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- Prim Care Companion J Clin Psychiatry
- v.7(4); 2005
Attention-Deficit/Hyperactivity Disorder: Presentation and Management in the Haitian American Child
A case study of a young Haitian American is presented that is illustrative of cultural issues that influence care of those with attention-deficit/hyperactivity disorder (ADHD). Medications are the preferred treatment for ADHD and can be combined with psychological intervention. However, many Haitians and Haitian Americans see psychoactive medications as leading to substance abuse or mental illness. Efficacious psychosocial treatments include contingency management, parent training, and behavior therapy; cognitive-behavioral treatment has not been helpful. Complementary and alternative medicine might have appeal; primary care physicians can help families to assess such treatments and not to be enticed by expensive ones of little benefit. A determinant of the treatment a family pursues is their perception of the cause of the ADHD behaviors. While there is no term for ADHD in the Haitian-Creole language, in the Haitian culture the behaviors consistent with the diagnosis might be interpreted as indicating a poorly raised child whose behavior could be modified by parental discipline, an intentionally bad child, or a psychically victimized child suffering from an “unnatural” condition. “Natural” ailments are attributed to natural forces (e.g., wind, temperature), while “unnatural” ones are attributed to bad spirits or punishment by God. Families may “lift their feet” ( Leve pye nou : to see a Hougan or voodoo priest) to determine the unnatural cause. Haitian Americans often combine therapeutic foods that are considered cold in nature, natural sedatives and purgatives from herbal medicine, religious treatments, and Western medicine. Immigrants often lack support of extended families in an environment not supportive of their interpretation of child behaviors and traditionally accepted parental disciplinary style. Stigma, language, cultural conceptions, concerns about governmental agencies, and physician bias can all be barriers to care for immigrant families. Primary care and behavioral integration are useful in managing families from other cultures.
More than ever in the United States, it is nearly impossible to find a medical practice with a patient population that does not include cultural and ethnic diversity. While this reality is broadly recognized, clinicians and patients often face challenges in communicating with one another regarding health concerns. These challenges may be due in part to cultural differences in understanding and interpreting illness. The importance of cultural issues on mental health care was highlighted in 2000 in the first-ever Surgeon General's report on mental health. 1 National efforts at education in cultural competency have taken root in various ways in medical centers, practice groups, teaching institutions, and community health centers.
Attention-deficit/hyperactivity disorder (ADHD) is one of the most commonly diagnosed chronic mental conditions of childhood. ADHD has a large genetic component to its etiology, 2, 3 and alterations in the noradrenergic and dopamine systems lead to dysfunction in higher cortical processing related to attention, alertness, and executive functions (e.g., planning, working memory, abstract reasoning, mental flexibility). 4
ADHD has been reported in all continents of the world. Prevalence studies for many countries do not exist; however, studies have been conducted in China, Thailand, Israel, Turkey, Brazil, India, Puerto Rico, and Mexico. 5 Although the signs and symptoms of ADHD are basically the same in these diverse countries, they each represent a different ethno-socio-cultural context in which the condition is interpreted and responded to by patients, their families, caring professionals, and others. 6 Several recent studies demonstrate that in 40% to 70% of children, ADHD persists into adulthood. 7, 8
Although ADHD has been well established as a condition in children worldwide, the subtler question of how the interpretation of symptoms and behaviors varies between locales remains elusive. Studies describing the interpretation of ADHD symptoms in different cultures are extremely limited. African American parents have been shown to be more unsure of the potential causes and treatments of ADHD and less likely to connect the school system to ADHD issues than white parents. 9 In another school-based study, white children with ADHD were twice as likely as African American children to receive evaluation, diagnosis, and treatment, and the threshold of parental recognition and seeking of services contributed to this discrepancy. 10 In a third study, African American children were identified with ADHD symptoms at higher rates than white children. 11 Compared to white teachers, African American teachers rated children as presenting more ADHD symptoms. 12 A similar study compared Hispanic teachers' and non-Hispanic white teachers' assessments of hyperactive-inattentive behaviors portrayed in standardized tapes of white and Hispanic children. Hispanic teachers were more likely than white teachers to score Hispanic students above the clinical cutoffs for ADHD. 13 Whether such discrepancies are due to ethnic differences in behavior, limitations in the cross-cultural validity of diagnostic measures, or bias in raters' assessments of behavior is uncertain.
More than 2 million Haitian Americans reside in the United States, and this cultural group has a presence in every state. The following case study of a young Haitian American illustrates the cultural issues that can influence the care of a person with ADHD and the difficulties that can result from culturally based disagreement or inadequate communication between medical professionals, educators, social service personnel, and families.
CASE PRESENTATION: MR. A
Mr. A is a 25-year-old man with a history of ADHD. He was an overactive child from early infancy, and his parents initially attributed his exuberant behavior to the natural tendencies of his sex. Mr. A's parents tried their best to keep his behavior under control by corralling him in his crib, verbally disciplining him, and occasionally spanking him.
From when Mr. A was 3 years of age, his parents became increasingly aware of his hyperactivity, impulsivity, and inability to follow directions. Throughout his pre-school years, he was repeatedly suspended from school and was forced to move from one school to the next. In his community, he developed a reputation for being mal élevé —a French term for “badly reared,” which in turn reflected negatively on his parents within their extended family and community. At age 5, Mr. A was diagnosed by a specialist as having ADHD. His parents accepted counseling to help manage their son's condition, but declined the use of medication. Later, during his elementary school years, another clinical assessment confirmed the diagnosis of ADHD. This time, Mr. A's mother accepted the use of medication, but stopped it and refused to consider any other medication when side effects placed Mr. A into a “zombie-like” state that included sluggishness, difficulty sleeping, and loss of appetite.
When Mr. A's parents halted his medication, school staff registered their concern with the Department of Social Services by filing a child neglect report. Mr. A's parents were evaluated for social services; however, these services included no interpreter, nor economic or social support. His parents were placed on the defensive all the time and began to feel threatened, stating that “the focus was no longer on [Mr. A's] condition, but on our parental abilities.” As a result, to attend to Mr. A and coordinate his care, his mother stopped working outside the home.
Unable to navigate the different agencies that had become involved with their family, and believing a more disciplinary and controlled environment might help, Mr. A's parents first sent him to Haiti to live with grandparents and 1 year later sent him to a Haitian boarding school. Neither environment had an effect on his behavior. Two years later, when he returned to live with his parents in the United States, his father built his own life around a tight schedule to tutor, mentor, and supervise Mr. A's school activities. Mr. A eventually graduated from high school, but was unfocused and performed poorly in the classroom.
After graduation, Mr. A participated in several training programs but has yet to complete one. He continues to be hyperactive and unfocused. At work, he is known as a “good guy” who regularly jumps to defend coworkers, a behavior that often costs him his own employment. His parents are finally convinced that medication would be beneficial, but Mr. A refuses to take medications and denies his disorder.
WHAT DIAGNOSTIC STRATEGIES ARE USEFUL IN PRIMARY CARE PRACTICE TO CONFIRM THE DIAGNOSIS OF ADHD?
Table 1 lists the DSM-IV criteria for the 3 subtypes of ADHD. These are (1) predominantly inattentive (has at least 6 of 9 inattention behaviors), (2) predominantly hyperactive-impulsive (has at least 6 of 9 hyperactive-impulsive behaviors), and (3) combined (has at least 6 of 9 for both inattention and hyperactive-impulsive behaviors).
DSM-IV Diagnostic Criteria for Attention-Deficit/Hyperactivity Disorder a
Due to their ability to function with ADHD during adolescence, children with the inattentive subtype of ADHD tend to be the easiest group to manage and are the least likely to have recurring problems; however, they often are the hardest to diagnose. Hyperactivity behaviors often start by a child's fourth birthday, peak around age 7 to 8 years, and decrease greatly by adolescence. Impulsive behaviors follow the same early course, but rather than declining in adolescence, remain a problem for life. 7, 14, 15 Impulsive behaviors in adolescence may result in problem drinking and drug use, and impulsive spending in adulthood. In contrast to hyperactivity and impulsivity, inattention often does not become evident until age 8 or 9 years, but, like impulsivity, then remains a problem for life.
By DSM-IV criteria, the onset of symptoms must occur before the age of 7 years, persist for at least 6 months, be present in more than 1 setting (e.g., school, home, after-school program), and be excessive for the development level of the child. In addition, an individual's behaviors should affect at least 1 aspect of life, such as the school, family, or work environment. As with Mr. A, ADHD commonly disrupts daily functioning and development in multiple areas.
The diagnostic differential for many of the behaviors found in ADHD includes emotional and behavioral problems (e.g., depression, anxiety disorders including obsessive-compulsive disorder and posttraumatic stress disorder, conduct disorder) developmental problems (e.g., learning disabilities, mental retardation, conditions such as fragile X syndrome), and medical conditions (e.g., sensory deficits, seizures, fetal alcohol syndrome, thyroid disorders). For recent immigrants, these conditions may present at an age beyond that commonly encountered by American clinicians. Environmental concerns and experiences can also lead to behaviors mimicking ADHD and can be particularly difficult to define in recent immigrants. 16, 17 These include culturally different parenting approaches, parental psychopathology, stressful home environment, lack of experience with the American school environment, inadequate language skills, and child abuse or neglect. 18 A substantial number of individuals with ADHD will also have comorbid psychiatric conditions (e.g., depression, oppositional defiant disorder, learning disabilities).
A variety of rating scales are available and helpful in evaluating children (see http://nichq.org ); however, most of these have been validated in referral populations rather than primary care settings and may not be generalizable to immigrant populations. These scales include ones for use by clinicians, parents, and teachers. Also, collecting information from other settings (e.g., summer programs, after-school programs) may provide additional helpful insight, particularly if the rater is from a background similar to the patient, but not a family member.
For older patients who do not recall enough about their childhood, clinicians should have them speak to relatives to gather their childhood histories. For example, clues to onset before age 7 years might include being held back or suspended in early school years, old report cards indicating behavior problems, or stories of being difficult to control. Scales for adults (e.g., the Wender Utah Rating Scale, 19 also available in French 20 ; the Copeland Symptom Checklist for Attention Deficit Disorders 21 ; the Conners Adult ADHD Rating Scale 22 ) can be useful, but yield large numbers of false positives and cannot be relied on for diagnosis without supportive evidence from clinical assessment. 23
Treatment approaches to ADHD include an array of psychotropic medications, behavioral and psychological treatments, and complementary and alternative medicine approaches. Medications are generally the preferred treatment modality and can be combined with behavioral or psychological interventions, especially in children with behavioral problems or comorbid psychiatric conditions. Stimulant medications and psychosocial treatment have been the major foci of clinical research; however, the duration of most randomized trials has been 3 months or less, and thus the literature on long-term treatment is sparse. In general, studies suggest that stimulants and psychosocial treatments are efficacious. 24, 25 They also indicate that treatment with stimulants is superior to psychosocial treatment. 26
Short-term trials of stimulants support their efficacy, with response rates in the 70%-to-90% range. 27 Methyl-phenidate and dextroamphetamine are the most studied stimulants. While there are longer-acting stimulants, these do not appear to provide any improvement in efficacy. Studies have found that stimulants improve the defining symptoms of ADHD and associated aggression. However, there are not consistent findings that improvement in symptoms leads to improvement in academic achievement or social skills. 28, 29
Aside from studies suggesting the efficacy of using stimulants, there are also studies of antidepressants showing that tricyclic antidepressants (e.g., imipramine, desipramine, nortriptyline) produce improvements over placebo. 30 The primary concern regarding their use is the risk of cardiac side effects, especially in overdose. Atomoxetine also has proven efficacy for ADHD 31, 32 ; it is the only medication approved by the U.S. Food and Drug Administration for use in adult ADHD, is not a controlled medication, and might be particularly useful when possible comorbid substance abuse is a concern. 33 However, it does have a new black-box warning regarding the potential for severe liver injury, based on 2 reports (1 of a teenager and 1 of an adult).
Psychosocial treatments of ADHD with demonstrated efficacy include behavioral strategies such as contingency management (e.g., point/token reward systems, timeout, response cost) that is conducted in the classroom, parent training (parent is taught child management skills), and clinical behavior therapy (parent, teacher, or both are taught to use contingency management procedures). 34 In contrast, cognitive-behavioral treatment (e.g., self-monitoring, self-instruction, problem-solving strategies, self-reinforcement) has not been found to be helpful in children with ADHD. 35, 36
Complementary and alternative medicine strategies are very commonly used and might have particular appeal to families from other cultures. 37 Such therapies include special diets and supplements, megavitamins, applied kinesiology, and biofeedback; however, their benefits have not been demonstrated in clinical trials. 38 Diet, including reducing sugar, affects behavior in less than 1% of children. 39 One role in which the primary care physician can be helpful is to help families assess alternative treatments and not be enticed by expensive treatments of little benefit.
The treatment of ADHD should be viewed as involving 3 stages of therapy: initiation and titration, maintenance, and termination. 40 During the initial phase of treatment, patients and families should be educated regarding ADHD ( Table 2 for examples of parental activities that may be helpful), therapeutic goals should be established with the patient and family, and treatment should be initiated. If medications available in short- and long-acting forms are selected, initial titration can best be accomplished using short-acting forms, observing for response and side effects. This can be followed by switching to longer-acting forms if desired. Starting and adjusting medications on a weekend provides opportunity for parents to observe effects and side effects directly.
Parent Activities That Can Help Modify the Behavior of a Child Who Has Attention-Deficit/Hyperactivity Disorder (ADHD) a
During the maintenance phase, ongoing family education, dosage adjustment, and monitoring of growth, efficacy, and side effects are appropriate. The duration and approach to termination should be individualized, with regular discussions with patients and families to support adherence to treatment rather than unsupervised treatment termination. Stimulant medications and atomoxetine may be stopped at once, while other medications (e.g., tricyclic antidepressants) may need to be tapered. Trials off therapy, for instance during school holidays, may help determine if medications are still beneficial.
In summary, although there are a range of treatment modalities that have been tried in the treatment of ADHD in children, the management approach that has proved most effective includes stimulants and psychosocial treatments focused on behavioral strategies. Of note, in one large study funded by the National Institute of Mental Health, there was no difference in response to treatment between ethnic groups (Latino, African American, and white). 41
ADHD AND ITS CARE FROM A HAITIAN PERSPECTIVE
While there is no corresponding term for ADHD in the Haitian-Creole language, in the Haitian culture the behaviors consistent with the diagnosis of ADHD might be interpreted as indicating the following:
- A “poorly raised child,” whose behavior could easily be modified through parental discipline. This can be stigmatizing within the Haitian community and places parents on the defensive. Mr. A's parents suffered from the reputation of having a mal élevé child.
- An “intentionally bad child” who embarrasses his or her parents. Children with ADHD are often compared to “good kids” who are held up to them as examples to follow. This can be a severe insult to both the child's and parents' self-esteem and their sense of self-efficacy.
- A “psychically victimized child,” or one suffering from an “unnatural” condition, a curse from a superior force. A religiously influenced family might believe a child is being punished for sins and direct attempts to intervene accordingly.
Among Haitians, the interpretation of ADHD-related behaviors varies widely from family to family depending on religious affiliations, level of education, and experience with school and primary care systems. Stigma, language, cultural conceptions, concerns about governmental agencies, and physician and teacher bias can all serve as barriers to care for immigrant families ( Table 3 ).
Five Barriers to Care for Haitian Immigrants With Attention-Deficit/Hyperactivity Disorder (ADHD)
An important determinant of the treatment or other intervention strategy a family pursues is their perception of the cause of the ADHD behaviors. Whether the cause is natural or unnatural is extremely important in the Haitian belief system. “Natural” ailments are often attributed to natural forces (heat/cold, gas, wind, temperature), while “unnatural” ailments are attributed to bad spirits or punishment inflicted by God. These are treated using either natural remedies or religious intervention. 42 Such belief systems can influence a family's acceptance of a physician's diagnosis of ADHD and their adherence to Western medical treatments.
In the United States, as in many other countries, the diagnosis of ADHD is mainly a medical one and involves pediatric and family medicine providers, social workers, and psychologists. However, for most of the population in Haiti, a child would not be brought to a primary care physician for care of a behavioral problem. Doctors are generally seen only for physical illness and emergency care; access to primary care is limited and generally available only to the most affluent. ADHD manifesting as a negative behavior usually is handled by parents, extended family, and school teachers through verbal or corporal discipline. Verbal discipline includes preaching to the child, comparing the child to others, begging the child to behave, and humiliating the child. Corporal discipline and punishment can be inflicted by any member of the family, neighbors, and schoolteachers, all of whom are given full authority to educate and “correct” the child.
Immigration adds a complex dimension to raising children. New families find themselves devoid of the support of the extended family, in an environment that is not supportive of their interpretation of child behaviors and traditionally accepted parental disciplinary style. Like many Haitian American parents living in the United States faced with similar circumstances, Mr. A's parents chose to send him back to Haiti with the hope that a more authoritative parenting style, the enforcement of discipline in school (schoolteachers are very respected), and removal of the interference of the American social worker would offer a better environment for rearing their child. Mr. A went to live with his grandmother first and then off to a boarding school, a setting seen by many Haitian parents as the ultimate answer to a child with behavioral problems.
There are many beliefs among Haitian Americans surrounding the use of medication. Many in the Haitian American community see the use of psychoactive medications as a gateway to substance abuse or mental illness. Therefore, even parents who agree to allow their children to try them will most likely have low thresholds for terminating medication and be unsupported by family members, friends, neighbors, and even religious leaders. Mr. A's parents received much unsolicited advice, and some friends wanted them to “lift their feet” ( Leve pye nou : to see a Hougan or voodoo priest) who might be able to determine the unnatural but real cause of their son's problem.
Being transnational and having access to both native Haitian medicine and Western medicine, Haitian Americans routinely combine therapeutic foods that are considered cold in nature, natural sedatives and purgatives from traditional herbal medicine, religious treatments, and Western medicine to treat illness. Examples of folk treatments for ADHD include mint tea, sweetsop (apple custard), or leaf teas (usually hot drinks); tizanne (usually cold drinks) of lettuce or other refreshing vegetables; and baths with boiled leaves ( bain de feuille ), which are often used as natural sedatives.
While it may be difficult to establish trust with Haitian families initially, such trust in the doctor-patient relationship is essential in obtaining their participation in the development of a treatment plan to which they will adhere. Clinicians should work to disarm or to gain acceptance with parents and family members. It may be helpful to learn a few words of Creole or tidbits of Haitian history, to be respectful of combining benign natural remedies with conventional Western medicine, and to find ways to show respect for the family's heritage. Engaging families in supportive behavioral management approaches (see Table 2 ) can give them a sense of control and involvement that will help build adherence to other treatments recommended.
Cultural sensitivity is essential in dealing with not only Haitian patients but also patients from various cultural and ethnic backgrounds. One definition of cultural competency is “a set of congruent attitudes, behaviors, and policies that come together in a system, agency, or amongst professionals and enables them to work effectively in cross-cultural situations.” 43 Haitians, like most immigrant patients, need sympathetic advice and help from their physicians, as they often feel governmental agencies such as the local department of social services place a great deal of pressure on them to either medicate their children or move their children to other school systems.
In direct contrast, it is also important not to “overemphasize” a patient's culture when considering a diagnosis and treatment. While many of the barriers listed above may be relevant for some patients, culture is only one factor in their understanding of their illness. Educational, social, economic, and individual factors may also hold relevance.
Because the interface of psychiatric disorders—in this case ADHD—and culture is complex, it is a useful context for examining the integration of psychiatric and primary care. While there are a number of models of such primary care and behavioral integration, one, called “primary mental health care,” 44–47 is particularly useful in managing families from other cultures. The goal of this approach is to resolve problems within the primary care service context: “primary mental health” is designed to support the ongoing behavioral health interventions of the primary care provider. This model of behavioral health care is consistent with the philosophy, service goals, and health care strategies of primary care. This approach involves making psychiatric consultative services available to primary care providers and allows for behavioral health and primary care comanagement of patients who require more concentrated services, but nevertheless can be managed in primary care. Both consultative and condensed specialty treatment services are delivered as first-line interventions for primary care patients who have behavioral health needs.
In summary, there are several options for assisting Mr. A and his family and other Haitian children and adults with ADHD:
- Gain insight into the patient's and family's perception of the problem, its cause, and impact on behavior and function. This often is the starting point for patient education and coming to a shared understanding of the diagnosis and potential interventions.
- Develop treatment plans using the family's experiences with helpful and unhelpful strategies as the starting ground. For example, it may be useful to ask the family, “Who (or what agencies) have you found helpful in working with Mr. A? Why?” If the family is unable to name anyone, it may be necessary to broaden the question to “What do you feel you need most in order for Mr. A's functioning to improve?” With this feedback from the patient and parents, it may be possible to revise strategies that have been unhelpful or alienating in the past. Setting appropriate short- and long-term goals for Mr. A is essential to monitor his progress with treatment and behavior.
- Support a team-oriented, collaborative approach that incorporates expertise from family and community members, mental health professionals, educators, and other disciplines if necessary, yet anchors the patient's care in a primary care context. In Mr. A's case, there were clearly gaps in communication between the family, school, medical professionals, and social service system, as each worked independently to solve the same problem. Department of Social Services involvement and the attitude of its workers can send a message to the parents that they may be investigated or punished rather than helped. A team-oriented approach might mitigate some of the resultant stress and negative perceptions. The primary care physician often needs to serve as the family's advocate in coordinating and mobilizing others involved.
- Identify a cultural consultant and/or case manager. This ideally is someone known and respected by the family. Mr. A and his parents might have benefited from close contact with a skilled case manager, who ideally could have served as a “cultural broker,” facilitating access to proper management for Mr. A's condition.
- Offer and encourage biomedical and psychosocial treatments that have been demonstrated to be effective, and invest time in directly discussing concerns and barriers that families have in accepting these treatments. Explicitly state a willingness to be flexible in supporting traditional cultural treatments as part of the care plan. If Mr. A and his family had felt that their concerns and beliefs were more deeply understood, they might have been more trusting and more willing to try different treatments.
- Follow through. Maintaining long-term contact and interest in the family and their problems and providing consistent and dependable follow-up are critical to families' developing trust and accepting interventions. It may be necessary to persist for some time in the face of lack of adherence to recommendations before the patient and family gain the confidence required to try new interventions if they have had previous negative experiences with “caring professionals.”
Drug names: atomoxetine (Strattera), desipramine (Norpramin and others), dextroamphetamine (Dexedrine, Dextrostat, and others), imipramine (Tofranil and others), methylphenidate (Metadate, Ritalin, and others), nortriptyline (Pamelor, Aventyl, and others).
Acknowledgments
The authors acknowledge Jean-Robert Boisrond, Coordinator of the Haitian Health Institute at Boston Medical Center, Boston, Mass., for assistance in preparation of the case and for commitment to the special needs of the Haitian people.
Editor'S Note
Cultural Currents presents clinical experience derived from the practices of clinicians caring for patients and families whose cultural backgrounds are outside of the mainstream of society. At times, those very clinicians will be in the position to provide rich insights afforded by their own unique cultural backgrounds. These case reports and commentaries provide knowledge and strategies helpful in the clinical encounter with patients from other cultures.
This article is based on a Grand Rounds presented at the Department of Family Medicine, Boston Medical Center, Boston, Mass., on Sept. 16, 2003.
The authors received no direct support related to this article.
Dr. Culpepper has been a consultant for Eli Lilly. Drs. Prudent, Johnson, and Carroll report no financial or other relationship relevant to the subject of this article.
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CASE STUDY Jen (attention-deficit/hyperactivity disorder)
Case study details.
Jen is a 29 year-old woman who presents to your clinic in distress. In the interview she fidgets and has a hard time sitting still. She opens up by telling you she is about to be fired from her job. In addition, she tearfully tells you that she is in a major fight with her husband of 1 year because he is ready to have children but she fears that she is “too disorganized to be a good mother.” As you break down some of the processes that have led to her current crises, you learn that she has a hard time with time management and tends to be disorganized. She chronically misplaces everyday objects like her keys and runs late to appointments. Although she wants her work to be perfect, she is prone to making careless mistakes. The struggle for perfection makes starting a new task feel very stressful, leading her to procrastinate starting in the first place. As a consequence, she has recently received a number of warnings from her boss related to missing deadlines for assignments and errors in her work, which has led to her acute fear of being fired. As her performance at work has plummeted and she has grown increasingly anxious and doubting of herself, she has grown more pessimistic about starting a family. You learn that she received extra time for test taking in school as a child but never had any formal neuropsychological testing. With Jen’s permission, you conduct additional structured assessments, including collecting collateral information from her fiancé, and conclude that she has adult ADHD.
- Concentration Difficulties
- Impulsivity
Diagnoses and Related Treatments
1. attention deficit hyperactivity disorder (adults).
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Pediatric Case Study: Child with ADHD
Nicole quint, dr.ot, otr/l.
- Early Intervention and School-Based
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Attention deficit hyperactivity disorder (adhd).
Hello everyone. Today, we are going to be talking about attention deficit hyperactivity disorder. I consider this to be under the umbrella of "invisible diagnoses." This population has a special place in my heart because it is very easy to misconstrue some of the challenges that they have as intentional and behavior-based, and therefore, sometimes they get a bad rap. Thus, I am always happy to help kids with ADHD.
Figure 1. Overview of ADHD.
Individuals with ADHD have a lot of challenges that affect their occupational participation and performance. I think most of us are very comfortable with the idea that inattention, hyperactivity, and impulsivity are the hallmarks, but what sometimes can get lost is the idea that executive functions are very much affected by impulsivity. Motor issues are also often involved with kids with ADHD and are not always considered. In fact, there is a lot of evidence to support that the motor needs of these kids often go unaddressed. Typically, these kids come to us when parents or schools have major concerns about their behavior. Therefore, this tends to be where everyone focuses their attention. Oftentimes, the motor issues then fly under the radar and do not get addressed. The cool thing is that motor interventions can be the means to make some really significant changes for these kids, particularly in the area of executive function. There is a win-win situation when we address the motor issues. Lastly, they tend to also have performance issues not only in their home environment but also in their school and social environments as well.
Figure 2. Other information from the NIMH Information Resource Center (2020).
I wanted to provide some information to help you to appreciate how diverse ADHD is. Many might still use ADD when we are talking about the children who have an inattentive type as it seems to make more sense. However, that is not how it is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5).
Etiology and Signs
The etiology and the signs are inattention, hyperactivity, and impulsivity. We also know there is a genetic predisposition to this. Neonatal exposure to cigarettes, alcohol, and drugs can also lead to ADHD. Low birth weight and toxin exposure are some of the environmental elements. ADHD can also be the result of a brain injury. This is not just a childhood disorder, and people do not grow out of it. In fact, the symptoms can actually get worse as life gets harder as one gets older. Adults who have ADHD can have some significant struggles, particularly if they do not know that they have ADHD or if it was never addressed.
There are three phenotypes: hyperactive-impulsive type, predominantly inattentive type, and a combination type. I think the hyperactive-impulsive type is the picture most people have when they think of ADHD. Then, we have the predominantly inattentive type. These are the daydreamers or the individuals that jump from one thought to the next. They have a really hard time staying focused for long. Lastly, there is the combined type. This is where we see both elements of inattention and hyperactivity and/or impulsivity. I think it is really important to also appreciate gender differences. You can see very different types of ADHD in girls versus boys. Boys obviously tend to be of the hyperactive-impulsive type, but even the inattentive type can be a little different. Girls, who have ADHD, tend to be talkative and a little more anxious. They definitely have a different predisposition as opposed to the boys. Thus, it might be the same diagnosis but look very different between the genders.
Functional Implications
Functional implications become extremely important. These are individuals who tend to overlook or miss details. They might make careless mistakes. They have difficulty following through with directions at school. Material management can become very challenging especially dealing with paperwork. They can miss deadlines and have a hard time keeping track of and prioritizing tasks. These are some of the higher-level executive functions. You might also see an avoidance or an expressed dislike of tasks that require a significant amount of sustained mental effort. They might tell you it is too hard, and they might feel very overwhelmed. They become very easily distracted by anything. The use of electronics adds to the issue. They can be forgetful in daily activities, talk excessively, have difficulty engaging in quiet activities, and tend to blurt out answers or finish others' sentences. Often, the perception is they are interrupting and being rude. They may have difficulty waiting for their turn or interrupt during someone else's turn. These are examples of impulsive behaviors. We will talk more about this when we get to executive functions.
Differential Diagnosis Between ADHD and SPD
- A high rate of comorbidity between SMD and ADHD
- ADHD and SMD
- Both at risk for limited participation in many aspects of daily life
- ADHD slightly worse attention scores than SMD
- Tactile, taste/smell, and movement sensitivity, visual-auditory sensitivity; behavioral manifestations of sensory systems
- Exaggerated electrodermal responses to sensory stimulation, thus increased risk of sympathetic “fight or flight” reactions
(Miller et al., 2012; Yochman et al., 2013)
Sometimes, kids who have ADHD also have some sensory issues. You may wonder, "Do they have just ADHD by itself?" This is probably one of the most common questions I get when working with kids with ADHD whether it is from teachers, other therapists, or from parents. Next, we are going to be talking about a child who has straight ADHD. However, for a few minutes, I want to talk about the whole idea of differential diagnosis between ADHD and SPD and how this all fits together. There is a very high comorbidity between sensory modulation disorder and ADHD. When I am referring to sensory modulation disorder, I am using the Lucy Jane Miller nosology. Sensory modulation disorder refers to the over-responsive, under-responsive, and/or craving of sensory input. For both ADHD and sensory modulation disorder, you will see that these diagnoses are both at risk for limited participation. These are kids who will not participate in certain activities because the sensory input is too much or overwhelming for them. ADHD will have slightly worse attention scores than SMD when you complete a formal attention test like the Test of Everyday Attention. However, you will see the same kind of impulsive behaviors.
Those with sensory modulation disorders tend to have difficulty with tactile, taste, smell, and movement sensitivities. You might also see some visual-auditory sensitivity so there are some behavioral manifestations that come of that. They might become stressed related to fears of vestibular or other movement input. They might also dislike certain noises or touch.
They found in the research that sensory modulation dysfunction, not ADHD , will have an exaggerated electrodermal response to sensory stimulation. This means that they have an increased risk of sympathetic activation which is the fight-or-flight, freeze/faint reactions, and meltdowns. When you have a child with meltdowns, you want to investigate if they have sensory modulation dysfunction right away. And, if you have a child with ADHD who does not have a history of meltdowns, that is a really good sign of your initial hypothesis. While this alone does not mean that they do not a sensory modulation dysfunction, chances are that they do not. Additionally, they might have dyspraxia or a discrimination disorder.
This is just a brief summary of how this all comes to play with an ADHD diagnosis and possible comorbidities.
Case Introduction: Jeremy (Age 9, ADHD, Combined Type)
- He lives with his mother and older sister in SFH and goes to his father’s house on the weekend (divorced)
- He is in the 4th grade and has an IEP for OHI
- Strengths: funny, good at math, helps the family to take care of pets, watches WWE with father, loves dogs, likes to play board games (Monopoly, Sorry)
- School concerns: material management, organization, completing tasks or losing work , impulsive, social difficulties (short-lived relationships, fights), “lacks self-control” and “messy”, underperforming and sometimes seems “lost”
- Family concerns: Fights with a sibling, sleep difficulties, messy room, messy notebooks, and backpack, loses things, avoids homework, resists bedtime, difficult to wake in the morning and slow with routine , poor hygiene
- Jeremy’s goal: make friends, be able to find his schoolwork, have good friends, be better at kickball and wrestling
Jeremy is nine, and his diagnosis is ADHD, combined type. I have a feeling Jeremy is probably similar to a lot of the kids you see. I know I have seen a lot of these types of kids. He lives with his mother and older sister in a single-family home and goes to his father's house on the weekend because of a divorce. He is in the fourth grade, is eligible for an IEP because of an OHI (other health impairment), and is eligible for special education services because of his diagnosis of ADHD.
I always like to start with strengths with all kids, especially ADHD because these kids can have a really hard time with confidence and self-esteem. They also get blamed for their behaviors. For his strengths, he is funny, good at math, and he likes to help take care of his pets at home. He likes to watch wrestling, World Wrestling Federation (WWF) with his father, loves dogs, and loves to play board games. He is really good at Monopoly and Sorry.
At school, he had challenges with material management, organization, completing tasks, and not losing work. These last two are highlighted as we are going to focus on that. He is impulsive, and he has social difficulties. His teacher described his relationships as short-lived. He would have a friend, and then all of a sudden, they were not friends anymore. She also reported that he lacked self-control, was messy, and thought he underperformed. And, she felt like he always seemed lost. When they were going through the instructions or going through something, he was always looking at his peer's work or looking confused while he was trying to figure out what was going on.
The family had some concerns about his fighting with a sibling, significant sleep difficulties, a messy room, messy notebooks and backpack, and that he would often lose things. He also avoided his homework and resisted bedtime. As a result, it was very difficult to wake him up in the morning, and he was slow with his AM routine. His mom said that he also had an impulsive way of performing hygiene tasks. For example, he would brush his teeth in two seconds and say he was done. Everything was quick and impulsive. This is very typical for boys with this type of ADHD.
His goals were to make friends and find his school work. He said it was very stressful to always feel like he was losing his school work. He was motivated to do well in school. He did not just want to make friends, but he wanted to have good friends. He also wanted to be better at kickball because that is what the kids played at recess and in PE. He also wanted to be better at wrestling as not only did he like to watch with his dad, but he also liked to wrestle with him.
I want to go back to the highlighted areas in my list: completing tasks, losing work, and difficulty waking in the morning. These are the areas we are going to focus on.
Assessments
Assessments are one of the most challenging things for people because they are often under a time crunch, and the reports are difficult to write up and are time-consuming. However, it is really important with these kids as it gives us a full perspective on where they are having challenges. Knowing that he has "ADHD combined type" does not really tell us about his occupational performance and participation. We want to really get all that information. I like to be pretty thorough, and I will scatter assessments throughout my time with them to try to get a good idea. Again, I really like to check out their motor skills. I have kids that are superstars in sports, but I will still find out that there are some motor problems.
Typically, the motor challenges with ADHD have to do with bilateral coordination, dexterity, and those kinds of things. They might be good at some things, like basketball or baseball, but this does not mean that they are good at fine manipulation. Thus, it is really important to find out where they are. Figure 3 shows a summary of the assessments I did with Jeremy.
Figure 3. Assessment results.
Using the BOT, I found that Jeremy was one standard deviation below the norm in fine motor, precision, and manual dexterity, which was not surprising. He was two standard deviations below the norm in bilateral coordination and balance. However, his overall strength, running speed, and agility were fine.
There are many great tools out there for sleep including free ones. One of my favorites is the Sleep Habits Questionnaire. It is free online. It is great because it uncovers behaviors regarding going to bed, sleep duration, daytime sleepiness, and sleep onset delay. Many kids with ADHD have an overactive thinking process which then causes a sleep latency problem. It is hard for them to settle their brain and get to sleep. They also might have difficulty with sleep duration and not get enough sleep or good quality of sleep. If their arousal level is still high at night, it' is hard to get them to calm down and want to go to bed, especially if they are very disorganized in their thinking. This questionnaire gives you good information. Our results with Jeremy found that had bedtime resistance, sleep duration, daytime sleepiness, and sleep onset delays that were all atypical scores.
I also did a social skills assessment with him because his goal was to make friends, and school indicated that he had a hard time with solid friendships. I like to have a social-emotional learning perspective, and the more I know about a child's emotional intelligence, the better. We want these kids to be successful in their social interactions because that affects their whole life. With the Social Skills Improvement System (SSIS) Rating Scales, I found challenges with cooperation, empathy, and self-control. His strengths included assertion, responsibility, and communication. Under "problem behaviors", I found inattention, hyperactivity, and some externalizing behaviors. With his diagnosis, this all seems to fit. For academics, he was motivated to learn and had competence in math achievement. We already knew he had strengths in math.
I also did the School Function Assessment. I love this tool. There is one section that is a little dated as it talks about a floppy disk or something, but the other information on there is fantastic. This is especially true if you have kids who have a hard time following rules, social conventions, and material management. You can give it to the teacher, and they can score that. I found that Jeremy had some affected areas with memory and understanding, following social conventions, and compliance with adult directives and school rules. Additionally, he had some behavioral regulation issues, and task behavior and completion were difficult for him. His strengths included positive interactions and functional communication. Communication is strong for him,= which is a good thing.
The BRIEF (Behavior Rating Inventory of Executive Function) is an executive function tool that I did that with his parents. What we found was that the organization of materials, monitoring, planning and organization, inhibition, and initiation were difficult for him. His strengths were his working memory. Additionally, cognitive shifting and emotional control were also strong. However, his global executive composite was one standard deviation below the mean which means that he was low in everything. While it was not devastatingly low, he was below the average in everything. He struggled the most in metacognition, and that was two standard deviations below the norm. Thinking about his own thinking was a struggle for him.
From an observation standpoint, I also got a video from him mom of his AM routine so I could see what that looked like. He was in slow motion, very tired, not wanting to do the routine, and his performance was of low quality, I would put it, writing examples from school, because sometimes you'll see that the handwriting is indicative kind of the brain and the body not matching up, the brain going a little faster than the body. And so I also had a homework video watching him kind of resist homework. And then I did ocular motor testing, checked his tracking, convergence, divergence, and saccades and those kinds of things. Because there is a correlation between having some difficulties with that sometimes. But he actually was fine, and that wasn't a complaint from parents. So I just wanted to make sure it wasn't an issue that we were missing. So that gave me a lot of information.
Research Implications: Assessment
This is information about some of the research implications regarding the assessment process and kind of why I chose the tools that I chose and why I recommend a comprehensive one.
- Motor: Children with parent-reported motor issues received more PT than those with teacher-reported motor issues (risk)/undertreated motor problems in children with ADHD (due to behavioral factors in referral); HW difficulties; higher ADHD and lower motor proficiency scores reported more sleep problems (Papadopoulos et al., 2018)
- Sleep: Sleep deficits negatively affect inhibitory control (Cremone-Caira et al., 2019); Difficulties initiating and maintaining sleep 25-50% in ADHD (Corkum et al., 1998); Prevalence of sleep disorders 84.8 % affecting QoL (Yurumez & Gunay Kilic, 2013)
- EF: Motor skills and EF related (Pan et al., 2015); boys with ADHD have lower EF abilities than typical peers on both performance-based and parent report tools, thus combo is recommended (Sgunibu et al., 2012)
- Social: Children with ADHD 50% lower odds of sports participation than children with asthma with higher incidences of screen time (Tanden et al., 2019); childhood ADHD associated with obesity (Kim et al., 2011); underlying lack of interpersonal empathy (Cordier et al., 2010); Playfulness indicators: ADHD group “typical” with some difficult items but difficulty with basic skills (sharking) (Wilkes-Gillan et al., 2014); seek green outdoor settings at a higher rate (Taylor & Kuo, 2011)
For motor, Papadopoulos and his group (2018) found that there is some difficulty with handwriting. They also reported the higher ADHD and lower motor proficiency scores, the more sleep problems. The fact that Jeremy had sleep problems made me want to look at his motor skills for this reason. This is another interesting one. Children with parent-reported motor issues received more PT than those with teacher-reported motor issues. The fact that we listen to the parents more than the teachers about motor issues is important to consider. Under-treated motor problems in children with ADHD are really due to a behavioral focus so that is why it tends to get missed.
Sleep deficits negatively affect inhibitory control (Cremone-Caira et al., 2019). If we know that these kids have inhibition issues, we need to help them get some sleep. Poor sleep is only reinforcing their challenges and making it worse. They found that there were difficulties initiating and maintaining sleep at a rate of 20 to 50% of kids with ADHD (Corkum et al., 1998). Now, granted, that was 20 years ago, but they have replicated that since. And, if you have a sleep disorder, there is an 84.8% chance that it is negatively affecting your quality of life (Yurumez & Gunay Kilic, 2013).
Motor skills and executive functions are related. If you have some motor difficulties, it is going to influence your executive function ability (Pan et al., 2015). Boys with ADHD have lower executive function ability than typical peers on both performance-based and parent report tools, thus, it is really important that you use a combination of both performance and parent report tools (Sgunibu et al., 2012).
Children with ADHD are 50% less likely to participate in sports than children with asthma (Tanden et al., 2019). I find that amazing. Kids with ADHD also have a higher incidence of screen time usage, and we know that that is always a challenge (Tanden et al., 2019). Childhood ADHD is also associated with obesity. Hence, if you are not doing anything physical and you are sitting there watching your computer or playing video games, and you are impulsive, you are more likely to be obese (Kim et al., 2011). An underlying lack of interpersonal empathy can be something that you often see in ADHD. This affects social abilities and participation and success (Cordier et al., 2010). There are also playfulness indicators. An ADHD group might score as "typical" with some difficult play criteria, but then have more difficulty with basic items (Wilkes-Gillan et al., 2014). Their play may be developmentally out of whack. Again, they might be okay with some high-level types of behaviors, but then when it comes to something simple like taking turns or sharing, they cannot do it. Sometimes we have to go back and practice these rudimentary skills. This might be why they are struggling socially because they are having problems with age-inappropriate items. Lastly, these kids with ADHD really seek green outdoor settings at a higher rate (Taylor & Kuo, 2011). It would be interesting to monitor how outside time might influence their performance on assessments.
EF and Self-Regulation Connection
- Inhibitory control
- Cognitive/mental flexibility
- Working memory
Can these kids self-regulate? When they cannot, it does not work out well for them in school or at home, and it does not work out well in terms of social abilities. When they become adults, they have trouble keeping and maintaining a job. This is the definition of EF.
Some of you might be very familiar with this definition, but it is also quite complicated. This is how we remember information, filter distractions, resist impulses, and sustain attention during an activity that is also goal-directed. While we also adjust our plan as needed to avoid frustration in the process. That is a lot of working parts. Many times, you see people refer to executive functions like an air traffic controller of information and materials. These are the "big 3."
This is how we remember information, filter distractions, resist impulses, and sustain attention during an activity that is goal-directed while adjusting our plan as necessary and avoiding frustration!
Miyake, A., Friedman, N. P., Emerson, M. J., Witzki, A. H., Howerter, A., & Wager, T. D. (2000). The unity and diversity of executive functions and their contributions to complex "frontal lobe" tasks: A latent variable analysis, Cognitive Psychology, 41 , 49-100.
- Impulse Control
- socially acceptable (Olson, 2010)
- Ability to store, update and manipulate /process information over short periods of time (Best & Miller, 2010)
- “Limited-capacity information-processing system” (Roman et al., 2015)
- Verbal, visuospatial, and coordinating central executive
- Ability to think flexibly and shift perspective and approaches easily, critical to learning new ideas (different perspectives)
- Switching between two or more mental sets with each set containing several tasks rules
- Feedback related (unlike inhibition) (Best & Miller, 2010)
All these things are important, but the three basic dimensions are inhibitory control, which develops first around four years of age, cognitive and mental flexibility, and working memory. Mental flexibility is the result of inhibitory control and working memory working together. If you have a problem with inhibition or working memory, or both, you are going to have problems with cognitive flexibility. The flip side of that would be rigidity. It is also being able to shift your thinking in the moment back and forth. The flip side of that would be to be stuck. Working memory is the ability to use your memory functionally. It is very important to know that we only have a very limited amount of memory capacity, and it is all we have. I like to call my working memory my suitcase. You have to make sure you pack the right things in there for the trip that you are going on. If you pack your suitcase for Fiji and you are going to Alaska, you are going to be on the beach with boots and a parka and be miserable. It is really important that we pull in the information that we need. This takes sustained attention. If you cannot sustain your attention, you are not going to capture the right memories. And again, if there are problems with inhibitory control or impulse control, this is going to be challenging. Impulse control is controlling yourself in the moment. If I can string those together, now I have more self-regulation ability. Again, these are the big three: inhibition, working memory, and cognitive flexibility and shifting.
I already explained these, but I want you to appreciate what the research says. Inhibition requires an arbitrary rule to be held in your mind while you are inhibiting one response to produce an alternative response, which is typically the one that is more socially acceptable. Working memory is storing, updating, and manipulating information over short periods of time. It has a limited capacity, and it is verbal and visuospatial. Then, for cognitive shifting and flexibility, there are two pieces to it. It is being open and being able to shift. Here is what is interesting. Cognitive flexibility and shifting respond really well to internal feedback. You can actually start to observe things and gain some insight and make changes. Why that is important is because inhibition does not get better from internal feedback. It only gets better from external feedback. Think about someone you know who interrupts a lot because they are impulsive. They see that they do it and do not change because no one has said anything to them. It requires external feedback for them to say, "Oh, I'm doing it wrong." We do not have this internal mechanism to change our impulsivity. We cannot assume these kids will figure it out and fix it, because they will not. We have to be very stern and to the point and say, "You're doing it wrong. This is why it's wrong and here's what you need to do instead." This is the key. Figure 4 is an executive function cheat sheet.
(Cooper-Kahn & Dietzel, 2008)
Figure 4. EF cheat sheet.
This is from Cooper-Kahn and Dietzel (2008). They tell you the executive function, what the function is, and then the end dysfunction. For inhibition, the dysfunction is impulsive. If you cannot cognitively shift, you can get stuck. If you do not have emotional control, you are going to be over or under-reactive. If you cannot initiate a task, you are stuck in inertia. If you do not have a good working memory, you are lost. If you cannot plan and organize, you are fragmented. If you cannot manage your materials, you are chaotic. And then, if you cannot self-monitor, you are clueless. The red ones are those that Jeremy struggled with. He was impulsive, had inertia, was lost, and chaotic. He was also a little fragmented and had a difficult time with organization. However, these four things were his biggest challenges.
Review of Evidence-based Interventions for Case
One of the objectives is to talk about evidence and how we are going to use the evidence to support our intervention. I focused on motor, social, executive functions, and sleep. These are the things that were assessed that also had evidence for different intervention strategies (see Figure 5).
Figure 5. Evidence-based interventions ((Hui Tseng, et al., 2004; Hahn-Markowitz et al., 2016; Washington University, n.d.; Diamond & Lee, 2011; White & Carlson, 2016; Winsler et al., 2009; Marjorek et al., 2004; Kuhn & Floress, 2008; Frike et al, 2006; Keshavarzi et al., 2014).
Motor/Social Categories
Let's look at the motor and social categories. What is really interesting is that attention and impulse control are related to fine motor and gross motor coordination. If we can work on coordination, we can also increase attention and impulse control. This is killing two birds with one stone in Jeremy's case. I do not know who is familiar with Hebbian's law, but it says is that the (brain) cells that fire together wire together. One of the ways to do that is through the concept of anticipation. Anticipation builds memory capacity and will improve working memory. Anticipation is a context, and you can basically put anticipation in anything. With turn-taking, there is anticipation. If there is a competition, there is anticipation among the competitors. If you know you are going to be called on, there is anticipation. If you are playing a game where something might jump out, there is anticipation. These are just a few examples of where you can build in anticipation. If you can add that into your activities, you can build memory capacity. Another study looked at how table tennis exercises improved executive function and object control skills. Table tennis does not require a lot of heavy-duty cardio and it is not a tiring exercise, but it requires a lot of hand-eye coordination and sustained attention. I think this is a really good occupation-based strategy to improve executive function and object control. Physical activity also improves working memory. I have had tons of success with kids doing physical activity both in therapy and at home to improve their working memory. Some of the social strategies that work really for kids, and we will talk about a few in a little bit, is taking a peer's perspective and working on empathy and imagination. These things were really shown to be effective ways to change someone's social success.
Executive Function
For executive function, you have to give them external feedback. You have to tell them when they are being impulsive, and then you have to tell them how to fix it. These are kids who are on a very fast, impulsive temporal context. I talk to them about the hare versus the turtle. I tell them to be more like the turtle. Yoga, mindfulness, and visual imagery are other strategies. Yoga and mindfulness are occupations, and you can incorporate visual imagery into any occupation. They are so effective especially living in a very stressful, fast-paced society. There is self-distancing involved which we know also helps with the social skills for these kids. Systems thinking and routines with visuals are other options. The more visuals we use, the better for these kids. If we can give them visual imagery, it helps. Here is an example of systems thinking. You have family coming over for Thanksgiving dinner. There are 17 people coming and three courses. Each dish takes this long and I need these ingredients for each. Additionally, these dishes all cook at different times so they come out at the right time. This is systems thinking. As a strategy, I gather my recipes and my materials and then put them in order for which ones I have to cook first and for how long. I form a little assembly line of what I am going to do. We can use this type of strategy for kids who struggle with material management and organization. It can be a game-changer. Other ideas include self-talk, martial arts, aerobics, and Montessori. I do not know if anyone has any experience with a Montessori approach. One of the reasons why it is effective is because Montessori uses self-distancing activities. Telling the kids what you want them to do instead of what you do not want them to do really works. It also includes structured routines that lead to self-regulation.
The last section shows that motor skills, as well as sleep hygiene, can improve sleep. Physical activity actually increases non-REM sleep. Deep pressure and proprioceptive can increase REM sleep. A sleep log is actually evidence-based as well. Shortly, I am going to describe a routine that works with kids that is evidence-based. All of these things here you can use as your evidence-based toolkit to work with kids with ADHD.
Case Study Application- Improve ADLs
Top-down analysis.
Jeremy's goal is to have a timely morning routine which involves waking up, dressing, brushing teeth, and packing a backpack. This is a top-down analysis in Figure 6.
Figure 6. Example of a top-down analysis for ADL routine.
When we use a top-down approach, we are starting with the actual occupation and the goal is to look at where this happens and in what context. I want you to think about where that would happen. In Jeremy's case, it is his bedroom and bathroom. Activity analysis is the bread and butter of OTs. His routine consists of waking up, dressing, brushing his teeth, and packing a backpack. During this analysis, we want to see what he can do and what he cannot do. What are some of your thoughts? Here are some answers from our audience:
- Being aware of time during all tasks/Using a timer. You are seeing a discrepancy between time awareness, time estimation, time monitoring, and time management. I would agree with you that he probably has a hard time all of those.
- Packing the backpack. We know that he is sleepy in the morning and he has a difficult time staying organized. This is especially true if he is half asleep or stressed in the morning.
- Finding his folders. Folders can be elusive sometimes to these kids, so that is a great point. Folders can be found in very strange places.
- Hygiene/organization. Even in hygiene, it is important to make sure that they are organized.
I used a PEO or person-occupation-environment perspective here. We started with some physical activity in the morning to help him to wake up. We did yoga. I asked, "What would Batman do?" He was a big Batman guy. We did some self-distancing by him coming up with strategies for Batman. Or, we used a wresting theme. These activities helped him to be more alert and be able to increase his attention.
We also used a task strip with positive reinforcement to help him see what he needed to do. Visuals can be very helpful for these kids.
Then, we used minimal distractions. We set things out the night before and used that visual so he could match things. We also devised a place where his folders could go. This all might seem trivial, but it really matters for this type of kid. The timer helps as well. You can make it a game.
Activities to Improve ADLs
- Focus on physical activity, motor skills with automaticity and incorporate aspects of yoga to increase sustained attention and memory
- Visual supports and routine with structure
- Self-talk and self-distancing strategies
- Positively reward
To improve ADLs, the key is to focus on physical activity and motor skills with the goal of automaticity. For example, we can incorporate yoga to increase sustained attention and memory. As we talked about earlier, visual supports and structured routines are other great ideas. I cannot emphasize enough the idea of self-talk. This helps with self-regulation and impulsivity on a lower level. The ability to "self-talk" should be pretty solid for kids around the age of seven, but the kids that we are talking about lack this skill. Self-distancing, or having them give strategies to someone other than themselves, is also great. Let them problem-solve and talk it through for someone else, like Batman or John Cena. This way they do not feel like they are picking on themselves or feeling pressured to figure it out for themselves. They are figuring out for someone else, and this strategy is evidence-based. We often forget to positively reward these kids. I like to do something like time with mom and dad, I develop short-term and long-term rewards with mom and dad. For example, Jeremy wanted a wrestling figure for his long term reward. But on a daily basis, he got wrestling bucks and that bought time to wrestle with dad on the weekends.
Case Study Application- Finish a Task with Necessary Supplies
Figure 7. Example of a top-down analysis for finishing a task with necessary supplies.
The next goal is to finish a task with the necessary supplies. You can fill in whatever task that he needed to do like homework, hygiene, or whatever it was with the necessary supplies. Typically, he would start something and then not have all the supplies he needed. He would then run to go get something and then lose track of what he was doing. Activities would not get done and then there would be a mess. We want to know when this would happen and the context. What is required of that activity, and then what can he do versus what he cannot do? Those are the discrepancies.
As I stated a few moments ago, he tends to not have the needed materials. That is the first issue right out of the gate. And because he is impulsive, he starts doing something else. Eventually, he does not finish anything due to a lack of persistence and distractibility. From a personal standpoint, we could work on using motor tasks for increased attention. We know that fine motor and gross motor tasks are going to help. We could also look at using coordination tasks, self-talk, and distancing. Cognitive training is also evidence-based. Can they start to use a checklist or something to create a better strategy?
Then, from an occupation standpoint, again we can use visuals and break down the task. We can also use a tracking system that we are going to go over in just a second.
From an environmental aspect, we can encourage the use of quiet areas to help with sustained attention and better memory. Here we can also use some visual supports or a Montessori approach. "This is what the task is supposed to look like when I am finished." If we have a task, what does the end result look like so that the person knows? And even better, what are the supplies pictured so I know what I have to get first, and then I know what the end result should look like. That is super helpful for someone who is so disorganized when putting materials together.
Activities for Completing Tasks
- Inhibition: Self-talk, slowing down, self-distancing, external feedback
- WM: physical activity
- Attention: physical activity
- Using environmental strategies and visuals to support
- Behavioral: task breakdown, positive reinforcers
- Occupation-based is imperative!
We want to use occupation-based tasks, but we want them to be fun and let the child make a choice. When things are getting easier, we can then move toward less preferred tasks. For example, we do not want to start with homework.
Case Study Application: Social
- Involve a peer or sibling
- Play-based model:
- Capture intrinsic motivations (WWE)
- Empathy focus
- Arrange the environment to foster mutually enjoyable social interaction and imagination
- Teaching social play language and reading expressive body language (can use dogs and their behavior)
- Incorporate parents and coach them so they can coach outside of therapy
(Cordier et al., 2009; Wilkes-Gillan et al., 2016)
There is a play-based model that is evidence-based. They recommend involving a peer or sibling. This play-based model focuses on intrinsic motivation. With Jeremy, we could do wrestling. We could focus on empathy. It is important to arrange the environment so that it is mutually enjoyable. We need to teach social play language and reading expressive body language. The evidence was interesting as it said to use dogs because it could help the child start to read behaviors. Dogs are a little bit easier than people. Jeremy loves dogs so that would work. You could then incorporate parents in order to coach him outside of therapy. They found that to be very successful.
Case Study Application: Sleep
- Turn off electronics 2 hours prior
- Hot bath or shower
- PJs prepped
- Boardgame in room
- Read in bed (parents, then alone
- Highlights with organizer, feelings
- Token reward system
- Flexibility on weekends
- Sleep logs are evidence-based
- Physical activity during day imperative
(Kuhn & Floress, 2008; Fricke et al., 2006)
For sleep, this is the protocol that is highly recommended for these kids. You should turn electronics off two hours prior. Do not shoot the messenger. I know that is really easier said than done. Another protocol is to have the child take a hot bath or shower. They need to have their pajamas prepared. It is a stimulus that can help them progress through the routine. They can do a board game in the room. Another activity is reading in bed. It can start out with the parents reading and then progress to the child reading alone. They can also organize their thoughts and feelings throughout the day. It will help the brain calm down. A token reward system is another great strategy. Make sure to incorporate flexibility on the weekends. It is ok. Sleep logs are evidence-based. And again, physical activity during the day really works.
Systems and Organization
This information is what we already talked about, but I wanted to give you a good resource as well in Figure 8.
Great resource: https://www.understood.org/~/media/040bfb1894284d019bf78ac01a5f1513.pdf
Figure 8. Systems and organization examples.
I like the idea of a mental movie approach. If they are piler and not a filer, we have to appreciate that and try to use things that can help them. This may be an accordion folder or something like that.
Self-Monitoring: GOAL Attainment Scaling
This is the idea of a Goal Attainment Scale (see Figure 9). It is a strategy to identify changes in academic and social behavior. It creates habits and routines.
Figure 9. Goal Attainment Scale overview.
The way that you do it is you select the target behavior. You describe that behavior outcome in objective terms and then you develop three to five (I typically use five) descriptions of probable outcomes from least favorable to most favorable.
Figure 10. Numerical ratings for the Goal Attainment Scale.
These are some options that you can use, frequency, quality, usage, percent complete.
- Frequency (Never–Sometimes–Very Often–Almost Always–Always)·
- Quality (Poor–Fair–Good–Excellent)·
- Development (Not Present–Emerging–Developing–Accomplished–Exceeding)·
- Usage (Unused–Inappropriate Use–Appropriate Use–Exceptional Use)·
- Timeliness (Late–On-Time–Early)·
- Percent complete (0%–25%–50%–75%–100%)·
- Accuracy (Totally Incorrect–Partially Correct–Totally Correct)·
- Effort (Not Attempted–Minimal Effort–Acceptable Effort–Outstanding Effort)·
- Amount of Support Needed (Totally Dependent–-Extensive Assistance–Some Assistance–Limited Assistance–Independent)·
- Engagement (None–Limited–Acceptable–Exceptional)
This is what the five looks like. You have two choices. You can do a baseline here at zero or the baseline at minus two where that is the worst with no change. Or, you can start at their baseline here at two and only go up. If they cannot handle seeing that they went down, you might choose that option instead. We do not want any negative things causing them anxiety. I have also listed the actual ratings. Here is the example for our friend Jeremy in Figure 11.
Figure 11. GAS scale example for Jeremy.
He wanted to perform his AM routine within 20 minutes according to his mom. On the first date, he was a +1, which is he did only 75% within 20 minutes. On Day 2, he had 50% of his stuff done within 20 minutes. Day three, he had only 25% done. On four, he was back up to 75%. Day five, he did everything in 20 minutes. Day six, he was back to 75%. And then you see on days seven and eight, he actually met his goal. And on day nine, he almost met his goal. Once you plot the dates you have a graph. This shows change over time and whether or not things are working. You can also do this at home to capture the change in a more specific and sensitive way. On that note, we focused on time.
Thanks for joining me today. I hope you find the information helpful. Feel free to reach out to me if you have any questions.
Best, J. R., & Miller, P. H. (2010). A developmental perspective on executive function. Child Development, 81 (6), 1641-1660.
Cremone-Caira, A., Root, H., Harvey, E. A., McDermott, J. M., & Spencer, R. M. (2019). Effects of sleep extension on inhibitory control in children with ADHD: A pilot study. Journal of Attention Disorders , 1087054719851575.
Corkum, P., Tannock, R., & Moldofsky, H. (1998). Sleep disturbances in children with attention-deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 37 , 637-646.
Cordier, R., Bundy, A., Hocking, C., & Einfeld, S. (2010). Empathy in the play of children with attention deficit hyperactivity disorder. OTJR: Occupation, Participation, and Health, 30 (3), 122-132.
Diamond, A. (2012). Activities and programs that improve children’s executive functions. Current Directions in Psychological Science, 21 (5), 335-341.
Levanon-Erez, N., Cohen, M., Traub Bar-Ilan, R., & Maeir, A. (2017). Occupational identity of adolescents with ADHD: A mixed methods study. Scandinavian journal of occupational therapy, 24 (1), 32-40.
Hahn-Markowitz, J., Berger, I., Manor, I., & Maeir, A. (2016). Efficacy of cognitive-functional (Cog-Fun) occupational therapy intervention among children with ADHD: An RCT. Journal of Attention Disorders , 1087054716666955.
Faber Taylor, A., & Kuo, F. E. (2011). Could exposure to everyday green spaces help treat ADHD? Evidence from children's play settings. Applied Psychology: Health and Well‐Being, 3 (3), 281-303.
Fricke L, Mitschke A, Wiater A, Lehmkuhl G. 2006. A new treatment program for children with sleep disorders – concept, practicability, and first empirical results. Prax Kinderpsychol Kinderpsychiatr 55 :141–154.
Keshavarzi, Z., Bajoghli, H., Mohamadi, M. R., Salmanian, M., Kirov, R., Gerber, M., ... & Brand, S. (2014). In a randomized case–control trial with 10-years olds suffering from attention deficit/hyperactivity disorder (ADHD) sleep and psychological functioning improved during a 12-week sleep-training program. The World Journal of Biological Psychiatry, 15 (8), 609-619.
Kuhn BR, Floress MT. (2008). Nonpharmacological interventions for sleep disorders in children. In Ivanenko A, ed. Sleep and psychiatric disorders in children and adolescents . New York, NY: Informa Healthcare USA Inc. pp 261–278.
Majored, M., Tüchelmann, T., & Heusser, P. (2004). Therapeutic Eurythmy—movement therapy for children with attention deficit hyperactivity disorder (ADHD): a pilot study. Complementary therapies in Nursing and Midwifery, 10 (1), 46-53.
Pan, C. Y., Tsai, C. L., Chu, C. H., Sung, M. C., Huang, C. Y., & Ma, W. Y. (2019). Effects of physical exercise intervention on motor skills and executive functions in children with ADHD: A pilot study. Journal of Attention Disorders, 23 (4), 384-397.
Papadopoulos, N., Stavropoulos, V., McGinley, J., Bellgrove, M., Tonge, B., Murphy, A., ... & Rinehart, N. (2019). Moderating effect of motor proficiency on the relationship between ADHD symptoms and sleep problems in children with attention deficit hyperactivity disorder–combined type. Behavioral Sleep Medicine, 17 (5), 646-656.
Tandon, P. S., Sasser, T., Gonzalez, E. S., Whitlock, K. B., Christakis, D. A., & Stein, M. A. (2019). Physical activity, screen time, and sleep in children with ADHD. Journal of Physical Activity and Health, 16 (6), 416-422.
Toplak, M. E., West, R. F., & Stanovich, K. E. (2017). The assessment of executive functions in attention-deficit/hyperactivity disorder: Performance-based measures versus ratings of behavior.
Tseng, M. H., Henderson, A., Chow, S. M., & Yao, G. (2004). Relationship between motor proficiency, attention, impulse, and activity in children with ADHD. Developmental Medicine and Child Neurology, 46 (6), 381-388.
Wilkes-Gillan, S., Bundy, A., Cordier, R., Lincoln, M., & Chen, Y. W. (2016). A randomised controlled trial of a play-based intervention to improve the social play skills of children with attention deficit hyperactivity disorder (ADHD). PLOS one, 11 (8), e0160558
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Quint, N. (2020). Pediatric case study: Child with ADHD. OccupationalTherapy.com, Article 5145 . Retrieved from http://OccupationalTherapy.com
Nicole Quint has been an occupational therapist for over 15 years, currently serving as an Associate Professor in the Occupational Therapy Department at Nova Southeastern University, teaching in both the Masters and Doctoral programs. She provides outpatient pediatric OT services, specializing in children and adolescents with Sensory Processing Disorder and concomitant disorders. She also provides consultation services for schools, professional development, and special education services. She provides continuing education on topics related to SPD, pediatric considerations on the occupation of sleep, occupational therapy and vision, reflective therapist, executive functions, leadership in occupational therapy and social emotional learning.
Related Courses
Making sense of meltdowns: how to identify and intervene for children with sensory based disruptive behaviors, course: #3106 level: intermediate 1 hour, fun, practical, client-centered activities to encourage social emotional development in pediatric practice, course: #3158 level: intermediate 2 hours, pediatric case study: child with oculomotor and perceptual challenges, course: #4536 level: intermediate 1 hour, course: #4577 level: intermediate 1 hour, motor skill acquisition for optimal occupational performance, course: #3747 level: introductory 1 hour.
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A Case Study on the Treatment of ADHD in Pregnancy
Attention-deficit/hyperactivity disorder (ADHD), once predominantly thought to be a disorder of childhood, is now recognized as commonly persisting into adulthood and the prime reproductive years. The author presents a case of a woman with a history of ADHD who is stable on stimulant therapy and presents for preconception counseling. The patient’s history is presented, and preconception counseling is provided. The author considers how clinicians should provide preconception counseling to women with ADHD by reviewing functional impairment caused by ADHD, in addition to the risks of ADHD treatment on the developing fetus.
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is common disorder among US adults, with a prevalence of approximately 4.4%. 1 Although there is a lack of data on the impact of ADHD on pregnancy, information from the general population has shown that ADHD can cause significant functional impairment. There are very effective pharmacologic treatment options for ADHD. However, knowledge about the impact of these medications on the developing fetus is limited. These two factors make preconception counseling for ADHD challenging. Here, the author presents a case of a woman seeking preconception counseling and the means by which a clinician should determine how to provide such counseling.
Case Report
Mrs. L. is a 38-year-old, married white woman with a history of ADHD. She presented to a reproductive psychiatry program for preconception counseling regarding treatment of her ADHD during a future pregnancy. Her symptoms were well controlled on a regimen of methylphenidate extended-release, 20 mg twice daily and methylphenidate immediate-release, 5 mg nightly. She had a history of the attentional subtype of ADHD, which was first diagnosed when she was in her early 20s; in retrospect, however, she admitted awareness of her symptoms from an early age.
Prior to stimulant treatment, she had had significant difficulty sustaining attention. When practicing the piano, she found herself “looking at the sky,” and when working, she became teary-eyed and overwhelmed by simple tasks such as having to answer the phone. These symptoms caused significant functional impairment, including an inability to finish her undergraduate degree at an Ivy League institution and to sustain full-time work. Results of neuropsychologic testing 14 years prior were consistent with attentional deficits and she had been started on stimulant treatment 9 years prior with significant improvement. With treatment, she was able to finish her undergraduate degree and had started a master’s degree program.
She has been on stimulants continuously for the past 9 years. She was uncertain if she wished to have children, but was concerned about the effects of her medication on a possible pregnancy and sought guidance prior to conception. She was counseled about the limited data on the effects of stimulant medication on the developing fetus. Given the paucity of data, it was recommended that, prior to conception, she attempt a slow taper off her stimulants. However, should she have a significant decline in functioning, she should consider remaining on stimulants during pregnancy. After the consultation, she decided not to conceive, but indicated that this decision was not based on the recommendation to attempt a taper off her stimulants.
ADHD is a common neuropsychologic disorder diagnosed by a careful clinical history. It is characterized by symptoms of inattention and/or hyperactivity and impulsivity. According to the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the symptoms must be present before age 7 years and occur in two or more settings. They must cause significant social, academic, or occupational impairment, and cannot be better accounted for by another mental disorder. 2 Once thought to be a disorder of childhood, it is now well recognized that the majority of cases persist into adulthood, during the prime reproductive-bearing age for women.
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“I Couldn’t Focus On Anything” : An ADHD Case Study
By: Practical Cures
by Andrea M. Darcy
Do you worry that you, or someone you love, has ADHD? Here I share my personal experience of just what it’s really like to grow up with attention deficit hyperactivity disorder.
(Want to read a list of symptoms? Read our comprehensive Guide to ADHD ).
ADHD – A Case Study
“It’s like she lives in a bubble of her own making”, read the note one teacher sent home to my parents. But as usual, my habit of not being present was just attributed to shyness and intelligence. Like many kids with ADHD , I was exceedingly bright.
The new research on ADHD now recognises that many girls go undiagnosed because instead of hyperactivity, they are prone more to the major symptom of inattention. They are dreamy and always ‘clocking out’. That was me.
Although to be fair, I did have hyperactivity too. I’d get overexcited, or as my mother would say, ‘she’s on the ceiling again’. After I’d crash and need a nap. My mother felt it was chocolate and treats that caused i,t so I was not allowed any.
I had a lot of stressful experiences because of my ADHD that I now realise other kids probably didn’t. For example, I had to pull my first all-nighter aged only eight. We knew we had a science project to do all year. And I procrastinated and then did the entire thing in the 24 hours before it was due, crying from the stress. But I still won second place.
Surviving adolescence with ADHD
By adolescence my ADHD was in full force, but it was just attributed to ‘ being a teen ‘. High school was in Canad.a (My father, who I’ll get back to, was always moving us. I went to eight different schools in total.)
I was inevitably late for my first class every day. I struggled to remember my schedule, was often losing things, and would get in trouble for chatting in class. Simply as I was too distracted to see that the teacher was talking again. Again, because I was smart and had good grades, teachers overlooked a lot of my behaviour.
By: Richard Smith
Socially I can see my ADHD was a problem. I would join teams then drop out. And became known for changing my social groups ‘like she changes her clothes’, I overheard someone say. The comment stung.
I now see this was the ADHD symptom of impulsivity . It was the same issue that had me rip a portrait into pieces in the middle of art class when I couldn’t quite get the face right. I was incredibly embarrassed to see my teacher and fellow students staring at me, the pieces of my artwork on the floor.
Over focus, putting too much energy on the wrong thing, was also big issue. I would spend hours making the perfect cover for an assignment. Then have to do the assignment itself frantically at the last moment.
A ‘special exception’ is made
I got sent to the principal’s office for skipping a lot of classes. I explained that I was bored out of my mind. They could see something was different with me, I see that now. The said I was ‘too smart’ and needed an exception. I could go to class when I wanted as long as I maintained high grades. Now this makes me sad. I often think, what if they had of realised then I had ADHD? How would my life be different? My intelligence was a curse really, it meant I kept not getting help.
Can ADHD ruin your life? Put it this way. I forgot to choose my classes in time for my final year of high school, and the ones I needed to graduate were full. I was so upset I dropped out of school for a month and looked for a job. But I knew it was the wrong thing to do, so then frantically found another high school to take me. But I had to travel two hours a day to get there and back, and spend my last year at a school where I knew nobody.
University life with adult ADHD
University was a shock. I just couldn’t focus on anything, and I had no idea how to be organised and study. The teachers didn’t know me, so were far from forgiving with my poor timekeeping and tendency to talk loudly out of turn.
I had to maintain straight As to keep my scholarship and there was an art class I took as an elective. The teacher obviously didn’t like me, despite my art being better than most. And gave me a B+ instead of an A, even though I scored high on all my assignments. It meant the rest of university I had to work two jobs to get by, which just made me even more of a scattered mess.
ADHD and dating
By: martinak15
In university I also started dating. This is one area where I think people need to talk about the damaging effects of ADHD more. I would rush into things before I knew someone then panic.
My tendency of talking in circles, or of wandering off mid-conversation, often had dates tell me they “couldn’t keep up with me”. Then there was the time I really liked someone and found out later he had no idea I was interested. I guess my distracted nature gave the entirely wrong sign.
Just like high school, I briefly dropped out of university, bored. Before begging my way back in at the last moment and finishing my degree. By the time I graduated, I was depressed.
I now realised there was something wrong with me, but just blamed myself for my inability to focus and be organised.
Finally getting the diagnosis of Adult ADHD
I began to drink and go out a lot, I suppose to bolster my falling self-esteem. It was at a party that I met a woman who spilled her soul to me, admitting she was seeing a psychiatrist for depression . I was fascinated. Could this help me? I’d never thought to try. She said she’d give me the number. I of course delayed calling for several weeks, but bumped into the woman again and felt pressured to go through with it.
And that was how I ended up sitting in a psychiatrist’s office across from a rather glamorous and aloof blonde doctor, expecting to be given antidepressants. Instead I was told I had ADHD and was offered a prescription for Ritalin . I walked out in a daze. I knew what ADHD was, but in my mind it equated to hyperactive children, not a 23 year-old like me. The way this woman diagnosed me in one hour flat left me feeling misunderstood and judged, too. I threw out the prescription, cancelled the next appointment, and didn’t talk about the experience to anyone.
Of course my life continued to be a mess. I kept messing up big opportunities by being impulsive. Like having a coveted big acting break, but instead hopping a plane and leaving the country when offered a last minute job teaching in Japan. My life was fun, but I was scattered, stressed, and lonely, and the depression kept returning.
Trying therapy when you have Adult ADHD
By: Banalities
At 28, feeling really awful about my inability to stay in a relationship, I again took a therapy referral from a friend.
This psychotherapist specialised in CBT ( cognitive behavioural therapy ). A slight man with little John Lennon glasses and a pink Ralph Lauren shirt in a soulless office with imitation expressionist art, I was sure it wouldn’t work and wanted to run out screaming.
I told him I had been diagnosed as ADHD but was sure it was a mistake. He ran me through a series of questionnaires and confirmed I did have it. But he said he was optimistic CBT would help.
My friend pushed me to try four sessions before quitting, promising me four was a magic number somehow. And oddly, she was right. Something clicked on the fourth session. I walked out liking him better and feeling hopeful I could make changes in my life.
This was the therapist that taught me about mindfulness meditation . It turned out he’d gone to Berkeley back in the day, and he was a lot cooler than his bad outfits. Near the end of my four months working with him I even went to a one-week meditation retreat, excited by how much calmer and focussed the meditation made me.
I continued the mindfulness meditation, and kept using what I had learned from the CBT process about questioning my thoughts before taking action. It really helped with my impulsivity and I had a few good years after that.
What other forms of therapy did I try?
I also tried psychodynamic psychotherapy . Friends had great results from it, but I would say that in some ways (and now I’ve read research to prove it) that was not the best choice for someone with ADHD. I started to overanalyse myself ,and my self-esteem , which people say therapy usually helps, got worse.
I do feel CBT is really a good choice for ADHD, as it helps reorganise the brain. Or nowadays I’d try a therapist who specialises in ADHD clients and see what they have to offer.
Life when you have Adult ADHD
I think that just accepting I had ADHD was the most helpful. It meant I could be more patient with myself, and focus on learning new ways of doing things that make living with ADHD easier . I am a huge fan, for example, of using a timer, as I have absolutely no sense of time and it helped me realise what can and can’t be done in an hour.
As for telling my family, I avoided it for years. I have an older sister who is very cynical and always making fun of my ideas about myself. To my surprise , when I did tell her about my diagnosis, she said she had thought so, and that it was hardly a surprise given our father. My father is a good example that ADHD often has a genetic component. He never sits down, never finishes a conversation. Alongside all those moves he put us through, he also burned his way through many jobs and is now on his fourth wife.
Did I try medication?
Yes. But not until an older adult. I was living in France at the time where the only option was was methlyphenidate. I tried both long release Concerta and just instant release Ritalin.
And it was awful, it did not work at all for me, no matter how I took it. It gave me bad headaches, severe insomnia, but what was the worst was that I was so dulled down I felt stupid. Yes, I’d sit oddly still for hours. But I’d get done in 4 hours what I could do in one hour unmedicated. So I stopped using any of it. I also then tried modafinil, it was the same thing. I felt spacey, stupid, slow, tired, and had brutal headaches.
Instead, now I make sure I keep up a regular routine of exercise, eat healthy, and take things like fish oils, which I feel help.
Would I wish to not have attention deficit disorder?
Of course being hard on oneself is another ADHD attribute, and when I remember that I try to shift my focus to see all I have achieved. I’ve travelled extensively, I run my own business, I was the first person I know to be a ‘digital nomad’, as I am always way ahead of the curve… I am doing ok.
And in some ways, I would not want to exchange the good sides of ADHD as I don’t know who I’d be without them. Like the way I can think fast and under pressure, see multiple perspectives all at once, be incredibly creative, etc.
If you feel you might have ADHD, it’s best not to self diagnose. Talk to your GP or book an assessment with a psychiatrist who specialises in Adult ADHD .
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I found this article very interesting thank you!
I just wonder how you managed to get mindfulness to work for you with impulsivity? Whenever I have tried it I either get too bored or unmotivated to do it, or I forget to do it when it really matters!
Hi Lauren, there are several things to try here. One is a support system. Join a group of others who you have to check in with, or have a mediation buddy who you check in with, or use an app that shares results with other users. Sometimes just knowing there is an audience can make even the most distracted amongst us more likely to perform. A timer is pretty essential too. And then there is the simple idea that you make it a non negotiable. You decide you will have a mindfulness practise, come what may. When you judge it as boring, you recognise that thought, let it go, and stay where you are, meditating, until that timer goes off. When you don’t want to do it, you again recognise this is just a thought, and that you have the choice to do it anyway. Brushing your teeth is pretty boring too, but we’d guess you’ve made that a non negotiable… see meditating as that important. the point is to do it every day if possible, so that it isn’t a case of doing it when it matters/doesn’t matter but an ingrained habit. With time you’ll see palpable results, and then you’ll probably want to keep it up, but until then, do it anyway. If there are days that are bad days and you miss it, then you don’t judge yourself. You just start again the next day. Best, HT.
Case Study in Attention Deficit Hyperactive Disorder
The corrective aspect of craniosacral fascial therapy.
Submitted to Explore for publication February 28, 2008
For verification of this report, please contact: Riley Hoekstra’s mother and father Joanna and Jason Hoekstra 96 Ridge Road Phoenixville, Pa. 19460 610-733-9810 [email protected]
His treating medical doctor is: Penn Care for Kids Dr. Amy Klein 824 Main Street Suite 100A Phoenixville, Pa. 19460 610-935-1330
Introduction
ADHD is a range of pediatric behavioral disorders, including such symptoms as poor concentration , hyperactivity, and impulsivity . Approximately 1,600,000 or 7% of American children from ages six to eleven have been diagnosed with ADHD.¹ The prevalence of ADHD is three times more in boys than in girls.¹
Conventional treatment consists of the long-term administration of methylphenidate. An alternative method of care can include the evaluation and treatment of the child’s craniosacral fascial system, which is an integration of the craniosacral and fascial or connective tissue components.
Literature Review
In 1899, William Sutherland D.O. discovered the craniosacral concept when he found that the brain had a slight “breathing” motion.² In the 1980s John Upledger D.O. discovered that cranial strain from trauma was primarily held in the meninges around the brain and not in the cranial bones.³ While physical trauma caused chronic conditions such as ADHD, manipulative therapy could restore normal neurophysiology and health to an individual.⁴
The fascial or connective tissue component of the craniosacral fascial system is a full body web that intertwines and infuses with every structural cell including nerves, muscles, blood and lymph vessels, organs, and bones.⁵ John Barnes P.T. found in trauma the fascia can become strained, leading to many diverse symptoms and conditions.⁶ These strain patterns can pull anywhere in the body, including the craniosacral structures, at up to 2,000 pounds per square inch.⁶
Anatomically in the craniosacral fascial system, the cerebrospinal fluid begins in the choroid plexus of the ventricles, gently fluctuates through the craniosacral tissues, and flows within the cranial and spinal nerve sheaths out into the fascial collagen tubules.⁷ Researchers confirmed this whole body system upon discovering cerebrospinal fluid in these tubules with surprisingly no ordinary ground substance, blood, or lymph present.⁸
The Goal of Craniosacral Fascial Therapy
The primary goal of therapy is to relieve the causative strain patterns around the brain. Traumas can occur anytime after conception, most notably due to the natural pressures and/or the mechanical intervention of birth . The brain cycle , the amount of seconds the brain inherently expands and contracts, is the best indicator to measure the function of the craniosacral fascial system.⁹
The clinical goal is a minimum brain cycle of fifty seconds, twenty-five seconds in the expansion phase and twenty-five seconds in the contraction phase. As brain cycles may go well over one hundred seconds, it appears that the longer the brain “breathes” and the easier the cerebrospinal fluid flows, the better the brain can function. Over the years methylphenidate has helped millions of children with ADHD, but now clinicians can directly address and correct a possible neurological root of the problem.
Case Presentation
A twenty-seven-month-old boy presented on November 8, 2006 for evaluation. His mother said his extreme hyperactive behavior necessitated the visit. He also had ear pain and frequent rashes .
Five months into her pregnancy she started to have Braxton Hicks contractions, which her doctor did not consider serious. When her contractions became intense at seven months, he admitted her into the hospital overnight and gave her magnesium sulfate to stop the birth. At eight months she was injured in a minor automobile accident, which did not appear to affect her fetus. At thirty-seven weeks since she had high blood pressure, could not sleep, and started heavy contractions again, her physician induced her.
When the fetus crowned, the doctor manually turned the head around to a more natural position. When the child was two days old, his body shook and he did not eat. When his blood sugar dropped precipitously, he spent an extra day in the neonatal intensive care unit to recover.
His parents first noticed unusual behavior at eighteen months of age when he started to screech and bang his head. As time went on, he became easily distracted, would not listen, and could not focus on any task. He often pulled his painful ears although he never had an ear infection.
His mother observed that he broke out in a rash while eating wheat cereal and upon exposure to certain chemicals around his home. He continually picked the skin of his arm to the point where it became raw. The only medication he had was an occasional infant’s acetaminophen in drop form (eight-tenths of one milliliter) for his ear pain. He was up-to-date on his immunizations.
She questioned his pediatrician about his bizarre behavior. His doctor was primarily concerned about a possible obsessive-compulsive disorder when day care sent home a report saying that he spent one hour washing his hands. The physician ordered a Developmental Assessment of Young Children Test that showed he was cognitively seven months behind his peers. The county health department then referred physical and occupational therapists to his home for weekly treatment.
There was no institutional pressure to calm him down with methylphenidate. But after he became totally disruptive one day by biting other children and screeching that could shatter fine crystal, his mother called me frantically saying that he had been “kicked out of day care!” Can she bring him for an evaluation as soon as possible?
Clinical Findings
When I held his cranium, I could not feel any perceptible motion. His brain cycle was zero seconds ; his tight cranial bones, sacrum , and dural tube were restricting the normal motion of his entire craniosacral fascial system. His left temporal bone was internally or medially rotated, and his right temporal bone was externally or laterally rotated. His oral structures were not a factor.
I explained to his mother that he had severe craniosacral fascial strain, which was totally restricting the motion of his brain. I outlined a series of thirty-minute visits to return his system to normal. At this point his desperate mother was ready to try any non-invasive approach.
Treatment and Results
The goal of his first treatment visit on November 8, 2006 was to help free his brain from the zero second state. His brain cycle opened to fifteen seconds as his cranium shifted to a more symmetrical position. His parents noticed that he behaved better the following week. During that time the allergy specialist also put him on a wheat-free diet . At the end of the second visit his cycle was at forty seconds, excellent progress from zero motion.
At his third visit the fascial strains from the craniosacral fascial system contributing to his brain tightness started to release from the rest of his body. When therapy mitigated these strains over the next five visits, his cycle opened to an acceptable seventy seconds. In between these visits he broke out in rashes as his body appeared to clear toxins through his skin . At the end of therapy his craniosacral fascial system was in synchronicity, and his head shape was symmetrical.
His mother said he became a different child. He was calmer and more attentive and ceased his head banging , screeching , and ear pulling . He also stopped biting other children and picking at his arm. His speech improved dramatically after the first three visits by enunciating his words more clearly and speaking in coherent sentences. She was able to now touch his head with activities such as hair washing and combing.
At his new day care center his teachers did not believe that he ever had a behavioral problem. He followed directions and participated in group functions like the other children. His physical and occupational therapists did not believe the change in his demeanor. He did not abuse his older sister, and there was now peace in the home.
About four months later on the morning of May 17, 2007 he fell approximately two feet from a table at school directly on the left side of his frontal bone . He was incoherent for about ten seconds, started to gag four or five times, and then screamed for five minutes, louder than anyone at school had ever heard him. When his left eye started to droop and redden, the emergency room physician ordered a CAT scan, which was normal.
For the next ten days his behavior became more challenging at home; he started biting his sister again, screeched, and had conduct issues at the dinner table. When he also had more trouble at school being rough with his classmates, yelling, not listening to directions, and not taking naps , his mother called me requesting a check-up visit.
Because of his previous therapy, the cranial dural meninges quickly released from his zero brain cycle in one visit, opening to an amplitude of one hundred seconds. She took him directly back to school without mentioning the nature of his appointment to anyone.
The next day his teacher told her that he was a completely different little boy. He used words more than actions in conflicts and noticeably thought of things before just doing them. He also took the longest nap he has ever taken that day. In the following weeks he behaved better at home, talked more, and slept well. He stopped biting his older sister, and peace returned once again.
Over the next nine months, I treated him within days after he had three separate injuries. Boys will be boys, as they jump off sofas and run outside and fall. In each case he presented with a single digit brain cycle with the accompanying issues, and each time left the office symptom-free with over a one hundred second brain cycle. The quality of his brain motion appeared to directly mirror his neurophysiological state; as long as his brain was “breathing” well, he was healthy and happy.
Three important aspects appeared to contribute to his recovery. First he avoided the toxic chemicals that were causing his skin rashes. Secondly, his mother eliminated wheat products, which the allergist said irritated his immune system. Lastly, craniosacral fascial therapy released the pressure around his brain, spinal cord, and fascial system to achieve neurophysiological homeostasis.
Craniosacral fascial trauma may also cause many other conditions such as asthma , headache, otitis media , strabismus , dysphagia , rhinitis , epilepsy , gastroesophageal reflux , otitis media, and colic .⁹ ¹⁰ Many children can experience correction of these illnesses as the craniosacral fascial strains are released over a series of visits.
After treating hundreds of children over thirty years with zero brain cycles, I have found that craniosacral fascial therapy is a key factor in the healing of the central nervous system . The slight physiological motion of the brain, affecting the flow of cerebrospinal fluid, has a tremendous influence on its function.¹¹ Many children, like this child, may be instinctively pulling their ears and banging their heads just to free up their own craniosacral fascial systems.
This severely restricted state has a predilection to take a slightly moving brain that may more commonly cause asthma, otitis media, and headache to the brain-injured depths of poor concentration, impulsiveness, hyperactivity, epilepsy, autism , and/or cerebral palsy . The quality of cerebrospinal fluid flow may be the key.¹² ¹³ Going from minor flow with minuscule brain motion to stagnation with no palpable movement may be a huge leap into the abyss of clinical neuropathology.
Another hypothesis suggests that if a child has severe restriction in his midbrain area involving the aggregate of his basal ganglion (putamen, substantia nigra, caudate nucleus, globus pallidus, and subthalamic nucleus), cerebellum, thalamus, and/or hypothalamus, physicians may commonly diagnose him with ADHD. With so little known in relating the quality of brain motion to pediatric neurophysiology, basic science research is urgently needed.
This child may have fallen through the cracks of the health care system as early as the birth. To help prevent ADHD and the other chronic pediatric diseases, birthing professionals must evaluate the craniosacral fascial system and treat newborns at the very beginning of life. Healthcare practitioners must also check them at well-visits to mitigate the normal bumps and bruises of childhood that may cause craniosacral fascial restriction.
The effectiveness of craniosacral fascial therapy for children with ADHD merits a research group to follow up with a pilot study . With this new piece of the neurological puzzle, the answer to ADHD and other central nervous system illnesses may be closer at hand.
1. Vital Health Statistics 10. Center for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, Md. 2006 Dec; (231): 1-84. 2. Sutherland, W. The Cranial Bowl. Mankato, Minn: Free Press Company, 1939. 3. Upledger, J., Vredevoogd, J. Craniosacral Therapy. Chicago: Eastland Press, 1983. 4. Magoun, H. Osteopathy in the Cranial Field. 3rd edition. Kirksville, Mo: Journal Printing Company, 1976. 5. Barnes, J. Myofascial Release: The Search for Excellence. Paoli, Pa: Rehabilatation Services T/A Myofascial Release Treatment Centers and MFR Seminars, 1990. 6. Katake, K. The strength for tension and bursting of human fascia. Journal of Kyoto Professional Medical University 1961; 69: 484-488. 7. Juhan, D. Job’s Body: A Handbook for Bodywork. Barrytown, New York 12507: Station Hill Press, 2003, page 73. 8. Kessel, R., Kardon, R. Tissues and Organs: A Text-Atlas of Scanning Electron Microscopy. San Francisco: W. H. Freeman and Company, 1979, page 15. 9. Gillespie, B. Case study in pediatric asthma: the corrective aspect of craniosacral fascial therapy. Explore: The Journal of Science and Healing. January 2008 Vol. 4, Issue 1, pages 48-51. 10. Gillespie, B. Healing Your Child. Philadelphia: Productions for Children’s Healing, 1999. 11. Gillespie, B. Brain Therapy for Children and Adults. Philadelphia: Productions for Children’s Healing, 2000. 12. Still, A. The Philosophy and Mechanical Principles of Osteopathy. Kansas City: Hudson-Kimberly Publishing Company, 1902, page 39. 13. Netter, F. The Ciba Collection of Medical Illustrations Volume 1 Nervous System Part 1 Anatomy and Physiology. West Caldwell, N.J. 07006: CIBA Pharmaceutical Company, 1983, page 31.
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