The majority of children drift away occasionally during a
boring class, and many find it impossible not to squirm during a long
movie. Still, most children, most of the time, can pay attention, sit
still, tune out distractions, organize tasks, and control their
behavior in an age-appropriate way, without a huge conscious effort.
This isn’t so easy for the estimated 8 million children in the United
States with attention deficit hyperactivity disorder, a neurobiological
condition marked by inattention, hyperactivity, and impulsivity.
This
isn’t so easy for the estimated 8 million children in the United States
with attention deficit hyperactivity disorder, a neurobiological
condition marked by inattention, hyperactivity, and impulsivity.
Although
the causes of ADHD are not fully known, one line of current thinking
suggests that the disorder stems from an impairment of the frontal
lobes of the cerebrum, the area of the brain involved in motor
function, impulse control, planning, problem solving, and other key
tasks.
Because ADHD affects about one in 20
children, PTs and PTAs who work with young patients are likely to
encounter at least a few children and teens with ADHD
during the course of their careers.
Focus on Facts
Children with ADHD are significantly more accident prone than
the general population, which means they may be more likely to sustain
injuries that require physical therapy. Studies have shown that 16% of
children with ADHD versus 5% of children in the general population have
had at least four serious accidental injuries, including fractures, and
that 40% of teens with ADHD compared to 6% of teens in the general
population have had two or more driving accidents.
The
inattentiveness, impulsivity, and hyperactivity that are the behavioral
hallmarks of ADHD can seep into PT sessions, making it harder to
accomplish the goals of treatment. These extra challenges can be
managed by understanding something about what makes children with ADHD
tick and by translating that insight into practice. According to
experts, the key to working effectively with children who have ADHD is
to provide the clarity, structure, and consistency that they have
trouble providing for themselves, and to combine it with liberal doses
of novelty and plenty of positive reinforcement for desired behavior.
Manage Behavior
Russell A. Barkley, PhD, author of “Attention-Deficit
Hyperactivity Disorder: A Handbook for Diagnosis and Treatment,” and a
research professor at the State University of New York Upstate Medical
University, Syracuse, recommends that PTs use many of the same
behavioral management strategies that have been found to work well for
teachers.
“Have clear rules for the
session, post them in a visible location, and review them just before
starting,” says Barkley, who is also the editor of The ADHD Report, a
newsletter for clinicians and parents. Among his other recommendations:
*
Use incentives, or rewards, for following the rules during the session.
Clearly explain those rewards and how they can be earned, and review
them with the child at the beginning of each session.
* Give the child specific feedback on his or her performance at the end of each session.
*
Send a note card home for parents reporting the child’s behavior during
the session. The card can be linked to home privileges that the child
values, such as video game or computer time.
“Since
many of these youth have organizational problems, clear, single-step
commands, and assuring that the child actually hears and understands
the commands, are essential,” notes Timothy Wilens, MD, a child
psychiatrist at Massachusetts General Hospital, Boston, who conducts
research on pharmacotherapy for ADHD.
“I
recommend using many of the techniques that PTs are so well-versed in,
applied aggressively,” Wilens says. “These youth need novel stimuli,
active engagement and re-engagement, frequent changes of venue,
positive reinforcement, and, of course, fun while doing activities.”
Michelle
Maniaci, PT, RYT, CIIM, a physical therapist and yoga instructor who
runs Nurturing Moves Inc. in Miami, can attest to the need for
engagement, re-engagement, and fun when working with children who have
ADHD.
“The therapist must motivate the
child or the child won’t pay attention,” she says. The key to that
motivation is devoting some additional time and energy to listening,
communicating with the child on his or her level, finding out what
kinds of activities he or she enjoys, and incorporating them into the
session if possible. It also means drawing on one’s “inner clown” as
needed, and being prepared to change activities as necessary to keep
the child interested.
Active Movement
According to many experts, regular exercise may help children and teens with ADHD focus and function more effectively.
John
Ratey, MD, associate clinical professor of psychiatry at Harvard
Medical School and co-author of “Driven to Distraction: Recognizing and
Coping with Attention Deficit Disorder from Childhood to Adulthood,”
believes that the increases in dopamine, norepinephrine, and serotonin
that occur with exercise can enhance the ability to focus and lower the
brain’s need for stimulation for the person with ADHD.
“Anecdotally,
parents clearly support that regular exercise not only improves a
[child with] ADHD’s ability to sit still, but to concentrate as well,”
Wilens agrees. “Limited literature that is emerging seems to suggest a
very similar phenomenon. That is, children with ADHD who exercise show
improved outcome in their attention spans, concentration, and their
academic performance.”
According to Wilens,
one form of regular exercise that parents routinely endorse is martial
arts. “Not only is the physicality of martial arts important, but the
mental effort that is required seems to complement a child with ADHD’s
attention limitations,” he says.
Calm Environments
Maniaci believes in the benefits of creating a soothing
environment at the beginning of each session. “The easiest thing the PT
can do is to change the environment so that the environment drives the
child to be calmer,” she says. She lowers the lights, filters out
distracting noises, and employs aromatherapy — lavender, specifically —
to “engage the relaxation response.”
Maniaci
describes her approach as holistic. “I’m not just working with the
child in isolation; the whole environment is causing the child to have
the mind-body experience,” she explains. “If there’s a background
noise, no matter how good a motivator I am, that child is going to want
to look at whatever is more exciting.”
She
says that instruction in diaphragmatic breathing is a critical part of
her holistic strategy because the technique helps to keep her patients
focused and “in the moment” during sessions. The technique works “with
any patient of any diagnosis,” she says, but it becomes particularly
useful with children who have ADHD. “If I work with the child on
diaphragmatic breathing, I’m going to have a calmer, organized,
posturally effective body,” she says, as well as a child who is more
receptive to therapy.
Resources
* Attention Deficit Hyperactivity Disorder, National Institute of Mental Health: www.nimh.nih.gov/health/publications/adhd/summary.shtml
* CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorder): www.chadd.org
* Barkley R. ADHD and accident proneness. The ADHD Report. 2002;10(2):2-5.
*
Haffner J, Roos J, Goldstein N, et al. The effectiveness of
body-oriented methods of therapy in the treatment of attention-deficit
hyperactivity disorder (ADHD): results of a controlled pilot study. Kinder Jugendpsychiatr Psychother. 2006;34(1):37-47.
Susan Birk is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.