
the family is crucial
as progression and
treatment strategies are
modified. Please see
Treatment summary,
above, for best
available research on
certain therapeutic
interventions
Progress each child
as indicated and
appropriate
Implement a home
program based on
specific needs of child
Reduced attention to
task
Improve attention to
task
Therapeutic strategies
_
Implement
occupational/physical
therapy interventions
based on the needs
of the child and
goals of the family.
Ongoing and open
communication with
the family is crucial
as progression and
treatment strategies are
modified. Please see
Treatment summary,
above, for best
available research on
certain therapeutic
interventions
Progress each child
as indicated and
appropriate
Implement a home
program based on
specific needs of child
.
Desired Outcomes/Outcome Measures
Desired outcomes
Improved coordination
Improved attention to task
Reduced impulsivity
Improved sensory self-regulation
Improved behavioral strategies
Improved ability to complete ADLs
Outcome measures
Assessment of Motor and Process Skills (AMPS)
Bayley Scales of Infant Motor Development-II
EIDP
PDMS-2
PEDI
BOT-2
Parent and teacher ratings
Maintenance or Prevention
A home program that incorporates successful therapeutic strategies into a childs daily routine is recommended
Patient Education
U.S. National Institute of Mental Health,
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder/complete-index.shtml
U.S. Centers for Disease Control and Prevention, http://www.cdc.gov/ncbddd/adhd/
National Institutes of Health publication Attention Deficit/Hyperactivity Disorder
http://www.nimh.nih.gov/health/publications/attention-deficit-hyperactivity-disorder-easy-to-read/complete.pdf
Mayo Clinic Website. Attention-deficit/hyperactivity disorder (ADHD) in children.
http://www.mayoclinic.org/diseases-conditions/adhd/basics/definition/con-20023647?DSECTION=all
Coding Matrix
References are rated using the following codes, listed in order of strength:
M Published meta-analysis
SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RV Published review of the literature
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
PP Policies, procedures, protocols
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation
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