As occupational therapists, it is our core function to ensure that our patients are able to function at their optimal levels in the activities of their everyday lives. WFOT defines occupations as the “everyday activities that people do…to occupy time and bring meaning and purpose to life. …include things people need to, want to and are expected to do.”
It is important to realise that ADHD is a real condition and not just bad behaviour, ill-disciplined children, a result of bad parenting or poor eating habits. While all of these can cause disruptive, maladjusted behaviours, these will be qualitatively different from ADHD and will need different management and treatment.
There are also other psychological and neurological conditions which can cause similar behavioural problems. This is why it is important to refer a child with on-going behavioural problems for a full assessment by a paediatric neurologist or psychiatrist.
There is no single test that can give a diagnosis and so the Neurologist will do an examination to rule out other neurological conditions and conditions resulting from dietary difficulties or sleep disturbances (eg: Low iron levels in the blood can cause listlessness and
difficulty maintaining attention; poor sleep due to congestion can cause poor attention and irritability). Sensory processing disorders often cause children to display hyperactive or even aggressive behaviours when their sense are overloaded; some may ‘shut down’ and appear inattentive. The key difference between these children and ADHD children is that you will notice over time and different situations, that their behaviour is situation-specific while the ADHD child’s behaviour happens in many different situations.
A strong reliance has to also be made on a full history given by the parents as well as information (usually in the form of completing a checklist) given by the teachers and other key people involved in the child’s care.
What is ADHD?
It is a condition involving the neural pathways in parts of the brain responsible for Executive Function, attention and inhibition. (Neuroimaging nowadays shows differences in the dorsal prefrontal cortex and basal ganglia; and positron emission tomography [PET] shows reduced metabolic rates in the left sensorimotor areas in children with ADHD and in the premotor and superior prefrontal cortices in ADHD adults (see 1 below) Dopamine, a neurotransmitter, is not working optimally in these pathways. Methylamphetamine medication increases the amount of dopamine available in the neural synapses, thus increasing the efficiency of neural transmission in people who have ADHD.
What is Executive Function (EF)? It is our ability to regulate our behaviours and to be goal-directed. It is our cognitive ability to stop an action, monitor and change our behaviour when needed; to plan ahead and to re-organise our approaches when faced with new and novel situations. We use our EF to anticipate outcomes and to be able to think abstractly; Working Memory is also part of EF and allows us to hold information in our heads while we manipulate
it and test it (an obvious example is mental arithmetic; but you can also see it when we decide that if we punch that big, muscle-bound brute who bullies us on the nose, we are likely to get beaten to a pulp – and so we refrain and choose rather to walk away, unavenged.
What do the Basal Ganglia do? They are very involved in voluntary movement control, emotions and “action selection” (ie: the choice of which of many possible behaviours to execute at a given time). They are closely linked to EF.
ADHD is what is known as a “spectrum disorder”. That is a disorder that can exist very mildly, right through to debilitating. This is one of the reasons there is often debate about many children as to whether or not they are on the ADHD “spectrum”. Not everyone on the
spectrum will be diagnosed or will need therapy. It depends on how it is impacting on the person’s life (social, educational, emotional, financial).
The inability to maintain focus of attention and to hold information in your head has a big
impact on our ability to learn. Therefore children with ADHD are often under-performers at school. They need extra input, time and multi-modal input to help them take in all the information, process it and have it available for later.
Let’s have a look at what the symptoms are:
ADHD children are likely to display the following symptoms:
- If the child about whom you are concerned checks 6 or more of the following, he or she should be referred for assessment. -
Note that the degree of the symptom should be maladaptive to the developmental age of the child and should have been present for at least 6 months.
i. Often has difficulty organising tasks and activities
ii. Often avoids or is reluctant to do tasks requiring sustained effort
iii. Is often easily distracted by extraneous stimuli
iv. Often forgets or loses things
i. Often fidgets or squirms in seat
ii. Often leaves seat in classroom
iii. Often runs or climbs excessively where inappropriate
iv. Often has difficulty playing quietly
v. Is often ‘on the go’ or acts as if ‘driven by a motor’
vi. Often talks excessively
i. Often blurts out answers before questions have been completed
ii. Often has difficulty awaiting turn
iii. Often interrupts
Is medication the only treatment? Is it the best treatment?
The answer to these two emotive questions is that medication is ONE of the treatments available and in some children it is a key constituent of the overall therapy and management;
but it is not the only treatment and should not be used in isolation. Home and class management, support and training to help the ADHD child develop appropriate coping strategies are very important. Research has shown over and again that the best outcomes result from combined therapy.
As a teacher, you are not expected to be able to diagnose ADHD, SPD (Sensory Processing Disorder) or any of the many other conditions that affect children’s behaviour and ability to learn. But you are in a key position to observe their behaviour and see developmentally inappropriate or maladaptive behaviour. Knowing what to look out for and understanding the implications on the child’s ability to socialise and to achieve academically at his actual potential will help you decide how best to help the child and parents.
What to do about the child displaying maladaptive behaviour?
1. Keep a record of when you first noticed the behaviour and every time since (describe the
Note the situations in which it occurs: eg: in group work or play; independent work or play; outings (where were you? Was the place particularly noisy/busy/quiet?; had there been sudden changes to a set plan/outing/lesson?)
Could the behaviour be explained by over- or under-reaction to sensory stimuli in the games or the environment?
Note what intervention you tried and what the response was.
2. Check with other teachers to see if they have observed similar behaviours.
3. Discuss the child’s behaviour with the parent in a private meeting.
Explain that you are not making assumptions or trying to diagnose; but that the behaviour is causing for the child in certain situations (this is where your record will be very useful).
If the parent does not feel threatened, they are more likely to be able to reflect on their child’s behaviour at home and in other situations and share this information with you.
Ask the parent what management strategies they have found work in those situations
and share the ones you have tried.
It is important that the parent understands that your concern is that their child’s ability to learn / socialise is being compromised and that by working as a team (parent and teacher) you hope to help the child find his equanimity and achieve at his real potential.
A well socialised child, content in his learning environment and home, has the
best chance of developing a strong positive self esteem. – this should be the
first goal of all play-groups and all parents.
4. If the child’s behaviour continues to be maladaptive, or improves only temporarily, it is time to refer.
5. The decision as to which professional intervention to seek first must always be the parent’s. But they might be prepared to be guided by you if you have an open and honest discussion with them.
6. Parent Support groups are very useful for parents to learn more about ADHD from both professionals and other parents who have had to travel through the same difficult path.
7. Assessments are expensive and bouncing from one professional to another is costly as well as upsetting for the child and parent. Your records will help you and the parent decide on the most likely best first port of call; but make it clear that you are in no way able to make a final recommendation. Some possible referral pointers:
If the behaviour is worst or most frequently occurs during certain challenging tasks (drawing / writing /….) an Occupational Therapist (OT) might be the first professional to
approach. This will be supported by you and the parents having noted difficulties with pencil grip, buttons, knife and fork…
The OT will also be able to begin therapy and support the parents and teacher while
helping the child develop skills and strategies when the behaviours seem to be situation specific, such as during sand play / outings / refusal or temper tantrums about wearing certain clothing…
Where the behaviours occur across different situations and include home, class and play, a paediatric neurologist is able to rule out other conditions which have similar symptoms but different management needs and different prognoses. Having made a final diagnosis, the
paediatrician is likely to then refer the child to other therapies (such as OT; Sensory Integration (also OT); Social Skills Group; Play therapy) and is likely to recommend that the parents have some counselling in the strategies and difficulties involved in parenting a child with ADHD (or the particular condition the child might have been diagnosed as having).
Management strategies that can help ADHD children:
Here are some strategies which you can use in your class to manage children with ADHD. These management strategies will help the child cope, learn, socialise better and feel more positive about himself.
First and most important: remember that these children cannot fully control their behaviour.
Secondly,(and this might seem to contradict the first): they cannot use their disorder as an excuse for bad behaviour.
Bringing the first two points together shows us that we need to direct, support and guide these children in the strategies that help them function easier and more efficiently.
Reward and appropriate praise are strong motivators and behaviour-shapers and can be used liberally. Note that I emphasise the word “appropriate”: tell the child what, exactly he has done well; and what earned him the praise or the reward. Flattery and praise when he has not really done his best, will undermine your future efforts.
Token systems and token charts will work if they are designed for the specific needs of the child and applied consistently. Trying to fit the child into the same token system you use for the whole class will not work because his needs are different; as soon as he realises he has little chance of earning the rewards others gain so easily (in his opinion), he will give up and your system becomes valueless.
Many of these children need to move: they rock in their seats, fidget, tap their fingers noisily on the desk, chew something or get up and walk about. These movements help them stimulate their neural system to work more efficiently. If you insist that they stay still or insult them for wanting to chew their clothing, you are impacting on their self-regulation. They may respond with very negative behaviour, spiral into hyper-activity or go into shut-down and learning will stop.
Design your lessons to include brief, movement breaks wherever possible. If you can see that a child needs to move when the lesson needs the children to be still and quiet, send him on an errand to the school secretary (eg: Give him an envelope to give to her, having previously arranged with her that this may happen. She gives him a reply to return to you. Both you and the secretary must tell the child that the errand is very urgent and he has to rush – otherwise he could well “loose himself in his thoughts” along the way and forget to return to
class. On his return, a reward for being quick will be a good reinforcer).
Young children with ADHD struggle with impulsivity even more than their peers. They are likely to punch and hit others who offend them and get into great trouble with their peers because they do not manage to stick to the rules of the games they play. Even though they may have been coached many times, they frustrate everyone by offending first and then remembering afterwards that they should do things differently. Don’t give up with the coaching; they need constant reminding. But try to be patient and remember, they
act first and think later. Remove them temporarily from the situation, give them a few minutes “on the naughty step” or some other quiet time and then re-introduce them to the group after a brief discussion with you on what they could have done better. This management strategy helps prevent the child from deciding that the world is against them and from blaming all altercations on others. He needs to take ownership of his behaviour (even with its difficulties) and he can only do that if he is not made to feel bad, unwanted or ostracized.
ADHD children are sensitive. They are sensitive to others as well as being easily upset and hurt themselves. They are constantly challenged to work against their neural chemistry and are aware of the frustration and annoyance it causes others. This can give them a low self esteem; they need help to feel just as worthwhile as any other child. Find a special role or task to give them, so that in this they can feel important.
ADHD children are often clever. They are often good at seeing things differently and
solving problems which need an “out of the box” approach. Look for their skill and nurture it. Make sure they get a sense of pride from it.
The best treatment for a child with ADHD occurs when the parents, therapists, teacher, paediatrician and child form a close-knit team. Everyone communicating and working together.
ADHD should not be left for the child to grow out of. A small percentage of children do; but for most, ADHD is a life-long condition. People who have early intervention and correct management usually go on to lead happy, fulfilled, successful lives. It is a condition that frustrates the child as much as it frustrates those who are trying to teach him and if it is not managed correctly, it leads to long term damage to socialisation, learning and self esteem. Many adults who have been on anti-depressants for years, later discover that they had not been correctly diagnosed as ADHD children and thus never were correctly supported. Once their ADHD is correctly diagnosed and managed, their depressive symptoms improve.
I want to leave you with this thought:
ADHD is, indeed, a real condition affecting neural pathways that we need for learning and functioning maximally in this modern world. But this same condition, that stops ADHD people filtering out extraneous information, making them aware of so much that it’s hard to focus on one topic at a time, also allows them to make connections the rest of us don’t notice. They are more likely than most to be intuitive, imaginative and adventurous in their approach to life. History is full of people who have ADHD and given us new inventions, timeless art and novels. Many have become great leaders and others have become famous entrepreneurs.
It is our job, as teachers, parents and therapists, to make sure that these young children grow into happy, self-confident adults, able to share their many talents for the next generation.
CLICK HERE To find out about the reading programme I developed which makes it easier for ADHD children to stay focussed and learn to read with fun and movement.
YOU MIGHT ALSO WANT TO READ: ADHD Children Need to Move to Learn
1 Brain Imaging Data of ADHD : By Amir Raz, Ph.D. | 01 August 2004 Dr. Raz is assistant professor of clinical neuroscience in the department of psychiatry, division of child and adolescent psychiatry, at the Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute
What is reading? Is there a part of the brain which is the "reading centre"? Is it a natural development for people to read? When we begin to ask ourselves these questions it helps us understand the complexities and why so many children have difficulty with reading.
Reading is not just a visual processing task. There is so much more involved. Reading is a visual processing task that is also an auditory processing task. We see visual cues that represent sounds and spoken language. So reading is in fact high level de-coding of a visual and auditory code.
There is not just one specialised area in the brain that is dedicated to reading. The visual processing of the code is done in the visual cortex near the back of the brain and the right temporal lobe, while the language processing is in the left temporal lobe. Then we have to remember that we have two eyes and two ears and these, effectively are on opposite sides of the brain. There is a lot of communication that needs to happen in our brains to see and recognise a symbol (letter), link it to the sound it represents and then combine both the visual sequence of the codes with the sound sequence and then remember what the resultant word means. This seems very complicated and it is! Yet, when we are reading we do this in a flash, faster than a millisecond! You see: c a t and your brain tells you what sound each visual symbol represents. You recognise the sequence as being different from: a c t and straight away you know that you have read about a little furry pet!
In Western countries we read across a page from left to right and Hebrew and Arabic are read from right to left. In order to make sense of a line of script and get smooth reading flow both our left and right fields of vision must combine smoothly. (This might be less important for languages where each column is read from top to bottom, rather than reading row by row). When given the choice, many of the children who come to see me, prefer to read columns of words rather than across the page. this way they keep in the same side visual field for longer and don't need to cross the visual field as they read.
We “see” the left field of our vision with our right side of our visual cortex and the right side of our visual field with the left side of our visual cortex. So information from both eyes; but only half of the visual field, goes to each side of the visual cortex. At the same time, our brain’s motor cortex controls muscles on the opposite side of our body; with the left motor cortex controlling the muscles on the right of our body and the right motor cortex controlling the left side of our body. So, just think of it: for our eyes to work together, both sides of our motor cortex in our brain must communicate and work together and to create one fluid field of vision from the two halves, both sides of our visual cortex in our brain must communicate and work well together.
For us to read a line of text across the page we need very good communication between the left and right sides of our brain at an eye-movement level, a “seeing” level and also from the level of interpreting and transferring a “visual code” into a representation of meaningful sounds and language!
So when we teach reading to children, we need to facilitate the communication across the brain. In occupational therapy we have found that using movement which stimulates the vestibular processes and uses coordinated, fun movement across the two sides of the body helps children develop their midline crossing and communication within the brain, even for non-movement processes. As soon as I began combining the occupational therapy approach to vestibular processing and bilateral integration with reading, many of the children made dramatic progress.
In this article I have only mentioned the link to bilateral integration. I will post an article to show you why I found vestibular-stimulating activities also important to reading.
To see GAMES and ideas of how to introduce movement when you teach reading: CLICK HERE
PREPARE YOUR CHILD FOR WRITING THROUGH PLAY
– BEFORE YOU TEACH HIM TO WRITE –
Occupational Therapists see so many children with poor pencil grip because they began to use a pencil before their early milestones were established. These days everyone seems to be in a race to see if they can get their child writing and reading earliest.
The problem is that development cannot be rushed. Development follows a roadmap and taking shortcuts when following a map can be hazardous!
Let’s take a look at what a child needs for good pencil grip and to learn to draw and write. When we appreciate that, we more deeply understand the importance of allowing
them time and our greatest support in achieving developmental foundations.
He needs to be able to sit comfortably at a desk, with good stability at his hips, around his trunk and at his shoulders.
He should have fully established fine motor dominance. He should automatically use the same hand as the leading hand and the other as the assisting hand. The brain sets down movement templates and if your child keeps altering hand during learning to write, he will be setting down templates for both hands. He can then access the less efficient template (ie: for his non-dominant hand) rather than directly and quickly accessing the efficient template. When we write with our left hands, the actual movements to make a letter are reversed, resulting in letter reversals.
Both hands must work together, yet do different things at the same time. We call this
“bi-lateral integration”: good communication between both sides of the brain. Both eyes need to work together with the writing hand, while the assisting hand holds the paper still.
Writing uses small, precise movements and this is best done when you can use the small muscles in the hand separately but together. We call this “finger isolation”; the fingers have different jobs and must each be able to do their own movements without interfering with the movements of the other fingers.
Motor planning is our ability to understand what exact movements we need to make and how they must combine in a sequence in order to carry out the movement pattern as a whole. It needs ideation (the idea of what movement is needed), sensory feedback and sensory feed-forward (the sensory pathways from muscles and joints to the brain and back). Vision, vestibular processing, balance and even our sense of touch affect how smoothly we can organise our movements.
Find out more about fine motor coordination and pencil grip development.
Any parent whose child has autism, Asperger's syndrome or sensory processing disorder (SPD), will love this book. Therapist, teachers and parents will all find useful information, told with empathy and respect.
Book review by: Ray Anne Cook M (O.T) and Sharon Stansfield BSc (OT)
Available through Amazon, UK or go to: www.ourgreatestallies.com
Seldom does an educational, self-help book capture the reader’s emotions as well as this beautiful description of young Matty and his mother, Lauren as they travel “the breadcrumb trail of allies” along the path of his early development.
Matty is a boy whose difference becomes apparent from very early on. His mother is a loving, caring, busy mother of five children. Lauren is also a working Mom, a Writer. It is thanks to Lauren’s openness and honesty in sharing her feelings as she and Matty travelled their
early journey with their Occupational Therapist, Maude Le Roux, that we are given such an opportunity to share and learn with them.
Maude Le Roux shows breadth and depth of knowledge in therapeutic interventions and she describes them in an easy to read and easy to understand way, linking the theory with the place Matty finds himself on along his path. Maude’s warmth and caring, shine throughout the book. She has an absolute respect for Matty and, indeed, for each and every child. She is clear in her conviction that every child is an individual, with individual needs and strengths. She believes that “We [as the adults in the child’s life] must learn how to get to know them”. She tells us to commit to “helping each and every child find their unique course of development…….and reach their highest potential.”
The title had us thinking: who are whose greatest allies? The child, mother,
family, Dr Greenspan, Dr Tomatis and Dr Jean Ayres as well as other health professionals and educators, create a strong team of allies. Matty’s journey highlights the important reality that if we join together and support one another we become a powerful team of allies. And it is in working together as a team, with mutual respect for each other and for the child that we can best help them find the path to reach their full potential as a respected happy child.
The way ‘Our Greatest Allies’ flows from mother’s perspective to therapist’s perspective and back, underscores the importance of the alliance between professional and family. Maude and Lauren remind us, not only through their journey with Matty but also by their chosen style for the book, that therapy is not a one-way relationship. As therapists empower parents and help the child along his path, we too can learn and gain so much. Maude reminds us that therapists need to listen and take time to truly get to know the children we work with. In doing that, we not only become one of the child’s and parent’s allies; but they become ours too.
Maude explains Sensory Processing and how our senses affect our emotions, behaviour and even our ability to focus attention. She believes that today’s focus on quantity rather than quality and of product rather than process, is a folly. Says Maude: “Give the child process and the product takes care of itself”.
Maude’s educational chapters alternate with Lauren’s account of Matty’s and her experiences, bringing the theory into real life. The theories are related to Matty’s life and his developmental journey and Lauren shares her experiences of these therapies from a mother’s perspective. Together, they give us a solid understanding of some of the most important therapies used
in treating children with autism today. These are: Sensory Integration pioneered by Dr. Jean Ayres, Tomatis Sound training pioneered by Dr. Alfred A. Tomatis and the DIR model of therapy pioneered by child psychiatrist, Stanley Greenspan MD.
The book begins with Matty’s birth and early feeding difficulties. Lauren shares with us how, when Matty was 20 months old, a Christmas portrait changed everything; redefining Matty’s journey but, we are reminded, not him. Matty’s early intervention takes several different paths before his mother learns to understand his real needs. Maude then takes us along our own journey: of understanding sensory processing and the systems that drive a child’s physiological, intellectual and social-emotional development and the impact on
behaviour. Lauren opens the door to DIR/Floortime therapy, learning the value of play and a child’s connection to meaning and purpose. We see the importance of forming a close link between school and home and are reminded that professionals working with children need to keep the child’s goals in sight and not only the professional’s goals. We see how Tomatis
Sound training catapults Matty’s development and Lauren and Maude share with us
how Matty learns to work through negative emotions and develop a stronger self concept through the DIR programme.
As we read Matty’s story, we are given an opportunity to enter his world and with Maude and Lauren steering us, we get a chance to understand.
By sharing their knowledge, skills, feelings and insights, Maude and Lauren have created a book which should help us all to understand other Mattys in the world and to be able to help and support them; to “humbly enter the child’s space without threatening it” and to “figure out ways to allow them to trust us and join in ours.”
Everyone who works with children should read this book. But it is also a very important ally for every parent who has a child whose developmental path is different - who may have been diagnosed as having autism or who is struggling to cope with the world into which they’ve arrived. In Lauren’s words: “Matt’s story is for two people – a parent and a child whom I don’t know andI will never meet. For that child, I will never know your beauty; but through Matt’s journey, I hope the rest of the world will.”
Review by: Ray Ann Cooke M.OT and SharonStansfield BSc (OT)