ATTENTION DEFICIT HYPERACTIVITY DISORDER

Compiled by Keri-Lee Roebert BSc (Occupational Therapy) (Wits) Post-graduate Diploma in Group Activities
(Pretoria)

1. INTRODUCTION

The occupational therapist has a vital role to play in the field of Psychiatry. She assists the
client to engage in more satisfying relationships and to display appropriate emotional
responses, treats specific problems, and aids in diagnosis. 1

She assesses and treats clients with visual perceptual and co-ordination difficulties. These
problems may occur in children with a variety of medical and psychiatric diagnoses. One
diagnosis in which these are frequently encountered is Attention Deficit Hyperactivity
Disorder (hereafter referred to as ADHD). 2

Referrals may come from a variety of settings and can include, but are not limited to:

• Hospitals,
• Schools and
• Private practice

2. THE DIAGNOSIS OF ADHD

According to the DSM-IV 3, ADHD can be predominantly inattentive type, or impulsive type,
or combined type. Symptoms need to cause impairment in two or more settings, e.g.
school/work and at home. There needs to be clinically significant impairment in social,
academic or occupational functioning.

There are a number of disorders associated with ADHD: 4, 5

• Specific Learning Disabilities

o Visual perceptual problems
o Auditory perceptual problems

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 o Delays in fine motor development

• Other disruptive behaviour disorders

o Oppositional Defiant Disorder
o Conduct Disorder

• Emotional difficulties
o Anxiety Disorder
o Depressive illness

• Tourette's Disorder/Syndrome

• Obsessive Compulsive Disorder

3. THE IMPACT OF ADHD ON OCCUPATION

Occupation refers to what a person "does". It refers to a person's work (or school for the
school-going child and adolescent), activities of daily living (ACTIVITIES OF DAILY LIVING),
and social and leisure activities.

Children with ADHD may experience significant functional problems, such as difficulties at
school with academic underachievement, problematic interpersonal relationships with family
members and peers, and a low self esteem. These symptoms may persist into adolescence
and adulthood. 5 As a result, the person's occupation could be negatively impacted upon at
all stages of their life, resulting in them not functioning optimally in any of the above
mentioned areas, i.e. work/school, activities of daily living, social activities and leisure
activities.

3.1 Work/School

A number of areas of academic difficulty have been identified for ADHD students: 6, 7

• Work rate

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They do little or no independent work and must be reminded continuously to return to the
task at hand. They often procrastinate on academic tasks. Work is done extremely
rapidly, with little attention to instructions and careless errors. The work rate can also be
so slow that written work is rarely completed within the given time constraints.

• Reading
They often reverse letters, inverse the letter order in words, confuse or transpose relatively
common words, produce dysgraphic misspellings, and make frequent visual substitutions
in oral reading. They can be so inattentive and distracted while reading that their
comprehension of the material is significantly impaired, or they process the reading
material so slowly that they forget the initial part of a paragraph or even a single sentence
before coming to its end.

• Writing
They write rapidly and pay little attention to the quality and legibility of their work. The
rules of punctuation and capitalisation are often ignored. Some learners exhibit an
extremely slow handwriting rate and their work appears methodical and laborious.

• Spelling
They lack the attention and focus to memorise spelling rules and patterns.

• Mathematics
They exhibit difficulty in computational accuracy and organization. Mathematical problems
are frequently miscopied, sloppily written, and they make numerous errors due to lack of
attention.

• Oral instructions
Their inattention and distractibility play a significant role in their ability to follow oral
instructions.

• Thought processing
Amongst others, they have difficulty understanding, organising and prioritising their
thoughts.

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• Attention focusing
They have difficulty sustaining attention, refocusing attention and blocking out distractions.

• Visual and auditory memory

Their inattentiveness affects their visual and auditory memory. They have difficulty
processing short-term memory to long-term memory.

• Prioritising
They battle to select the main idea in reading, listening or writing.

• Bridging
Remembering two or more instructions and linking one fact to another is problematic for
them.

• Decoding
They do not comprehend what is read, understand abstract concepts, or connect cause-
and-effect.

• Encoding
They have difficulty finding the correct word with which to express their ideas.

• Neatness
Their work is untidy and often full of smudges.

• Recalling
They forget to bring materials and completed work to school and have difficulty recalling
isolated facts such as names and dates.

• Organizing
They have difficulty ordering things into a logical sequence, selecting important information
and leaving out unnecessary aspects.

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 • Perceiving spatial relationships
They have poor left-right discrimination, form constancy figure-ground perception and
struggle with basic concepts, such as size, colour and shape.

• Eye-hand co-ordination
They struggle with visual tracking, do not keep their place while reading and have poor
handwriting.

• Content areas
They have difficulty with note taking and organisation, they fail to follow through on oral
instructions and do not complete homework. They have difficulty structuring and
organising their study time.

Children with perceptual-motor problems (such as perceiving spatial relationships and eye-
hand co-ordination, mentioned above) may also have some additional emotional problems.
These emotional difficulties may be precipitated by the stress they experience in dealing with
their perceptual-motor problems. In many other instances, a primary emotional stress
exacerbates an underlying perceptual-motor problem. The occupational therapist working
with children referred for visual perception or co-ordination problems needs to pay attention
to these emotional needs in therapy as treatment needs to be holistic. 2

Adolescents may be inattentive, withdrawn, impatient, intellectually dependent, have

negative feelings towards school, and poor relationships with peers and teachers. They may
also have secondary emotional problems which in turn, cause a drop in school performance.
A negative cycle develops, with poor academic performance causing low self-esteem which
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contributes to further emotional problems and so on. As with children, the occupational
therapist also needs to pay attention to the emotional problems as the adolescent is viewed,
and therefore treated, holistically.

Adults with ADHD experience difficulty in the sphere of work as they are unable to maintain a
job. They often change jobs frequently due to impulsivity. They are unable to form stable,
appropriate interpersonal relationships with work colleagues and superiors. They often have

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unconsolidated pre-vocational skills. This will impact on their personal presentation, social
presentation and work competency skills in the work place.

12.2 Activities of Daily Living

The person with ADHD usually has the age appropriate skills to perform activities of daily
living activities. The quality of these activities, however, is usually poor. They show little
attention to detail and their impulsivity results in them completing tasks hastily and untidily.

12.3 Leisure Activities

A person with ADHD has difficulty organising and planning. As a result, they may not be
actively engaged in constructive leisure activities as they experience difficulty in planning
their time and organising appropriate activities.

They may also be involved in inappropriate leisure activities, such as those requiring high
risk, due to their risk-taking behaviour.

If they are involved in leisure activities, e.g. team sports, their behaviour is often
inappropriate and impulsive on the sports field resulting in them receiving disciplinary action,
e.g. a yellow card.

12.4 Social Activities

A person is required to function on a social level in all areas of their life. People with ADHD
have difficulty forming and maintaining appropriate relationships, whether they are with
subordinates, colleagues or authority figures at work, their friends on an informal level or
intimate relationships.

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4. THE IMPACT OF ADHD ON ROLES, HABITS AND ROUTINES

A person with ADHD may not form appropriate interpersonal relationships. This impacts on
their ability to fulfil their roles; such as father/mother, son/daughter, worker/scholar/student,
friend, appropriately. Due to their impulsivity and poor planning, they may also experience
difficulty in balancing their roles appropriately; for example, they may spend an inappropriate
amount of time being a volunteer when they need to be involved in full-time paid
employment.

The risk-taking behaviour of people with ADHD, especially adolescents and adults, could
result in them engaging in risk-taking habits, such as drug use. They are also more inclined
to drive under the influence of alcohol.

They have difficulty planning and adhering to a routine due to poor planning and
organisational skills. They need firmly established boundaries so they know what is
expected of them. They cope better with changes in routine when prepared in advance for
this.

5. LEVELS OF HEALTHCARE AND PILLARS OF HEALTH IN RELATION TO ADHD

5.1 The Levels of Healthcare

The treatment of ADHD is largely at a primary level as clients are usually seen on an "out
patient" basis. A client is rarely seen in a hospital (secondary level) or academic hospital
(tertiary level) for the treatment of ADHD. If this is the case it is normally for the treatment of
a co-morbid condition, such as a behavioural or emotional disorder.

5.2 The Pillars of Health

Treatment at a preventive level involves educating educators and parents in the identification
of the symptoms of ADHD so that the child can be referred to the appropriate healthcare
professional.

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Promotive care, in the case of ADHD, takes more of a consultative role, where the
occupational therapist can assist the educator in structuring the classroom, for example, so
that optimal learning can take place for the ADHD student. The occupational therapist can
also be involved in the work place where the employer is consulted with in terms of making
reasonable accommodations for the person with ADHD at work.

Treatment of ADHD takes place largely on a curative level where the occupational therapist
treats both the internal performance components, e.g. impulsivity, and the occupational
performance area, e.g. school/work, which have been impacted upon.

At a rehabilitative level, clients are given the necessary coping skills to function as optimally
as possible, within the limitations of their ADHD, and to maintain their quality of life.

6. ASSESSMENT OF ADHD

Assessment and evaluation is an ongoing process. It needs to precede treatment, be

repeated at least once during intervention, and conclude the therapy process. 1

6.1 Referral

A referral for an occupational therapy assessment may be made by a psychologist, doctor,

physiotherapist, speech therapist or teacher. It is recommended that if long-term therapy is
required the referral comes from a doctor. 2

6.2 Interview

An interview is conducted with the parent/guardian/caregiver in the case of a child or the

client himself if an adolescent or adult. During the interview detailed background information
is gathered. Information gained during the interview often clarifies or expands on the
assessment findings1, 2, 8
. If a background questionnaire has been completed by the
parent/guardian/caregiver/client prior to the interview, the interview can be expected to take
half an hour. 2 If not, a longer time will be needed.

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6.3 Evaluation

The occupational therapy assessment evaluates the client holistically.

During evaluation the occupational therapist observes the child's: 1

• Behaviour
• Conduct
• Motor behaviour
• Attention span
• Play
• Language
• Activities
• Habitual manipulations
• Sexual behaviour
• Mood
• Relationships towards peers and staff

The adolescent's environment and community (family, culture and peer group), basic abilities
(cognition, affect and conation), task performance (school, leisure time, ACTIVITIES OF
DAILY LIVING and interpersonal relationships) and aspects specific to adolescents
(developmental tasks and values) should all be assessed. 8

The occupational therapist makes use of standardised and non-standardised assessment

tasks.

The choice of tests used depend upon factors such as the age of the child, presenting
problems, the time available for assessment and the occupational therapist's qualifications
and experience. 2

Non-standardised assessment tasks are, for example, cutting with a pair of scissors, ball
2
throwing and catching, and handwriting samples. With adolescents, for example, activities
are used, where they are required to produce an end product, which assess their internal

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 8
components and functional abilities. Group sessions assist in assessing a client's
dysfunction in terms of interpersonal relationships. 8

Below is a table of some of the standardised tests available to occupational therapists to

assess a client diagnosed with ADHD: 1, 2, 8

Test Age Aspects assessed

The Test of Visual Motor
Integration (3rd revision)
(Beery, K.E.)
Developmental Test
Visual Perception (2nd ed)
(DTVP-2)
(Hammill,et al)
Test of Visual Perceptual
Skills (TVPS non-motor)
(Gardner, M.F.)
Test of Visual Perceptual
Skills (non-motor) Upper
Level (TVPS-UL)
(Gardner, M.F.)
Test of Visual Motor Skills
(TVMS)
(Gardner, M.F.)
Test of Visual Motor Skills
Upper Level (TVMS-UL)
(Gardner, M.F.)
Motor-free Visual
Perceptual Test (MVPT)
(Colarusso and Hammill)
Visual motor integration ability:
4 years 0 months to • Visual perception
17 years 11 months • Transducing
• Motor reproduction
of
Eye-hand co-ordination
4 years to 10 years
Motor reduced visual perception
11 months
Visual motor integration
4 years to 12 years
Visual perception (no motor skills are required)
11 months
12 years to 17 years
Visual perception (no motor skills are required)
11 months
2 years to 12 years
Visual motor integration ability
11 months
12 years to 39 years
Visual motor integration ability
11 months
4 years to 8 years Screening test of visual perception (no motor skills are
11 months required)

Test of Motor Impairment

5 years to 11 years Fine and gross motor co-ordination
(Stott, Moyes Henderson)

Fine and gross motor co-ordination

Pre-School Test
2 years 6 months to Visual perception
(Geselle Institute of
6 years Visual motor integration
Human Development)
Language

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Southern California Visual perception
4 years to 10 years
Sensory Integration Test Somatosensory perception
11 months
(Ayres, A.J.) Fine and gross motor co-ordination

Clinical Observations 4 years to 10 years Gross motor co-ordination

(Ayres, A.J.) 11 months Neurological screening

Modular Arrangement for

Adolescents and Applied to assess school and work functioning in terms of
Predetermined Time
adults physical tasks
Standards

The evaluation varies from 1 ½ to 3 hours, depending on the client's tolerance, attention
span and age1, 2. Sometimes an evaluation needs to be divided into two or three sessions.

6.4 Assessment Report

The assessment report is a compilation of information obtained during the interview and
evaluation. The information contained in the report is used to:
• Plan a therapy programme
• Evaluate progress after a period of treatment
• Inform other professionals involved in the client's treatment

6.5 The Feedback Interview

Finally, feedback is given on the assessment findings. Feedback is usually given to parents
to discuss the findings of the assessment and to make recommendations based on the
findings. 2

7. APPROACHES, PRINCIPLES AND TECHNIQUES USED

The occupational therapist forms part of the multi-disciplinary team. The team decides on
the best therapeutic approach and handling strategies to use for a client and all involved in
the treatment of the client are expected to adhere to the decision. 1, 8

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7.1 Approaches

The occupational therapist uses a variety of approaches during therapy. They may use one
approach or a combination of approaches for a single client to direct therapy.

7.1.1 Client centered approach

Occupational Therapists make use of a client centered approach whereby the client is
involved in the decision making process regarding the direction of their therapy. Their
interests, roles, needs and habits are taken into consideration during therapy.

7.1.2 Analytical approach

Therapy is directed at improving the client's insight and understanding of himself and their
environment. The occupational therapist does not interpret, but assists the client to reflect
on the past and their feelings. 8

7.1.3 Interactive approach

This approach is used largely during occupational group therapy where focus is on the here
and now, and on the interaction between the group members and the insight the client gains
from this. 8

7.1.4 Cognitive-behavioural approach

The client learns to solve problems more effectively, and acquires new skills in interpersonal
relationships, e.g. assertiveness training. 8

7.1.5 Behavioural approach

Therapy aims at changing dysfunctional behaviour, and learning and reinforcing appropriate
behaviour.

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7.2 Principles and Techniques

Based on assessment findings a detailed treatment programme is planned.

Therapy with children is usually through the medium of play, and they are usually treated
individually. 1

Occupational group therapy is the therapy of choice for adolescents and adults, particularly
where their interpersonal relationships are dysfunctional. 8

As clients are treated holistically, the occupational therapist will address concurrent
emotional and behavioural problems, as well as any perceptual and co-ordination problems
so that the treatment programme can be implemented effectively. 2

Once the treatment programme has been drawn up, the occupational therapist needs to
decide on the duration and frequency of the treatment sessions. Each individual session
usually lasts from half an hour to one hour and the client could be seen once or twice a
week. Two ½ hour sessions a week are often more beneficial for the young, preschool child
than one longer session once a week. 2

If the client is treated in a group, the treatment session is usually 1 ½ hours long.

Appropriate activities are selected for therapy taking, amongst others, the following into
account: 2
• The principles of therapy
• The client's level of motivation and action 9

While a child is receiving occupational therapy, the parents need to observe and discuss the
treatment programme with the occupational therapist. These appointments need to be
arranged regularly (monthly or once a quarter). The frequency of these appointments will
depend on the nature and severity of the child's problems. 2

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Most clients requiring occupational therapy require it for an extended period of time, i.e. 12 to
18 months. 2

6. RESEARCH EVIDENCE

Author Study Type of Treatment Outcome Findings

population design group variable
Adolescents in Life skills
grade 10 at a programme with Life skills have
Abrahams,
high school in a 16 grade 10 Reflective a positive effect
Creighton,
low socio- Qualitative learners: 7 boys worksheets and on adolescents
Naidoo, Parker,
economic area research design and 9 girls journals after in terms of
Pillay and
of the Western whose ages life skills groups independent
Wegner (1999)
Cape, South ranged from 14 adjustment
Africa to 16 years
Behaviour
30 primary ratings showed
Primary school
school children significant
Arnold, Clark, children who
Controlled who met the Behaviour improvement at
Sachs, Jakim met the criteria
clinical trial criteria for ratings the end of the
and Smithies for ADHD with
ADHD with last treatment
hyperactivity
hyperactivity and at follow-up
1 year later
The use of
therapy balls for
th
Schilling, Children with A single subject, American 4 In-seat students with
Washington, attention deficit A-B-A-B grade children behaviour and ADHD may
Billingsley and hyperactivity interrupted time (2 boys, 1 girl) legible word facilitate in-seat
Deitz (2003) disorder series design with ADHD productivity behaviour and
legible word
productivity
Shaffer, The Interactive
Boys, 6-12 56 boys, 6-12
Jacokes, Metronome
years old, with years old
Cassily, Controlled Cognitive and training appears
attention deficit previously
Greenspan, clinical trial motor skills to facilitate a
hyperactivity diagnosed with
Tuchman, number of
disorder ADHD
Stemmer capacities;

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 including
attention, motor
control, and
selected
academic skills
in boys with
ADHD
On-task Wearing a
Children with
4 American behaviour weighted vest
Van Den Berg attention deficit Qualitative
students with during fine increased on-
(2001) hyperactivity research design
ADHD motor activities task behaviour
disorder
in the classroom by 18-25%

7. CONCLUSION

Literature shows that occupational therapy intervention has a significant impact on the
performance capacity of people with ADHD in all spheres of life. It is, therefore, clear that
the occupational therapist has a vital roe to play in the assessment, treatment and
management of this disorder.

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8. REFERENCES

1. Crouch, R.B. Occupational Therapy in Child Psychiatry in Crouch, R.B. and Alers,
V.M. Occupational Therapy in Psychiatry and Mental Health, 3rd ed. Maskew Millar
Longman: South Africa. 1997.

2. Kitchin, L.M. Occupational Therapy for Children with Perceptual, Motor and Emotional
Difficulties in Crouch, R.B. and Alers, V.M. Occupational Therapy in Psychiatry and
Mental Health, 3rd ed. Maskew Millar Longman: South Africa. 1997.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders, 4th ed. American Psychiatric Association: Washington. 1994.

4. Attention Deficit Hyperactivity Booklet. Sponsored by Novartis.

5. Committee on Quality Improvement, Subcommittee on AD/HD. Clinical Practice

Guidelines: Diagnosis and Evaluation of the Child with Attention-Deficit/Hyperactivity
Disorder. American Academy of Paediatrics. Vol 105, No 5. May 2000.

6. Taylor, J.F. The ABC's of ADD and Related Conditions for Parents, Teachers,
Counsellors and Other Involved Caregivers. 2002 International Conference on
Attention Deficit Hyperactivity Disorder and Co-Morbid Disorders. Pretoria, 2002.

7. Copeland, E. Academic Problems of ADHD/ADD Students. 2002 International

Conference on Attention Deficit Hyperactivity Disorder and Co-Morbid Disorders.
Pretoria, 2002

8. Post, L. and van Antwerpen, T. Occupational Therapy with Adolescents in Crouch,

R.B. and Alers, V.M. Occupational Therapy in Psychiatry and Mental Health, 3rd ed.
Maskew Millar Longman: South Africa. 1997.

9. Du Toit, V. Patient Volition and Action in Occupational Therapy. Vona and Mariè du
Toit Foundation: South Africa. 1991.

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