Attention-Deficit/Hyperactivity Disorder

Diagnostic Criteria According to the DSM-5™

The DSM- 5 names the disorder, “Attention-Deficit/ Hyperactivity Disorder” (AD/HD) and specifies the following presentations:
1. Predominantly inattentive. The majority of symptoms fall under inattention.
2. Predominantly hyperactive/impulsive. The majority of symptoms are hyperactive and impulsive.
3. Combined. This is a mix of inattentive symptoms and hyperactive/impulsive symptoms.

To meet the criteria for a diagnosis of AD/HD:

A: There must be a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2).

1. Inattention: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
a. Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).
b. Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).
c. Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).
d. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).
e. Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).
f. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).
g. Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
h. Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).
i. Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments).

2. Hyperactivity and Impulsivity: Six (or more) of the following symptoms have persisted for at least 6 months to a degree that is inconsistent with developmental level and that negatively impacts directly on social and academic/occupational activities:
a. Often fidgets with or taps hands or feet or squirms in seat.
b. Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).
c. Often runs about or climbs in situations where it is inappropriate.
d. Often unable to play or engage in leisure activities quietly.
e. Is often “on the go,” acting as if “driven by a motor” (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).
f. Often talks excessively.
g. Often blurts out an answer before a question has been completed (e.g., completes people’s sentences; cannot wait for turn in conversation).
h. Often has difficulty waiting his or her turn (e.g., while waiting in line).
i. Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people’s things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing).

B. Several inattentive or hyperactive-impulsive symptoms were present prior to age 12 years.

C. Several inattentive or hyperactive-impulsive symptoms are present in two or more settings (e.g., at
home, school, or work; with friends or relatives; in other activities).

D. There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or
occupational functioning.

E. The symptoms do not occur exclusively during the course of schizophrenia or another psychotic
disorder and are not better explained by another mental disorder (e.g., mood disorder, anxiety
disorder, dissociative disorder, personality disorder, substance intoxication or withdrawal).

  In the classroom

A common role of the school-based OT practitioner is collaborating with teachers to develop strategies to improve behavior and classroom performance of students with ADD/ADHD. Children with inattentive (traditionally called ADD), hyperactive-impulse (traditionally called ADHD), and combined disorders work best under close monitoring and with minimal distractions.

Strategies 

Seating in the classroom
– Avoid seating children with ADD/ADHD in large clusters of tables with many students at each table. It is often better to have the student either sit at a single desk or at a paired desk.
– Place the student closest to the teacher. This enables discreet interaction between the teacher and the student and helps keep them on task.
– Seat the student near the front of the classroom away from distractions. Being at the front of the class diminishes many visual distractions, including the movement and activities of the other students.
– Use positive peer models. Encourage the student to sit near positive role models to ease the distractions from other students with challenging or diverting behaviors. Place the student next to quiet, hardworking peers.
– Adapt the environment to meet the student’s needs by implementing sensory modulation strategies. Example: Use dynamic sitting such as a stability ball.
A stability ball acts on the CNS and is intended to help the body attain its optimal state of arousal required for learning. A student sitting on a stability ball is experiencing a sense of instability that differs from sitting on a regular classroom chair. This instability allows the student to engage their vestibular and proprioceptive systems while in their seat, which aids them in organizing and integrating sensory information. These systems are movement dependent which facilitates cerebellar functioning. Research has shown that the cerebellum plays a role in attention, spatial perception, long-term memory, and impulse control. With increased input to the cerebellum there is also increased input to the pre-frontal cortex where attention is housed. The ultimate goal is intended to increase the student’s attention while they are sitting on the stability ball to maximize their engagement in classroom tasks.

Coping with classwork
– Rules and routines are important for these students as they provide structure. Changes to daily routines can be very unsettling, so if there is going to be a change, explain what’s going to happen in advance. Rules for all the students in the classroom can be posted in the classroom. Rules should be short, simple and visible.
– Staying in a seat for any length of time can be difficult for students with ADHD. Consider allowing the student to stand for short periods, as long as they are not too disruptive to others.
– Prepare the student in advance of what will be expected of them and this will prevent them from a feeling of uncertainty and insecurity. Prepare for transitions. Remind the student about what is coming next (next class, recess, time for a different book, etc.). For special events like field trips or other activities, be sure to give plenty of advance notice and reminders. Help the student in preparing for the end of the day and going home, supervise the student’s book bag for necessary items needed for homework.
– Students with ADD/ADHD tend to respond better to concrete learning experiences and often require instructions to be repeatedly reinforced. They tend to avoid classwork that is too difficult or too long. Therefore, it is important to assign them work according to their skill level.
– Students with ADD/ADHD typically have problems organizing themselves and so they really need help with study skills:
* For daily routines, stick a timetable to their desk
* When they are working on projects, draw up a checklist to ensure every point is covered
* To avoid confusion, don’t give them more than one assignment at a time
– Provide visual reminders. Students with ADD/ADHD respond well to visual cues and examples. For example, demonstrate a skill like essay writing on a board, and leave key points about a topic visible on the board so when the student works independently, they can refer to the board for cues.

Managing behavior
– It’s hard to stop students with ADD/ADHD, especially those with the hyperactive/impulsive subtype, from fiddling and fidgeting but it is helpful to be proactive rather than reactive to this. It is a good idea to give them something to fiddle with, such as spinners, squeezable balls, tangle toys or small building blocks.
– Allow for movement. Allow the student to move around, preferably by creating reasons for the movement. Incorporate opportunities for physical action into the curriculum.
– It can be difficult for these students to wind down, especially after break time. Going from the relative calm of the classroom to the playground and back again can be quite difficult for them. After a break, they may need to settle down for a few minutes before focusing on specific tasks.
– Keep in mind that these students tend to get overstimulated when working in group situations.

Accommodations in the classroom
– Students with ADD/ADHD may need school accommodations. Some accommodations can be as easy as monitoring the student’s work and developing a plan to help them not fall behind and even accepting the occasional late assignment.
Other common ADD/ADHD accommodations include:
* Extended time on tests
* Homework can be reduced or differentiated to that which is essential
* Shortened assignments
* Instruction in note-taking or designating a class notetaker
* Segmented assignments for long-term projects (with separate due dates and grades).
* Ways of reducing writing requirements to that which is essential by using technology.
 

Resources:
https://www.additudemag.com/teaching-strategies-for-students-with-adhd/
https://www.education.vic.gov.au/Documents/school/principals/participation/tipsmanagingadhdinclass.pdf
https://www.adhdfoundation.org.uk/wp-content/uploads/2019/01/Teaching-and-Managing-Students_FINAL.pdf
https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_ADHD.pdf
https://www.uwlax.edu/globalassets/academics/grad/occupational-therapy/cats/2016-17/stability-ball.pdf