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Dx and tx of ADD
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Attention Deficit Disorder- Definition

Persistent and frequent pattern of developmentally

inappropriate inattention and impulsivity with or without hyperactivity (Merck). Heterogeneous behavioral disorder of uncertain cause Always present in Childhood, usually adolescence, and may persist into adulthood

Diagnosing also considers:

symptoms must be more frequent or severe compared to

other children the same age. In adults, the symptoms must affect the ability to function in daily life and persist from childhood. behaviors must create significant difficulty in at least two areas of life, such as home, social settings, school, or work. Symptoms must be present for at least six months.

Behavioral observations- checklist

Done by psychiatrists, psychologists, school

psychologists among others

One of the most common neurobehavioral disorders in

childhood Estimated prevalence in 3 to 5% of school age population Occurs three times more often in boys than girls

Causes not clear, recent research looking at:

Genetic factors- seems to run in families

Neurologic factors Frontal parietal lobe activity is low Frontal orbital under functioning and thus limbic system

to which it is linked Neurochemical imbalances- medications that influence neurotransmitters are effective in some

Subtypes in DSMIV-TR
The DSM-IV identifies three sub-types of ADHD,

depending on the presence or absence of particular symptoms: Inattentive type, Hyperactive type, and Combined type. To be diagnosed with ADHD, individuals must have six of the nine characteristics in either or both DSM-IV categories listed below.

ADHD - Predominantly Inattentive Type

Fails to give close attention to details or makes careless

mistakes. Has difficulty sustaining attention. Does not appear to listen. Struggles to follow through on instructions. Has difficulty with organization. Avoids or dislikes tasks requiring sustained mental effort. Loses things. Is easily distracted. Is forgetful in daily activities.

ADHD - Predominantly Hyperactive/Impulsive Type

Fidgets with hands or feet or squirms in chair.

Has difficulty remaining seated.

Runs about or climbs excessively. Difficulty engaging in activities quietly. Acts as if driven by a motor. Talks excessively. Blurts out answers before questions have been

completed. Difficulty waiting or taking turns. Interrupts or intrudes upon others.

ADHD - Combined Type

Individual meets both sets of

inattention and hyperactive/impulsive criteria.

What we see:
Frequent and severe inattention (poor sustained

attention) and impulsivity, including: oFailure to attend to details oPoor attention during play oDifficulty actively listening to instructions or conversation, o Difficult organizing tasks oAvoidance of tasks requiring sustained attention oEasily distracted

What we see with hyperactivity

Inability to remain seated when

expected Frequent fidgeting Constantly on the go Difficulty playing quietly Excessive talking

Inability to wait ones turn

Frequent and incessant interruptions

Blurting out answers before question is


Low frustration tolerance
Sleep disturbances Demands for attention poor self esteem At risk for injury due to risk taking and

impulsive behavior

Similar conditions
Certain conditions that could mimic ADHD or cause the

ADHD-like behaviors are: A sudden life changes (such as divorce, a death in the family, or moving) Undetected seizures Thyroid problems Sleep problems Anxiety Depression Lead toxicity

into adolescence and adulthood

Problems with academic failure, low self esteem, diff with

socially appropriate behavior ADD with impulsivity/hyperactivity: Higher incidence of personality trait and ab nitsocial personality Impulsivity, restlessness, and poor social skills continue Both: Adjust better to work than school Depression, interpersonal problems, low intelligience

Medical management
Medications psychostimulants help with overactivity,

attention span, impulsivity, self control common names are Ritalin, Concerta, Focolan, Adderall May take time to determine which one(s) work best for child (side effects) Behavioral interventions for persistent behaviors (even with medications) Counseling, cognitive behavioral therapy, behavior modification, social skills training Educational support, OT, Speech, behavior specialists

Occupational Therapy Intervention

Referrals in school setting are quite common, for:

Sensory modulation and self regulation

Handwriting, Organizational skills Social skills Environmental modifications Coordination Fine motor skills

The Occupational Therapy Practice Framework

Areas of Occupation Client Factors Performance Skills Performance Patterns Context & Envir. Activity Demands


Values, Beliefs & Spirituality

Sensory Perceptual Skills Motor & Praxis Skills Emotional Regulation Skills Cognitive Skills Comm. & Social Skills



Objects Used & Their Properties Space Demands Social Demands

IADLs Rest & Sleep

Body Functions Body Structures

Routines Roles

Personal Physical

Education Work Play Leisure Social Particip.


Social Temporal Virtual

Seque. & Timing Required Actions Required Body Funct Required Body Structures


A group of problems that affect a childs ability to master

school tasks, process information, and communicate effectively. Most children have average or above average intelligence Do not have deafness or blindness As defined by IDEA: Group of disorders that interfere with child's ability to learn in typical classroom Discrepancy between childs cognitive ability and their academic achievement

Affects 4 to 5% of the school

population More boys than girls affected by ratio of 4 to 1. Girls may be less frequently diagnosed

No single cause defined

Neurologic defects presumed or evident

Genetic influences Maternal causes: illness, drug use, Complications during pregnancy or delivery: spotting, toxemia, prolonged labor, precipitous labor Neonatal problems: prematurity, low birth weight, jaundice, perinatal asphyxia, respiratory distress

Signs and Symptoms (associated problems)

Child may exhibit any number of these behaviors:

Disorders of motor function may include: Clumsiness, poor gross and fine motor skills, dyspraxia (motor planning), problems with balance and sensorimotor problems
Educational disorders in one or more subject area. Related problems with copying from board, handwriting, organizing time and materials, understanding written and oral directions, letter reversals, cutting, coloring, drawing. Disorders of attention and concentration (ADD ADHD)

Disorders of thinking and memory: abstract reasoning, and concept formation, poor short and long term memory

Signs and Symptoms (cont)

Problems with Speech and Communication: Sequencing words, sentences, sounds, articulation problems, shifting topics, conversation Sensory Integration and perceptual disorders,

including laterality, directionality as well as other Visual Perceptual problems Psychosocial problems: Social delays, tantrums, antisocial behaviors, poor self esteem (have the intellect to know they are not performing as peers, may be teased)

Specific Learning Disability may include:

Dyslexia affects how a person processes language.

Reading and writing are difficult, as are grammar and reading comprehension. May also have trouble expressing themselves verbally and putting together thoughts during conversation. Dysgraphia affects a person's writing abilities. May have a variety of problems, including: handwriting, spelling, putting thoughts on paper Dyscalculia affects a person's ability to do math. Many forms and different symptoms seen. In young children, dyscalculia may affect learning to count and recognize numbers. In the older child, trouble solving basic math problems or memorizing things like multiplication tables may occur.

Signs and Symptoms (cont)

Auditory difficulties that have a huge impact on school

performance: problems with auditory perception and auditory memory, not hearing acuity. Auditory memory, Phonemic synthesis sound out words and blends Speech in noise screen out background noise Auditory sequencing of sounds, words, or numbers

best tested by audiologists for CAPD

(Central Auditory Processing Disorder)

Diagnosing Learning Disability

Neurologic or neurodevelopmental eval

Testing by a clinical psychologist, a school

psychologist, a developmental psychologist. Evaluations may also be done by an occupational therapist, or a speech and language therapist

Management of Learning Disabilities

Special education Under the Individuals With

Disabilities Education Act (IDEA), qualified children with learning disorders are entitled to receive special education services for free in public schools. A team of special educators create an individualized education program (IEP) that outlines what special services he needs to learn at school. Educators and related services personnel implement IEP.

Management (cont)
Resources are also available outside of the public school

system, including: Private schools that specialize in treating children with learning disabilities After-school programs designed for children with learning disabilities At-home tutoring and therapy services

Early intervention is critical
Outcomes can be good depending on how extensive the

learning problem and appropriate support for learning and psychosocial issues Life and career options can be made to capitalize on ones strengths College is not out of the questions LD is much more recognized and accepted, and resources are available even on college level

Impact of the Condition on Occupation

Areas of Occupation
Client Factors: Values, beliefs and spirituality,
Body function, Body structure

Performance Skills-Sensory perceptual skills,

Motor and praxis skills, Emotional regulation Cognition, Communication and Social skills



Rest and Sleep Education

Work Play

Leisure and Social skills

OT Intervention
Sensory motor

Sensory integration
Handwriting Organizational skills Visual perceptual remediation Social skills Community and vocational skills Visual Perceptual problems

Case-Smith, J. and OBrien, J. Occupational Therapy for

Children, Sixth edition(2010). Maryland Heights: Mosby Elsevier. Beers, M and Berkow, R., (eds). The Merck Manual of Diagnosis and Therapy, 17th edition(1999). Whitehouse Station: Merck Research Laboratories http://children.webmd.com/detecting-learning-disabilities http://children.webmd.com/detecting-learning-disabilities http://www.chadd.org