Attention Deficit Hyperactivity Disorder

MEDICAL PART:
Definition:
 Children with ADHD exhibit inattention, hyperactivity, and impulsivity,
which cause impairment in ADLs before 7 years of age.
 Children with ADHD display the early onset of symptoms consisting of
developmentally inappropriate overactivity, inattention, academic
underachievement, and impulsive behavior.

Epidemiology:
 3% and 5% of the school-age population, or approximately 2 million
children
 Three times more often in boys than in girls

Etiology:
Genertic, environmental, and neurologic factors, and neurochemical
imbalances. ADHD is also related to food allergies or food additives
and the amount of sugar in a child’s diet.

Parts of the Brain:

4 Major Regions:
 Frontal - located anterior to the central sulcus and consists of the
primary motor, premotor, and prefrontal regions.
 Parietal - the primary somatosensory cortex is located in the anterior
parietal lobe; in addition, other cortical regions that are related to
complex visual and somatosensory functions are located in the
posterior parietal lobe.
 Temporal - the superior portion of the temporal lobe contains the
primary auditory cortex and other auditory regions; the inferior portion
contains regions devoted to complex visual functions. In addition,
 some regions of the superior temporal sulcus receive a convergence of
input from the visual, somatosensory, and auditory sensory areas.
 Occipital lobe - consists of the primary visual cortex and other visual
association areas.

Pathophysiology:

Signs and Symptoms:

Diagnostic Criteria:
A. A persistent pattern of inattention and/or hyperactivity-impulsivity that
interferes with functioning or development, as characterized by (1) and/or
(2):
1. Inattention: Six (or more) of the following symptoms have persisted for at
least 6 months to a degree that is inconsistent with developmental level and
that negatively impacts directly on social and academic/occupational
activities:Note: The symptoms are not solely a manifestation of oppositional
behavior, defiance, hostility, or failure to understand tasks or instructions. For
older adolescents and adults (age 17 and older), at least five symptoms are
required.
 a. Often fails to give close attention to details or makes careless mistakes
in schoolwork, at work, or during other activities (e.g., overlooks or
misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g.,
has difficulty remaining focused during lectures, conversations, or
lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind
seems else where, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (e.g., starts tasks but
quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty
managing sequential tasks; difficulty keeping materials and belongings
in order; messy, disorganized work; has poor time management; fails
to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require
sustained mental effort (e.g., schoolwork or homework; for older
adolescents and adults, preparing reports, completing forms, reviewing
lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school
materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses,
mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents
and adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands;
for older adolescents and adults, returning calls, paying bills, keeping
appointments).

2. Hyperactivity and impulsivity: Six (or more) of the following symptoms

have persisted for at least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social and
academic/occupational activities: Note: The symptoms are not solely a
manifestation of oppositional behavior, defiance, hostility, or a failure to
understand tasks or instructions. For older adolescents and adults (age 17
and older), at least five symptoms are required.
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected
(e.g., leaves his or her place in the classroom, in the office or other
workplace, or in other situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate.
(Note: In adolescents or adults, may be limited to feeling restless.)
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to
be or uncomfortable being still for extended time, as in restaurants,
 meetings; may be experienced by others as being restless or difficult
to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed
(e.g., completes people’s sentences; cannot wait for turn in
conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations,
games, oractivities; may start using other people’s things without
asking or receiving per mission; for adolescents and adults, may
intrude into or take over what others are doing).
B. Several inattentive or hyperactive-impulsive symptoms were present
prior to age 12 years.
C. Severalinattentiveorhyperactive-
impulsivesymptomsarepresentintwoormoreset tings (e.g., at home,
school, or work; with friends or relatives; in other activities).
D. There is clear evidence that the symptoms interfere with, or reduce
the quality of, social, academic, or occupational functioning.
E. Thesymptomsdonotoccurexclusivelyduringthecourseofschizophreniaor
another psychotic disorder and are not better explained by another
mental disorder (e.g., mood disorder, anxiety disorder, dissociative
disorder, personality disorder, substance intoxication or withdrawal).

Differential Diagnosis:
 Oppositional defiant disorder. Individuals with oppositional defiant
disorder may resist work or school tasks that require self-application
because they resist conforming to others' demands. Their behavior is
characterized by negativity, hostility, and defiance. These symptoms
must be differentiated from aversion to school or mentally demanding
tasks due to difficulty in sustaining mental effort, forgetting
instructions, and impulsivity in individuals with ADHD. Complicating
the differential diagnosis is the fact that some individuals with ADHD
may develop secondary oppositional attitudes toward such tasks and
devalue their importance.
 Specific learning disorder. Children with specific learning disorder may
appear inattentive because of frustration, lack of interest, or limited
ability. However, inattention in individuals with a specific learning
disorder who do not have ADHD is not impairing out side of academic
work.
 Intellectual disability (intellectual developmental disorder). Symptoms
of ADHD are common among children placed in academic settings that
 are inappropriate to their intellectual ability. In such cases, the
symptoms are not evident during non-academic tasks. A diagnosis of
ADHD in intellectual disability requires that inattention or hyperactivity
be excessive for mental age.
 Autism spectrum disorder. Individuals with ADHD and those with
autism spectrum disorder exhibit inattention, social dysfunction, and
difficult-to-manage behavior. The social dysfunction and peer rejection
seen in individuals with ADHD must be distinguished from the social
disengagement, isolation, and indifference to facial and tonal
communication cues seen in individuals with autism spectrum
disorder. Children with autism spectrum disorder may display tantrums
because of an inability to tolerate a change from their expected course
of events. In contrast, children with ADHD may misbehave or have a
tantrum during a major transition because of impulsivity or poor self-
control.

Course and Prognosis:

 Toddlers: first observe excessive motor activity but symptoms are
difficult to distinguish from highly variable normative behaviors before
age 4 years.
 Elementary School Years: ADHD is most often identified and
inattention becomes more prominent and impairing.
 Adolescence: The disorder is relatively stable but some individuals
have a worsened course with development of antisocial behaviors. In
most individuals with ADHD, symptoms of motoric hyperactivity
become less obvious but difficulties with restlessness, inattention, poor
planning, and impulsivity persist.
 Adulthood: A substantial proportion of children with ADHD remain
relatively impaired.

 Preschool: the main manifestation is hyperactivity.

 Elementary School: Inattention becomes more prominent.
 Adolescence: signs of hyperactivity (e.g., running and climbing) are
less common and may be confined to fidgetiness or an inner feeling of
jitteriness, restlessness, or impatience.
 Adulthood, along with inattention and restlessness, impulsivity may
remain problematic even when hyperactivity has diminished.
Laboratory Tests:
Both structural and functional neuroimaging studies have contributed to
elucidating the etiology of ADHD.
 Magnetic resonance imaging (MRI)
 Positron emission tomography (PET)

Medical Surgical Treatment:

 Aderall
 Methylphenidate
 Dextroamphetamine
 Amphetamine salt combinations

OT PART:
Frames of Reference:
 Behavioral FOR - learning
 Developmental FOR - milestones
 Aquisitional FOR - acquisition
 Sensory Integration FOR - sensory integration

Assessment Tools:
 KidCOTE
o Behavioral, General behavior, Interpersonal behavior
o 0-complete mastery, 3-extreme difficulty

 Visual Motor Coordination - copy a model

 Visual Perception - blindfold, same figure
 Motor Coordination - trace the inside of the figure

 Revised Knox Preschool Play Scale

o Two 30-minute observations of the child in the setting
o Play behaviors
o 4 dimensions of play

General Goals:
 Social Participation
 Activities of Daily Living
 Education Participation

Intervention:
 Behavioral Modification Techniques
o Reinforcement
o Token Economies
o Shaping
o Forward and Backward Chaining
o Modeling
o Role Playing
 Sensory Integration
o Sensory Diet
o Sensory Massage
 Environmental Techniques
o Minimize Distractions