A family-centred occupational therapy assessment and treatment package for

children with attention deficit hyperactivity disorder (ADHD) was evaluated. The
package involves a multidimensional evaluation and a multifaceted intervention,
which are aimed at achieving a goodness-of-fit etween the child, the task
demands and the environment in which the child carries out the task. The package
lasts for ! months, with "# weekly contacts with the child, parents and teacher.
A multicentre study was carried out, with #$ occupational therapists
participating. %ollowing a !-day training course, they implemented the
package and supplied the data that they had collected from #$ children. The
outcomes were assessed using the ADHD &ating 'cales, pre-intervention and
post-intervention. The results showed ehavioural improvement in the
ma(ority of the children. The )easure of *rocesses of +are , #$ -item version
()*-+-#$) provided data on the parents. perceptions of the family-
centredness of the package and also showed positive ratings.
The results offer some support for the package and the guiding model of
practice, ut caution should e e/ercised in generalising the results ecause
of the small sample si0e, lack of randomisation, asence of a control group
and potential e/perimenter effects from the research therapists. A larger-
scale randomised controlled trial should e carried out to evaluate the
efficacy of an improved package.
-ccupational Therapy for +hildren with
Attention Deficit Hyperactivity Disorder
(ADHD), *art #1 a )ulticentre 2valuation of
an Assessment and Treatment *ackage
Sidney Chu
1
and Frances Reynolds
2
3ntroduction
In part 1 of this article, an occupational therapy model of
practice for children with attention deficit hyperactivity
disorder (ADHD) was described (Chu and Reynolds
!!")# It addressed some specific areas of human
functionin$ related to children with ADHD in order to
$uide the practice of occupational therapy# %he model
1
&alin$ 'rimary Care %rust#
2
(runel )niversity, )*brid$e, +iddlese*#
Corresponding author: Dr ,idney Chu, 'aediatric -ccupational %herapy ,ervice
+ana$er, &alin$ 'rimary Care %rust, .indmill /od$e (&alin$ Hospital ,ite),
)*brid$e Road, ,outhall, +iddlese* )(1 0&)# &mail1 sidney#chu2nhs#net
Submitted: 3 +ay !!4# Accepted: 10 5uly !!"# Key
words: +odel of practice, attention deficit hyperactivity
disorder, outcome study#
Reference: Chu ,, Reynolds 6 (!!") -ccupational therapy for
children with attention deficit hyperactivity disorder (ADHD), part 1
a multicentre evaluation of an assessment and treatment pac7a$e#
British ournal of !ccupational "herapy# $%&1%'# 809:88;#
provides an approach to identifyin$ and
communicatin$ occupational performance difficulties in
relation to the interaction between the child, the
environment and the demands of the tas7# A family:
centred occupational therapy assessment and
treatment pac7a$e based on the model was outlined#
%he delivery of the pac7a$e was underpinned by the
principles of the family:centred care approach#
'art of this two:part article reports on a
multicentre study, which was desi$ned to evaluate
the effectiveness and acceptability of the proposed
assessment and treatment pac7a$e and thereby to
offer some validation of the delineation model#
It is important to note that no treatment has yet been
proved to <cure= the condition of ADHD or to produce any
endurin$ effects in affected children once the treatment is
withdrawn# ,o far, the only empirically validated treatments
for children with ADHD with substantial research evidence
are psychostimulant medication, behavioural and
educational mana$ement, and combined medication and
behavioural mana$ement (Du'aul and (ar7ley 1990,
4ritish 5ournal of -ccupational Therapy -ctober !!" "!(1!) 6!7
5ensen 1999, +%A Cooperative >roup 1999)# In clinical
practice, it is recommended that a dia$nosis of ADHD
should not lead automatically to medication treatment
(%aylor and Hemsley 1993), and that the first line of
treatment should be educatin$ the parents, implementin$
behavioural mana$ement, and usin$ educational
mana$ement with the teacher (5ou$lin and ?wi 1999)#
>oldstein and >oldstein (199;) noted that over the
short term, a combination of treatments provides $reater
symptom relief and therapeutic $ains than the use of any
sin$le approach# 6rom the occupational therapy
perspective, the multidimensional evaluation and the
multifaceted intervention framewor7 advocated in the
model of practice described in part 1 of this article provide
a systematic approach in deliverin$ a combination of
treatments# However, it is important to evaluate the
effectiveness of any combined treatments proposed#
&esearch 8uestions
In this study, a family:centred, occupational therapy assessment
and treatment pac7a$e was delivered to improve the
behavioural patterns of children with ADHD a$ed 3:1! years#
%here were two principal research @uestions1
1# Is a defined family:centred occupational therapy
assessment and treatment pac7a$e carried out
over 0 months effective in producin$ si$nificant
chan$es in the behavioural patterns of children
with ADHD a$ed between 3 and 1! yearsA
# Does a family:centred care approach elicit
positive parental perceptions of the care that
they and their children have receivedA
)ethod
&esearch design
In this study, the effectiveness of the pac7a$e in producin$
si$nificant chan$es in the behavioural patterns of children
with ADHD was assessed usin$ the ADHD Ratin$ ,cale
B IC (Du'aul et al 199;) before and after treatment, that is,
outcome e(aluation# A sin$le:$roup pretest:posttest desi$n
was used to evaluate chan$e# %he de$ree of family:
centredness of the pac7a$e was evaluated, usin$ the
validated +easure of 'rocesses of Care B !:item version
(+'-C:!) (Din$ et al 1993, Din$ et al 199;) to measure
parents= perceptions of the e*tent to which the health
services that they and their child(ren) had received were
family centred, that is, process e(aluation# A sin$le:$roup
posttest:only desi$n was used in this part of the study#
2thical approval of the study
&thical approval for this study was $ranted by the .est
+idlands +ulti:Centre Research &thics Committee
(+R&C), and relevant /ocal Research &thics Committee
(/R&C) and Research +ana$ement and >overnance
Committee (R+E>C) for each local researcher#
*rotocol of a family-centred occupational
therapy assessment and treatment package
%he pac7a$e was based on the principles of a family:centred
care approach and the theoretical concepts described in the
delineation model of occupational therapy practice for
children with ADHD (see part 1 of the article, Chu and
Reynolds !!")# %he model recommends choosin$ from a
number of evaluation procedures and intervention strate$ies,
includin$ environmental adaptation, trainin$ for parents and
teachers, behavioural and educational mana$ement, the
selection of appropriate tas7s, and the remediation of
sensory, perceptual:motor and functional difficulties# %he
pac7a$e lasts for 0 months, with a total of 1 wee7ly
contacts with the child, parents and teachers (6i$# 1, Chu
and Reynolds !!")#
'election of local researchers
A team of ! paediatric occupational therapists was
selected from the four countries in the )nited
Din$dom ()D)# %hey were part of the " therapists
who had participated in a Consensus Development
Research study on the role of occupational therapy
for children with ADHD conducted by the first author
(Chu !!3)# %he therapists who had e*pressed an
interest in participatin$ in this study were invited to
complete an application form# %he followin$ selection
criteria were used when recruitin$ participants1
1# Appropriate service settin$s, that is, those who
had direct access to children with ADHD
# Fears of clinical e*perience (with a balance of
Gunior and senior therapists)
0# Dnowled$e and s7ills in wor7in$ with children
with ADHD and related developmental problems,
such as developmental coordination disorder
(DCD), and their families
8# Dnowled$e and s7ills in usin$ standardised tests
3# &*perience of wor7in$ within a multidisciplinary team#
Althou$h the above criteria were set, the selection
process also depended on the bac7$round and number
of therapists who submitted an application# As far as
possible, a diversity of therapists wor7in$ at different
$rades in the four countries of the )D was sou$ht#
A total of 8 therapists applied to participate in the study#
6our applicants were eliminated because they did not
have direct access to children with ADHD within their
service settin$s# %he ! remainin$ therapists were
as7ed to complete both a consent form for their
participation in the study and an a$reement letter for
providin$ research data after their attendance at a free
trainin$ course, which is described below#
Training of local researchers on the use
of the package
%he ! therapists were invited to attend a 0:day trainin$
course in /ondon# %he course consisted of comprehensive
trainin$ sessions on the research processes and each
component of the assessment and treatment pac7a$e
(see %able 1 for details of the trainin$ pro$ramme)#
66$ 4ritish 5ournal of -ccupational Therapy -ctober !!" "!(1!)
Fig) 1) Clinical pathway of the assessment and treatment pac*age &Chu and
Reynolds 2%%$# p+,%')
pro$ramme, the therapists were
encoura$ed to select appropriate
treatment procedures from the
various treatment strate$ies covered
in the trainin$ course, as appropriate
to the child# Althou$h this reduced the
homo$eneity of the intervention, it
ensured an intervention that was
more child and family appropriate yet
was still compatible with the
delineation model of practice#
+'-C (Din$ et al 1993, 199;)H ADHD Ratin$ ,cale (Du'aul et al 199;)#
%he participants in the trainin$ course were $iven a
comprehensive manual, with details of all the
assessment and treatment procedures used in the
research# Attendance at the trainin$ course was free
of char$e in return for the submission of data#
%he therapists were instructed to complete the whole
pac7a$e and to use the core assessment procedures
outlined in the trainin$ course, e*cept in the areas of
assessin$ perceptual:motor and functional s7ills where they
were permitted to use the tools adopted in their local
services# In developin$ the multifaceted intervention
Therapists. selection
of children
6ollowin$ the trainin$, each
therapist was as7ed to select
two children who had been
newly dia$nosed with ADHD by
a consultant child psychiatrist
or consultant paediatrician who
had special interest in ADHD#
%he child should not have been
involved in any other form of
treatment# %he therapists used
the followin$ criteria to recruit
children into the study1
1# Children a$ed 3 to 1! years who
were referred to the service because
of concerns related to ADHD
# Children with avera$e intellectual
capacity, that is, with no
identifiable learnin$ disability
0# Children without other 7nown
neurolo$ical disorders, such
as traumatic brain inGury
8# Children without any other
pervasive developmental
disorder, includin$ autism
3# Children without other assessed
comorbid mental health problems,
such as childhood schiIophrenia or
conduct disorder
4# Children with normal birth and
delivery, that is, not children
who were born preterm and
with low birth wei$ht#
-taining consent
'arental consent was obtained by as7in$ parents to si$n a
consent form# %he parents were $iven an information sheet
on the study so that they could ma7e a decision on
participation based on informed choice# %he process of
obtainin$ consent was based on the $uidance and ethics
set by the +R&C, /R&C and R+E>C, such as voluntary
participation and the opportunity to refuse involvement#
6or the children, an information sheet in picture format
was developed# Consent for !ccupational "herapy
(Colle$e of -ccupational %herapists !!0, section 8#)
4ritish 5ournal of -ccupational Therapy -ctober !!" "!(1!) 66"
Tale ". +ontents of the !-day training programme
1# Details of the research protocol (includin$ the research @uestions,
research desi$n, selection of subGects, obtainin$ consent, codin$ system
for data protection and data collection for outcome measures)
#. An overview of the assessment protocol
0# 'rinciples of family:centred approach
8# %he +easure of 'rocesses of Care (+'-C)
3# D,+:IC Dia$nostic Criteria of ADHD
4# ADHD Ratin$ ,cale B administration, scorin$ and interpretation
"# ,ensory 'rofile B administration, scorin$ and interpretation
;# Interview with parents, teachers and the child
9# -bservational assessment within school environment
1!# -ther assessment areas and tools, such as
perceptual:motor and functional s7ills
11# -verall interpretation of assessment results
1# Report writin$ and case e*amples
"!. An overview of the treatment protocol
18# 6eedbac7 session with parents and teachers
13# >oal settin$ and treatment plannin$ with parents and teachers
14# 'sychoeducational pac7s for parents and teachers
1"# (ehavioural mana$ement
1;# %he application of principles of sensory modulation and
intervention strate$ies in the treatment of children with ADHD
19# Classroom mana$ement and environmental adaptation
!# Appendices B all the assessment forms, consent information and
forms, psychoeducational pac7s and treatment pro$rammes#
and See*ing Consent: -or*ing with Children (Department of
Health !!1) were used to $uide therapists in $ainin$ assent
from the children# 6or the child=s $eneral practitioner and
teacher, information sheets were developed about the
purpose of the research proGect#
*rocedures of data collection and the
coding system for data protection
In order to ensure the reliability and validity of the data
collected, the chief investi$ator (the first author) had
maintained re$ular communication with the ! therapists#
He provided advice and consultation to each therapist
on the implementation of the research processes and
different aspects of the pac7a$e# All therapists were
re@uested to send to the chief investi$ator details of the
assessment results, interpretation of the
multidimensional evaluation, $oals and obGectives set,
and treatment pro$rammes with all procedures selected#
If there were any anomalies identified, such as incorrect
scorin$ of assessment tools or missin$ data, the chief
investi$ator @ueried these as soon as possible#
In order to adhere to the Data 'rotection Act, a
codin$ system was used to ensure that the families and
children could not be identified# %he allocated codes
were used in all the forms and documentations sent to
the chief investi$ator# All data were 7ept securely#
-utcome measures and method
of data analysis
After the implementation of the pac7a$e, two outcome
measures were used in collectin$ data for the
outcome and process evaluation of the pac7a$e#
6or the outcome e(aluation, the Reliable Chan$e Inde*
(RCI) for each child was calculated by comparin$ the
scores of the ADHD Ratin$ ,cale B IC Home and ,chool
Cersions (Du'aul et al 199;) before and after treatment#
Accordin$ to 5acobsen and %rua* (1991, cited in Du'aul et
al 199;), the RCI is e@ual to the difference between a
child=s pretreatment score and posttreatment score, divided
by the standard error of difference between the two test
scores# In the manual of the ADHD Ratin$
,cale B IC (Du'aul et al 199;), two tables of the
standard errors of difference for the ,chool Cersion and
the Home Cersion are available for calculatin$ the RCI#
.hen the value of RCI e*ceeds 1#94, it indicates that
the chan$e from pretreatment to posttreatment is not
due to chance (p J !#!3)# %hus, the RCI serves as a
measure of the de$ree to which an improvement in
functionin$ is li7ely to be due to the effects of treatment
rather than to imprecise measurement#
6or the process e(aluation, the descriptive statistics
for the +'-C were used to analyse the e*tent to which
the parents perceived the intervention to have been
family centred# %he ori$inal version of the +'-C is a
34:item @uestionnaire# As of 199;, there is a shorter, !:
item version (Din$ et al 199;)# %he validity evidence
shows that the +'-C:! can capture parents=
perceptions of care:$ivin$ re$ardless of the child=s
dia$nosis or a$e (Din$ et al !!8)#
%he +'-C contains five scales1 (1) &nablin$ and
'artnership, () 'rovidin$ >eneral Information, (0)
'rovidin$ ,pecific Information about the Child, (8)
Coordinated and Comprehensive Care for the Child and
6amily, and (3) Respectful and ,upportive Care# %he data
from a respondent yield five scores, one for each
of the scales# %here is no total score because it is
thou$ht to be more informative clinically to
e*amine the relationships of the individual scales
to other variables (Din$ et al 1993)#
&esults
+haracteristics of therapists
participating in the study
%he demo$raphic data for the ! therapists who participated
in the study were as follows# %here were 11 therapists from
&n$land, 8 from ,cotland, from .ales and 0 from Korthern
Ireland# &leven therapists were wor7in$ at senior I $rade#
%here was 1 therapist at senior II $rade,
0 at clinical specialist $rade, 8 at head III $rade and 1 senior
therapist in independent practice for a local primary care
trust# %hirteen of these therapists wor7ed in a child health
settin$ within the community# %here were " therapists who
wor7ed in a child psychiatry settin$ in &n$land and ,cotland
but none in .ales and Korthern Ireland# %he therapists=
years of wor7in$ e*perience in all clinical areas of
occupational therapy ran$ed from 4 to 08 years, with
66# 4ritish 5ournal of -ccupational Therapy -ctober !!" "!(1!)
Tale #. +linical characteristics of the #$ children
+hildren 9ender: 'utypes of ADHD 'ensory processing dysfunctions +omoridity with D+D
Age (years) 3AH3+;-' *.&eg '.'tim '.'eek '.Avoi )i/ed Definitely 'uspected *ro. not
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IA M ADHD Inattentive %ype, HI M ADHD Hyperactive:Impulsive %ype, C M ADHD Combined %ype, K-, M ADHD
Kot -therwise ,pecified# '#Re$ M 'oor Re$istration, ,#,tim M ,ensitivity to ,timuli, ,#,ee7 M ,ensory ,ee7in$,
,#Avoi M ,ensory Avoidance, +i*ed M +i*ed 'atterns# DCD M Developmental coordination disorder#
a mean of 1"#" years and a standard deviation of
;#3# %heir e*perience of wor7in$ with children ran$ed
from #3 to 08 years, with a mean of 1#4 years and
a standard deviation of ;#9#
;umer and demographic
characteristics of the children
Althou$h 8! cases were sou$ht, data were returned
on ! children due to various reasons, such as the
non:availability of children matchin$ the selection criteria
and incomplete data because of families movin$ away#
%here were 1; boys and $irls# %he mean a$e for the
1; boys was 91#0 months (" years "#0 months), with a
ran$e of 4 months (3 years months) to 1; months
(1! years ; months)# %he mean a$e for the two $irls
was 1!0 months (; years " months), with actual a$es
of ; years 4 months and ; years ; months#
+linical characteristics of the #$ children
%he clinical characteristics of each child are presented
in %able # %he children were arran$ed in the order of
their chronolo$ical a$es# All children were assessed by
usin$ the ran$e of evaluation procedures and
assessment tools specified in the pac7a$e (see %able
1)# %he information obtained enabled the therapists to
differentiate subtypes of ADHD, identify underlyin$
sensory processin$ dysfunctions, evaluate the de$ree
of comorbidity with DCD and plan the treatment
pro$ramme by selectin$ appropriate components
within the multifaceted intervention model described#
Althou$h these data will not be used for measurin$
the outcomes of the pac7a$e, they are useful in
analysin$ the specificity of each case# %he
children=s clinical characteristics are presented in
the followin$ areas# %he representativeness of the
sample will be returned to in the discussion#
1# "he subtypes of A./. were identified# %hese
were based on the results of the ADHD Ratin$
,cales and other assessment procedures
administered by the research therapists, such as
classroom observation# %he subtypes included
(American 'sychiatric Association 1998)1
a# ADHD 'redominantly Inattentive %ype (ADHD:IA)
b# ADHD 'redominantly Hyperactive:Impulsive
%ype (ADHD:HI)
c# ADHD Combined %ype (ADHD:C)
d# ADHD Kot -therwise ,pecified (ADHD K-,)#
# "he types of sensory processing dysfunction that
were present in the sample were based on the
cate$ories described in the ,ensory 'rofile (Dunn
1999)# A child could have behavioural features
related to one or more of the cate$ories below1
a# 'oor Re$istration B uninterested, dull affect,
withdrawn, overly tired, apathetic and self:absorbed
b# ,ensitivity to ,timuli B distractible and hyperactive
c# ,ensation ,ee7in$ B active, fid$ety and e*citable
d# ,ensation Avoidin$ B resistant to chan$e and
reliant on ri$id rituals
e# +i*ed 'atterns B presents a mi*ture of behavioural
features related to more than one cate$ory#
4ritish 5ournal of -ccupational Therapy -ctober !!" "!(1!) 66!
Tale !. -utcomes of the ADHD &ating 'cale , Home and 'chool <ersions
+hildren <ersion *retreatment scores *osttreatment scores '2D &+3
9ender, +A 3A H3 Total 3A H3 Total 3A H3 Total 3A H3 Total
Case 1################# Home############## 1; ########## 1 #######09#############
18 ######### 13
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Case 0################# Home############## 1 ########## 4 ####### 8"############# 18######### ######### 04############# 0#0" ######## #98 ######## 3#84 ############ #.$?= ###### 1#04 ######### #.$#=###
+, 4:! ################# ,chool############# 1; ########## 4 ####### 88 ############### : ########### : ########### :############# 0#39 ######## 0#;3 ######## 4#30 ################## : ############## : ############### : #####
Case 8################# Home############## 1" ########## 1" ####### 08############# 0######### 0######### 84############# 0#0" ######## #98 ######## 3#84 ########### :1#"; ####### :#!8 ######## :#! #####
+, 4:! ################# ,chool############# 14 ########## 1" ####### 00############# 18######### !######### 08############# 0#39 ######## 0#;3 ######## 4#30 ############ !#34 ####### :!#"; ######## :!#13 #####
Case 3################# Home############## ########## 3 ####### 8"############# 14######### 10######### 9############# 0#0" ######## #98 ######## 3#84 ############ 1#"; ######## 6.$?=####### !.!$=###
+, 4:3 ################# ,chool############### 9 ########## 11 ####### !############### "###########9######### 14############# 0#39 ######## 0#;3 ######## 4#30 ############ !#34 ######## !#3 ######### !#41 #####
Case 4################# Home############## 1 ########## 8 ####### 83############# 11######### 13######### 4############# 0#0" ######## #98 ######## 3#84 ############ #.7>=###### !.$@=####### !.6?=###
+, 4:11 ############### ,chool############# 1 ########## 0 ####### 88 ############### : ########### : ########### :############# 0#39 ######## 0#;3 ######## 4#30 ################## : ############## : ############### : #####
Case "################# Home############## ! ########## 19 ####### 09############# !######### 19######### 09############# 0#0" ######## #98 ######## 3#84 ############ !#!! ######## !#!! ######### !#!! #####
+, ":! ################# ,chool############# 13 ########## 1; ####### 00############# 1"########### ;######### 3############# 0#39 ######## 0#;3 ######## 4#30 ########### :!#34 ######## #.@$=####### 1#0 #####
Case ;################# Home############## 18 ########## 3 ####### 09############# 10######### !######### 00############# 0#0" ######## #98 ######## 3#84 ############ !#0! ######## 1#"! ######### 1#! #####
+, ":! ################# ,chool############# ! ########## ! ####### 8!############# !######### !######### 8!############# 0#39 ######## 0#;3 ######## 4#30 ############ !#!! ######## !#!! ######### !#!! #####
Case 9################# Home############## 4 ########## 4 ####### 3############# 19######### 1"######### 04############# 0#0" ######## #98 ######## 3#84 ############ #.$?=###### !.$@=####### #.7!=###
+, ":11 ############### ,chool############# 3 ########## 1 ####### 84############# ######### 19######### 81############# 0#39 ######## 0#;3 ######## 4#30 ############ !#;8 ######## !#3 ######### !#"" #####
Case 1!############### Home############## 1; ########## 1 ####### 09############# 18######### !######### 08############# 0#38 ######## #"" ######## 3#0" ############ 1#10 ######## !#04 ######### !#90 #####
+, ;:! ################# ,chool############# 8 ########## 0 ####### 8"############# 1######### 1######### 8############# 0#99 ######## 0#93 ######## 4#90 ############ !#"3 ######## !#31 ######### !#" #####
Case 11############### Home############## 1 ########## ####### 80############# 1;######### 14######### 08############# #;; ######## #!1 ######## 8#1 ############ 1#!8 ######## #.77=####### #."?=###
6, ;:4 ################### ,chool############# 4 ########## " ####### 30############# !######### 1;######### 0;############# 0#8 ######## 0#!1 ######## 3#48 ############ 1#"3 ######## #.77=####### #.@@=###
Case 1############### Home############## 8 ########## 18 ####### 0;############# 19######### 10######### 0############# 0#38 ######## #"" ######## 3#0" ############ 1#81 ######## !#04 ######### 1#1 #####
+, ;:" ################# ,chool############# 1" ########## 1" ####### 08############# 18######### 18######### ;############# 0#99 ######## 0#93 ######## 4#90 ############ !#"3 ######## !#"4 ######### !#;" #####
Case 10############### Home############## 8 ########## 1 ####### 04############# 18######### 10######### "############# #;; ######## #!1 ######## 8#1 ############ !.6>=##### :!#3! ######### #."?=###
6, ;:; ################### ,chool############# 1" ########## 1 ####### 9############# 1########### 9######### 1############# 0#8 ######## 0#!1 ######## 3#48 ############ 1#84 ######## 1#!! ######### 1#8 #####
Case 18############### Home############## 8 ########## 13 ####### 09############# 1;######### 13######### 00############# 0#38 ######## #"" ######## 3#0" ############ 1#"! ######## !#!! ######### 1#1 #####
+, ;:1! ############### ,chool############# 19 ########## 14 ####### 03############### 9###########;######### 1"############# 0#99 ######## 0#93 ######## 4#90 ############ #.A"=###### #.$!=####### #.@$=###
Case 13############### Home############## 1; ########## 1; ####### 04############# !######### 1;######### 0;############# 0#38 ######## #"" ######## 3#0" ########### :!#34 ######## !#!! ######## :!#0" #####
+, ;:11 ############### ,chool############# 13 ############ ####### 1"############# !########### ######### ############# 0#99 ######## 0#93 ######## 4#90 ########### :1#3 ######## !#!! ######## :!#" #####
Case 14############### Home############## 3 ############ 9 ####### 08############### ;###########4######### 18############# 0#38 ######## #"" ######## 3#0" ############ 6.?$= ###### 1#!; ######### !.>#=###
+, 9:! ################# ,chool############# 8 ########## 18 ####### 0;############# 14########### 3######### 1############# 0#99 ######## 0#93 ######## 4#90 ############ #.$"=###### #.#?=####### #.6A=###
Case 1"############### Home############## 4 ########## " ####### 30############### "###########"######### 18############# 0#38 ######## #"" ######## 3#0" ############ A.!>=###### >.##=####### >.#@=###
+, 9: ################# ,chool############### ############ " ######### 9 ############### : ########### : ########### :############# 0#99 ######## 0#93 ######## 4#90 ################## : ############## : ############### : #####
Case 1;############### Home############## 3 ########## ####### 8"############# 8######### 8######### 8;############# 0#38 ######## #"" ######## 3#0" ############ !#; ####### :!#" ######## :!#19 #####
+, 9: ################# ,chool############# 18 ########## 1 ####### 03############# 14######### !######### 04############# 0#99 ######## 0#93 ######## 4#90 ########### :!#3! ######## !#3 ######## :!#18 #####
Case 19############### Home############## " ########## 4 ####### 30############# 8######### 1######### 83############# 0#38 ######## #"" ######## 3#0" ############ !#;3 ######## 1#;1 ######### 1#13 #####
+, 9:3 ################# ,chool############# ! ########## 0 ####### 80############# 19######### 19######### 0;############# 0#99 ######## 0#93 ######## 4#90 ############ !#3 ######## 1#!1 ######### !#" #####
Case !############### Home############## 19 ########## 18 ####### 00############# 10########### 9######### ############# 0#38 ######## #"" ######## 3#0" ############ 1#"! ######## 1#;1 ######### #.$A=###
+, 1!:; ############### ,chool############# ! ############ " ####### "############# 1########### 0######### 13############# 0#99 ######## 0#93 ######## 4#90 ############ #.$"= ###### 1#!1 ######### 1#"0 #####
CA M Chronolo$ical a$eH IA M Inattention ,ubscale, HI M Hyperactivity:Impulsivity ,ubscaleH N M /evel of si$nificance (p J
!#!3)H ,&D M ,tandard errors of difference (fi$ures from test manual)H RCI M Reliable Chan$e Inde*#
Tale 6. Descriptive statistics for the )easure of *rocesses of +are ()*-+-#$)
'cale name )ean 'D 'cores within )in. )a/. &ange )ode )edian Buartiles
()) ) C 'D #AD A$D >AD
&nablin$ and 'artnership ######################### @.#! #### 1#!########## 3#1 to "#3############# 3#########"
############################
"########## 4#4"############ 4#!!###### 4#4"###### 4#9###
'rovidin$ >eneral Information ################# A.@> #### 1#8########## 8#3 to "#!9############# #########"########### 3################# 4N######## 4#!!############ 3#!3###### 4#!!###### 4#"3###
'rovidin$ ,pecific Information
about the Child ####################################### @.!> #### !#9;########## 3#09 to "#03############# 3#########"########### ################# "########## 4#4"############ 4#!;###### 4#4"###### "#!!###
Coordinated and Comprehensive Care######### @.6? #### !#";########## 3#"! to "#4############# 0#########"########### 8################# "########## 4#;9############ 4#!!###### 4#;9###### "#!!###
Respectful and ,upportive Care################ @.6# #### !#"!########## 3#" to "#1############# 8#########"########### 0################# "########## 4#;!############ 3#"3###### 4#;!###### 4#93###
+ M +ean, ,D M ,tandard deviation, +in# M +inimum, +a*# M +a*imum, N+ore than one mode (4 and "), the lower value bein$ reported#
666 4ritish 5ournal of -ccupational Therapy -ctober !!" "!(1!)
0# "he absence or presence of .C. was identified
in each child# Cate$orisation was based on the
results of different perceptual and motor tests
administered by the research therapists# %he
de$ree of DCD was described as follows1
a# Definitely an indication of DCD
b# ,uspected of havin$ DCD
c# 'robably not DCD#
were similar# As indicated in %able 8, the mode for the
five scales was ", that is, <to a $reat e*tent=, with the
e*ception of the scale <'rovidin$ >eneral Information=,
which had two values of mode at 4 and "# %he
medians for the five scales were all at and above 4#
%hey were consistent with the mean values calculated
for each scale# %he inter@uartile ran$e was 3:"#
-utcomes of the ADHD &ating 'cales
%he scores for both the Home and ,chool Cersions of the
ADHD Ratin$ ,cales were obtained before and after the
completion of the pac7a$e, e*cept in three cases where no
scores were obtained for the posttreatment ,chool Cersion
of the ADHD Ratin$ ,cale owin$ to the commencement of
the summer holiday# %he RCI for each child was calculated
and is presented in %able 0# As stated, if the value of the RCI
e*ceeds 1#94, it indicates that the chan$e from pretreatment
to posttreatment is due not to chance (p J !#!3) but to the
effectiveness of the care pac7a$e#
-verall, 1" children showed an improvement in the
scores before and after treatment, and 0 children showed a
sli$ht deterioration in the scores after treatment# %hirteen
children showed statistically si$nificant chan$es in scores in
at least one of the subscales, and 11 children showed
statistically si$nificant chan$es in scores in either one or
both of the total scales in the whole ADHD Ratin$ ,cales#
-utcomes of the )*-+-#$
%he descriptive statistics for the five scales of the +'-C:
! are reported in %able 8# In the +'-C manual, the use
of mean, standard deviation (,D) and ran$e of scores is
recommended to analyse the data (Din$ et al 1993)# A
mean score around 8 indicates that, on avera$e, parents
report that the service <sometimes= meets their needs on
that scale, and a mean score of " (or Gust sli$htly less
than ") indicates that needs are bein$ met <to a $reat
e*tent=# In addition to these descriptions for certain mean
values, the mean plus the standard deviation and the ran$e
of scores provided useful information about how much
variability or dispersion there was in the data set#
%he hi$hest mean score (4#8;) obtained was in the
scale of <Coordinated and Comprehensive Care=, while the
lowest mean score (3#4") was in the scale of <'rovidin$
>eneral Information=# -verall, the mean scores for all the
five scales were hi$her than the score of 8# In e*aminin$ the
scores within :1 ,D and O1 ,D, most of the scores were
above 3, with only the scale <'rovidin$ >eneral Information=
havin$ a lower score at 8#3# 6or the ran$e of scores from
minimum to ma*imum, only two parents $ave low scores of
and 0# %he overall results indicated that the parents
e*perienced $ood levels of family:centred care, as delivered
by the research therapists when they were implementin$
the pac7a$e#
In view of the recommendation for analysin$ ordinal data
based on a /i7ert scale (for e*ample, >iles !!), other
descriptive statistics (that is, mode, median and @uartiles)
were also used to analyse the data# %he findin$s
Discussion
Demographic characteristics of
the #$ therapists
As reported, the occupational therapists were selected
from the four countries, with &n$land havin$ the hi$her
number because of the lar$er population siIe# %here was
a $ood mi* of therapists wor7in$ at different $rades and
in different service settin$s# A maGority of the therapists
had considerable clinical e*perience in wor7in$ with
children, with the mean years of e*perience bein$ 1#4#
Althou$h the $rade, wor7 settin$ and years of e*perience
of the research therapists were not considered in the
process and outcome evaluations, these factors could
have enhanced the effectiveness of the pac7a$e#
Demographic and clinical
characteristics of the #$ children
%he hi$her ratio of boys to $irls in this study reflects clinical
populations (American 'sychiatric Association 1998, >omeI
et al 1999, Kational Institute for Clinical &*cellence !!!)#
>irls with ADHD are less prevalent and usually present with
the Inattentive %ype (Carlson et al 1999, +ilich et al !!1)#
-f the two $irls (cases 11 and 10) in this study, one was
identified as havin$ the Inattentive %ype#
.ith re$ard to the whole cohort of ! children,
five children (cases 8, 10, 18, 14 and !) were identified as
havin$ the Inattentive %ype# %his is relatively unusual
because such children are not usually identified and referred
to a clinical service until a later sta$e in their education
(.odrich 1998)# Children with the Inattentive %ype have a
different behavioural pattern from that of children with the
Hyperactive:Impulsive %ype and the Combined %ype# %here
is a view that the Inattentive %ype mi$ht have different
aetiolo$ical factors and be a separate disorder (Carlson
et al 1999)# In e*aminin$ the types of sensory processin$
dysfunction in these five children, four did not have the
typical ,ensory ,ee7in$ pattern identified in children with
ADHD (Dunn 1999, Dunn and (ennett !!)# %hey
presented either a +i*ed 'attern or a pattern opposite to the
,ensory ,ee7in$ pattern, that is, the ,ensitivity to ,timuli
pattern# %entatively, the clinical characteristics of these five
children did support the ar$ument that children with the
Inattentive %ype do have different underlyin$ dysfunctions#
%herefore, it is important to assess their underlyin$
neurolo$ical functions in order to decide on the choice of
treatment approaches# %his findin$ further reinforced the
importance of adoptin$ the multidimensional evaluation
procedures advocated in the model of practice#
4ritish 5ournal of -ccupational Therapy -ctober !!" "!(1!) 66A
-f the other 13 children, most had the Combined
%ype, which is the most common subtype of ADHD
referred to a clinical service# ,i* children were classified
as ADHD Kot -therwise ,pecified (K-,) because they
did present features of ADHD but did not completely
meet the dia$nostic criteria# A maGority of the children
presented with the ,ensory ,ee7in$ pattern commonly
identified in children with ADHD# %his is consistent with
the research findin$s of +an$eot et al (!!1) and Dunn
and (ennett (!!)# %hese data supported the use of
sensory inte$rative treatment techni@ues as part of the
multifaceted treatment pro$ramme#
-ver half of the children in this study presented
comorbidity with DCD# %his is consistent with the
research findin$s by >illber$ and DadesGo (!!!) that the
prevalence of comorbid ADHD and DCD is as hi$h as
3!P# %hese data supported the importance of assessin$
other developmental s7ills as part of the multidimensional
evaluation model, since many children with ADHD
referred to a clinical service additionally present problems
in either $ross motor s7ills or fine motor s7ills, or both
(.hitmont and Clar7 1994, Harvey and Reid 199", 'ie7
et al 1999, Christiansen !!!, 5ohnson and Rosen !!!,
'itcher et al !!0, %sen$ et al !!8)#
%he clinical characteristics of these ! children, as
identified above, had consistent lin7s to previous
research findin$s of children with ADHD# %his su$$ested
that the study used a reasonably representative sample#
2fficacy of the package as measured
y the ADHD &ating 'cales
-ne of the uni@ue features of the pac7a$e was the
combination of intervention strate$ies at the child, tas7
and environment levels, chosen fle*ibly to suit the child
and family# It was aimed at empowerin$ parents and
teachers to mana$e the child=s behaviours by usin$
different treatment strate$ies, which hopefully should be
more lon$ lastin$ than medication# Another uni@ue
feature was the family:centred care approach in service
delivery# It made the whole pac7a$e one coherent entity
that was very different from other available combined
treatment methods#
&ven thou$h it was implemented in a relatively short
timescale, a maGority of the children showed
improvement in the scores after the implementation of
the pac7a$e, as measured by the posttreatment ADHD
Ratin$ ,cales# -ver half of the children had si$nificant
chan$es in scores (as indicated by the value of the RCI
in %able 0) in at least one of the subscales or in one or
both of the total scales of the ADHD Ratin$ ,cales# It
was interestin$ to note that the most si$nificant chan$es
in scores were related to the Home Cersion of the ADHD
Ratin$ ,cale# %his could be related to the family:
centredness of the care pac7a$e or to the fact that it was
more difficult for teachers to ma7e chan$es within the
school environment within such a short timescale#
In view of the short duration of the treatment component
of the pac7a$e (that is, " to ; contacts within months
after the multidimensional evaluation), the results were
encoura$in$ and comparable to other efficacy studies
usin$ different forms of treatments (+%A Cooperative
>roup 1999, Dlein et al !!8)# %he results of this
multicentre study could provide a steppin$ stone to
developin$ a form of intervention to replace or reduce the
use of medication treatment, which mainly provides
temporary relief of the si$ns and symptoms of ADHD# It is
important to note that the avera$e positive response rate
in usin$ medication as a sin$le treatment modality has
been found to be "!P (,pencer et al 1994)# Fet once the
effect of medication subsides, the child will return to his
or her ori$inal behavioural state# %herefore, other forms
of treatment that could have a lon$:lastin$ effect should
be e*plored# %his pac7a$e enables parents to use
different behavioural and sensory modulation techni@ues,
teaches the children different copin$ strate$ies, and
empowers teachers to adapt the learnin$ environment
and to select appropriate tas7s for a child with ADHD#
%hree children (cases 8, 13 and 1;) showed some
deterioration in their scores after the treatment# %he
decline in behavioural functionin$ could be coincidental#
Alternatively, there may have been specific factors
related to the therapist in the implementation of the
pac7a$e (for e*ample, years of clinical e*perience)#
However, the sample in this study is too small for the
matter to be resolved satisfactorily# 6or further research
re$ardin$ the pac7a$e, it mi$ht be helpful to e*plore
factors related to the efficacy of the research therapists,
such as the effect of the years of clinical e*perience of
the therapists, the ran$e of post$raduate trainin$
completed and the service settin$ in which they wor7#
The degree of family-centredness in
the delivery of the package as
measured y the )*-+-#$
,helton et al (19;") hi$hli$hted that parent:therapist
collaboration was central to family:centred care, with
both offerin$ different perspectives and sources of
e*pertise# Althou$h therapists can offer the e*pertise of
their s7ills and 7nowled$e $ained from wor7in$ with a
number of children, parents are the only ones who can
contribute information about their particular child in all
settin$s# 'arent:therapist collaboration can lead to
more comprehensive and more appropriate treatment
plans, which are individually tailored to both the child=s
and family=s stren$ths and needs#
%he positive results of the +'-C:! supported the
importance of parent:therapist collaboration, since most
parents reported $ains in confidence in mana$in$ their
children with ADHD# %he only wea7er score was in the
scale of <'rovidin$ >eneral Information=# %his could be
improved in future interventions by (a) providin$ more
opportunities for the entire family to obtain informationH
(b) havin$ information available in various forms, such as
boo7let, 7it and videoH and
(c) providin$ more advice on how to $et
information or to contact other parents#
66@ 4ritish 5ournal of -ccupational Therapy -ctober !!" "!(1!)
Althou$h the +'-C:! was used as an outcome
measure in this study, the +'-C:34 is a tool that is still
particularly useful for research and a more in:depth
assessment# %he additional content of the +'-C:34,
which has more items within each scale, provides more
concrete ideas for improvement# 6or any further lar$er:
scale study, the +'-C:34 is recommended#
Eimitations of the study
Althou$h positive results were achieved in this study,
caution should be e*ercised in $eneralisin$ the results,
$iven the small sample siIe, the lac7 of randomisation in
the selection of participants and the absence of a control
$roup# %here mi$ht also have been e*perimenter effects
on the part of the research therapists in collectin$ the
data, since they mi$ht have been particularly enthusiastic
followin$ the trainin$ days# %his eventuality could be
minimised by havin$ a therapist who implements the
pac7a$e and a separate person who collects the data# A
further lar$er:scale study needs to be carried out usin$ a
randomised controlled trial#
Althou$h the research therapists were instructed to
complete the whole pac7a$e, no formal procedure was
underta7en to ascertain the fidelity to treatment, which
refers to the e*tent to which an intervention is faithful to
its underlyin$ theoretical and clinical $uidelines ('arham
et al !!")# %herefore, it is important to e*amine therapist
fidelity to the pac7a$e as well as the influence of different
variables on behavioural outcomes# &*amples of the
latter are the duration of the pac7a$e, the combination of
different treatment components, specific factors related to
the 7nowled$e and s7ills of the research therapists, the
educational levels and cultural bac7$round of the
parents, and factors associated with school and teachers
such as the teachin$ style of the teacher#
As most effective outcomes were achieved at home, it
would be difficult to come to a firm conclusion about
the efficacy of the pac7a$e within the school environment#
Conse@uently, it is important to stren$then the types of input
that can be provided to schools if a lar$er:scale randomised
controlled trial is to be carried out# 6or e*ample, a structured
trainin$ pro$ramme for school
staff could be developed in order to promote a better
understandin$ of children with ADHD, as could a
whole:school approach in supportin$ and mana$in$
children with ADHD# It mi$ht also be helpful to e*tend
the duration of the care pac7a$e in order to provide
more re$ular support to the class teacher, althou$h
this carries resource implications#
Another limitation of the present study was the lac7 of
information about the lon$:lastin$ effects of the pac7a$e#
%his could be overcome by reassessin$ this cohort of
! children after 4 and 1 months to establish whether
improvements are maintained# However, it may be difficult to
measure the child=s behavioural status in school, or to relate
this to the intervention, because there are li7ely to be
chan$es in staffin$ and the learnin$ environment over lon$er
periods# %herefore, perhaps lon$er:term follow:up
should be carried out in the home environment,
focusin$ on parental perceptions of the child=s
behaviour and also direct observation of the child#
+onclusion
%his study has established the value of the delineation
model of occupational therapy practice for children with
ADHD by e*aminin$ the effectiveness of an assessment
and treatment pac7a$e based on the model# %he results
are encoura$in$ and comparable to other efficacy
studies# %he pac7a$e encoura$ed the occupational
therapists to reco$nise the vital role of parents in the
therapeutic process, to increase their understandin$ of
the parent:child interaction and to e*pand their s7ills to
include effective collaboration with parents for the benefit
of the child# However, further wor7 needs to be done to
understand the reported differences in the results
between home and school in order to facilitate better
teacher:therapist collaboration re$ardin$ the
mana$ement of children with ADHD#
It is important to note that caution should be e*ercised in
$eneralisin$ the results because of the small sample siIe,
the lac7 of randomisation, the absence of a control $roup in
the research desi$n and the potential e*perimenter effects
on the part of the research therapists# As there are many
@uestions left unanswered, a lar$er:scale randomised
controlled trial should be carried out to evaluate the efficacy
of an improved care pac7a$e, with inputs from research
therapists and parents#
Althou$h there were various limitations, this study should
be viewed as a si$nificant initial step in the continuin$
development and validation of a multifaceted model of
occupational therapy practice for children with ADHD# ,ince
a model of practice represents the most dynamic arena of
7nowled$e development in the profession, constant chan$e
is to be e*pected and valued# %he information $enerated in
this study will be used to refine and modify the theoretical
constructs of the model and the structure and content of the
intervention pac7a$e#
Acknowledgements
%he first author would li7e to than7 the Colle$e of -ccupational %herapists in
awardin$ the (yers +emorial 6und and also the Hospital ,avin$ Association
in awardin$ the 'hD ,cholarship Award !!1 for his doctoral study at the
,chool of Health ,ciences and ,ocial Care, (runel )niversity#
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