Attention Deficit Hyperactivity Disorder (ADHD) in Children

CLINICALREVIEW

AuthorsAmy Lombara, PT, DPT

Ellenore Palmer, BScPT, MScCinahl Information Systems, Glendale, CA

ReviewersDiane Matlick, PT

Cinahl Information Systems, Glendale, CAAndrea Callanen, MPT

Cinahl Information Systems, Glendale, CARehabilitation Operations CouncilGlendale Adventist Medical Center,

Glendale, CA

EditorSharon 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 rightsreserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or byany information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for adviceor information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcareprofessional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Attention Deficit Hyperactivity Disorder (ADHD) inChildren

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 ADHDMost common neurobehavioral disorder in children(47,48)

ADHD is a common neurobiologic disorder characterized by developmentallyinappropriate levels of inattention, hyperactivity, and impulsivity(2)

Viewed as a chronic condition;(3)more than 60% of children diagnosed will havesymptoms 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 thatsignificantly interferes with academic achievement or activities of daily living

- Developmental coordination disorder may coexist in as many as 50% of cases ofADHD

- 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, itis generally considered a variant presentation of the same disorder, not a distinctdisorder

- 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

PrevalenceIn 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 symptomsImpulsivity(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 andanterior 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 controlsCertain 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 uponoverstimulation

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/injuryGeneral 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 cardiovascularrisk(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 ofhyperactivity-impulsiveness that have persisted for at least 6 months to a degree inconsistent with developmental leveland 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 otherconditions 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 symptomsPattern 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 variablesSleep 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 movementdisorder, sleep-disordered breathing)(18,19)

Other symptoms: Document other symptoms patient may be experiencing that could be indicative of a need to refer tophysician (e.g., dizziness, bowel/bladder dysfunction)

Psychosocial statusObtain results of neuropsychological testing performed by other disciplines where availableDocument 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-matchedadolescents 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 attemptedto 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 oppositionaldefiant 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 substanceabuse 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 generalGeneral 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 beappropriate to patient medical condition, functional status, and setting.) Listed below is a sample of available generalassessment 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-legstance 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 achilds 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 BilateralCoordination subscale of BOT-2

A comparative study in Sweden that evaluated the ability of children with ADHD to program and execute upper extremitymovements 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)

movementsImpaired 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 jumpingat different rates(51)

- The group with ADHD showed greater variation in time between tasks. The children without ADHD were able tomodify 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 ofsimultaneous 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 throughfunctional 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 indicatedUse 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 occupationalabilities

- 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 assessmentDevelopmental Test of Visual-Motor Integration (VMI)

- The VMI identifies problems in integrating or coordinating visual perceptual and motor abilities (finger and handmovement)

- 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 summarypresented 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 tocomplete 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 thephysician 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, specialeducation teacher/resource specialist

Referral for physical therapy may be appropriate to address any gross motor impairments, difficulties with bilateralcoordination, 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 describedimprovement in some facet of life after the initiation of some form of treatment(26)

268 parents and 265 teenagers were surveyedTreatment participants had undergone counseling, behavior therapy, medication, and school servicesReported 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 reviewReview included 4 randomized trials evaluating meditation in 83 children and adults with ADHDOf 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 childrenwith ADHD(31)

Based on a randomized crossover trial conducted in the United Kingdom involving 38 children with ADHD in grades 68Children 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 greaterimprovement 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 treatmentfor preschoolers with ADHD be behavioral modification, followed by pharmacotherapy with the first-line medicationmethylphenidate 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 andmanage 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 firstline(52)

- It is unclear why so many clinicians who specialize in the management of ADHD do not follow treatment guidelines Treatment summary

Physical therapyIntensive 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 andstimulus-related processing after exercise

- After the single 20-minute session of exercise, children in the ADHD group showed selective enhancements inregulatory processes compared to after sitting

Sustained involvement in structured physical activity may provide benefits in motor, cognitive, social, and behavioralfunctioning 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 trainingSocial 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 motorsubtest scores than the children with ADHD

- However, post treatment the children with ADHD no longer differed significantly in AMPS test resultsBehavioral 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 developingage-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 trainingparameters; 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 andexecuting 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 aninternal sense of rhythmicity(39)

Interactive Metronome training may improve attention, language processing, reading, motor control, and ability toregulate 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 40/58for the video game group

- The parents of the children in the Interactive Metronome training group ranked their kids as significantly less aggressivepost 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 activitiesin 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 taskThe 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 attentionUse 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 therapyMassage 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 classroombehavior

Electrotherapeutic modalitiesElectroacupuncture 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 aexperimental group (electroacupuncture and behavior therapy) or a control group (sham electroacupuncture andbehavior therapy)

- The experimental group had a greater improvement in symptoms than the control groupTranscutaneous 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 parentaland teacher knowledgeregarding ADHD

Improved parental andteacher knowledgeregarding ADHD

Parent Education_Behavioralmanagement programsmay improve parentaland teacher knowledgeregarding ADHD(45)__Parent trainingprograms may improvebehavior in childrenwith ADHD(46)

Progress as indicatedand appropriate

Provide parents withwritten information

Impaired coordination,strength, and motorcontrol

Improve coordination,strength, and motorcontrol

Therapeutic strategies_Implementoccupational/physicaltherapy interventionsbased on the needsof the child andgoals of the family.Ongoing and opencommunication withthe family is crucialas progression andtreatment strategies aremodified. Please seeTreatment summary,above, for bestavailable research oncertain therapeuticinterventions

Progress each childas indicated andappropriate

Implement a homeprogram based onspecific needs of child

Impulsivity Reduce impulsivity Therapeutic strategies_Implementoccupational/physicaltherapy interventionsbased on the needsof the child andgoals of the family.Ongoing and opencommunication withthe family is crucialas progression andtreatment strategies aremodified. Please seeTreatment summary,above, for bestavailable research oncertain therapeuticinterventions



Delayed achievementof developmentalmilestones

Improve achievementof developmentalmilestones




Sensory processingdisorder

Improve sensory self-regulation




Reduced attention totask

Improve attention totask




.

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 MatrixReferences are rated using the following codes, listed in order of strength:

M Published meta-analysisSR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)R Published research (not randomized controlled trial)C Case histories, case studiesG Published guidelines

RV Published review of the literatureRU Published research utilization reportQI Published quality improvement reportL Legislation

PGR Published government reportPFR Published funded report

PP Policies, procedures, protocolsX Practice exemplars, stories, opinions

GI General or background information/texts/reportsU Unpublished research, reviews, poster presentations or

other such materialsCP Conference proceedings, abstracts, presentation

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Attention Deficit Hyperactivity Disorder (ADHD) in Children