Classroom Interventions for Children with ADHD

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Classroom Interventions for Children with ADHD

• Jessica Soileau

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Background

• Children with ADHD receive medical attention to
  reduce the core symptoms of inattention,
  hyperactivity, and impulsivity
• Inattention typically results in
• off-task behavior in the classroom, failure to
  listen to instructions, forgetting to complete or
  turn in assignments, and changing activities
  often
• Hyperactivity effects the childs ability to
• manage staying seated in the classroom, excessive
  fidgeting, and being noisy
• Impulsivity tends to exhibit
• inability to withhold active responses resulting
  in poor multiple choice test performance,
  inadequate planning, and incompletion of
  long-term projects

(Raggi and Chronis, 2006)
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Background

• Children with ADHD are frequently affected by
  deficiencies in sensory integration and sensory
  modulation5
• Sensory integration is the neurological
  organization of sensory information from an
  individuals environment for adaptive motor or
  behavioral responses6
• Sensory modulation is the facilitation or
  inhibition of information and has a direct effect
  on a persons attention and behavior6

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Objective

• The aim of this study was to determine the
  effectiveness of occupational therapists role in
  decreasing impulsivity and inattentiveness in the
  classroom for children with Attention Deficit
  Hyperactivity Disorder.

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Search strategy

• Database
• Google Scholar (1995 through September 2009)
• American Occupational Therapy Association (1995
  through September 2009)
• Pubmed- indexed for Medline (1995 to September
  2009)
• Search terms used included
• ADHD, Treatment strategies, Children,
  School-based therapy, Occupational Therapy,
  Sensory Integration, Dynamic Seating

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Description of studies

• Types of Studies
• non-randomized control trial, randomized control
  trial, single subject design, and a literature
  review
• Interventions
• seating devices, Interactive Metronome Training,
  Sensory Challenge Protocols, family centered
  treatment package, weighted vest, medication
  management, behavioral treatment, and community
  care
• Outcome Measures
• in-seat behavior, legible word productivity,
  attention to task, self-regulation, language
  processing, motor control, aggressive symptoms,
  social skills, sensory sensitivity, and overall
  behavior

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Description of Studies

• Inclusion
• 4-12 year olds
• ADHD- DSM-IV
• Attention difficulties
• Normal IQ-Wechsler

• Exclusion
• Inner ear difficulties
• Clearly defined developmental disorders (CP, PDD)

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Methodolical quality

• Only 1 of the 4 randomized studies provided their
  randomization procedure6
• One study only included boys9
• Small sample sizes for 3 studies8,9,10
• Parental report was the only measure11
• Potential bias
• Limited to specific populations
• Informal assessments for academic success
• Lack of a control group

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results
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Seating devices

• Disc o sit cushion

• Therapy Balls

• One-way ANOVA (plt.05) comparing pre and post
  test6
• Small to medium effect
• GEC scores (n2 .324)
• BRI scores (n2 .229)
• Small effect
• MI scores (n2 .145)

• Graphed and visually analyzed for differences
  between AB phases8
• Therapy balls facilitate in-seat behavior and
  legible word productivity

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Individualized Plan

• Medication shows a response rate of 60-90 to
  reduce core symptoms however, pharmacotherapy
  alone does not improve the long-term outcome for
  any domain of functioning2
• Multimodal therapy is a naturally powerful
  intervention
• Integrating pharmacotherapy with a number of
  environmental, educational, psychotherapeutic and
  school-based approaches
• Matches the childs particular problems to a
  selection from a choice of focused interventions

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Individualized plan

• Two of the studies evaluated 4 treatment
  strategies using the random-effects regression
  analysis 3,4
• Over half the variables revealed significant
  treatment effects for children in the combined
  treatment group compared to behavioral and
  community interventions4
• Combined treatment and medication management are
  superior treatments to reduce ADHD symptoms over
  time3

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Individualized plan

• A study which emphasized the interaction between
  the child, the task to be carried out, and the
  environment in which the child carries out the
  task used the Reliable Change Index1
• RCI compared the scores of the ADHD Rating
  Scale-IV Home and School Version pre and post
  treatment to determine change in inattention and
  hyperactivity-impulsivity behaviors
• 13 children showed significant changes in scores
  in at least one of the subscales while 11
  children showed significant changes in scores in
  either one or both of the total scales

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Sensory processing

• Based upon mothers perceptions using the Sensory
  Profile, children with ADHD demonstrated
  statistically significant differences from
  children without ADHD11
• sensory responsiveness as reflected in 6 out of 9
  factor scores (p lt .001.05)
• sensory processing, modulation, and behavioral
  and emotional responses, as reflected in 11 out
  of 14 section scores (p lt .001.05)

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Sensory Processing

• A study examined sensory processing using both
  physiological responses and parental report
  accounted for differences significant at plt0.0015
• The group with ADHD showed significantly lower
  scores on 6 of 7 subscales on SSP
• Analysis of physiological reactions showed the
  effect for treatment group was marginally
  significant (p0.056)
• the group with ADHD showed greater reactivity to
  sensory stimuli than did the control group

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Interactive metronome

• Evaluating the effectiveness of Interactive
  Metronome, a pattern analysis of 58 pretest
  factors was used to examine the overall direction
  of mean differences between pretest and posttest
  phases for each group9
• control group had 28 scores improve and 30
  decline (p .8955)
• Interactive Metronome and video game groups
  produced significant improvement decline
  patterns with 53 of the 58 variables showing
  improvement (p .0001)
• video game group, 40 of 58 variables showed
  improvement (p .0058)

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Weighted Vest

• Effects of wearing a weighted vest used the
  2-standard deviation band method of analyses10
• 3 students demonstrated 2 consecutive data points
  above 2SD
• a significant change occurred from the baseline
  phase to the intervention phase
• A mean increase of 17 to 25 in on-task behavior
  while wearing the vests

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discussion

• Combination of medication and behavioral
  interventions tends to yield the greatest
  improvement in social skills and school
  performance2
• Information on sensory processing implies that
  multiple interventions may help children with
  ADHD to better organize and tend to incoming
  information5,6,8,9,10,11
• seating devices, weighted vests, and interactive
  metronome training

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Discussion

• Seating devices use the principle of engaging the
  proprioceptive and vestibular systems6,8
• Keep the sensory systems at an optimal state of
  arousal needed to attend to relevant stimuli and
  focused on task
• Weighted vest use the same principle of applying
  proprioceptive feedback10
• Applies deep pressure and increases on-task
  behavior while engaged in fine motor activities

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Discussion

• Interactive metronome training is developed from
  the dynamic systems theory9
• The theory declares that in order to construct a
  complex adaptive pattern, such as attending to
  and carrying out multistep actions in school, a
  variety of processing capacities are interacting
  with each other

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conclusions

• Implications for practice
• Combined treatment
• Educate family and teachers
• Comprehensive evaluation
• Multifaceted intervention
• SENSORY INTERVENTIONS!!
• Dynamic seating, weighted vests, interactive
  metronome

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conclusions

• Implications for research
• Larger populations
• Longitudinal use of interventions
• Co-morbidities
• Medicated vs non-medicated
• Account for classroom noise and peer
  relationships
• Measure performance in academic areas using test
  scores (grades)

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References

• 1. Chu, S., Reynolds, F. (2007). Occupational
  Therapy for children with attention deficit
  hyperactivity disorder (ADHD), part 2 a
  multicentre evaluation of an assessment and
  treatment package. British Journal of
  Occupational Therapy, 70 (10), 439-448.
• 2. Goldman, L., Genel, M., Bezman R., Slanetz,
  P. (1998). Diagnosis and treatment of
  attention-deficit/hyperactivity disorder in
  children and adolescents. Journal of American
  Medical Association, 279, 1100-1107.
• 3. Hinshaw, S. P. (1999). Moderators and
  mediators of treatment response for children with
  attention-deficit/hyperactivity disorder.
  Archives of General Psychiatry, 56, 1088-1096.
• 4. Jensen, P. S. (1999). A 14-month randomized
  clinical trial of treatment strategies for
  attention-deficit/hyperactivity disorder.
  Archives of General Psychiatry, 56, 1073-1086.
• 5. Mangeot, S. D., Miller, L. J., McIntosh, D.
  N., Clarke, J. M., Hagerman, R. J, Goldson, E.
  (2001). Sensory modulation dysfunction in
  children with attention-deficit-hyperactivity
  disorder. Developmental Medicine Child
  Neurology. 43, 399-406.

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references

• 6. Pfeiffer, B., Henry, A., Miller, S.,
  Witherell, S. (2008). The effectiveness of Disc
  O Sit cushions on attention to task in
  second-grade students with attention
  difficulties. American Journal of Occupational
  Therapy, 62, 274-281.
• 7. Raggi, V.L., Chronis, A.M. (2006).
  Interventions to address the academic impairment
  of children and adolescents with ADHD. Clinical
  Child and Family Psychology Review, 9 (2),
  85-111.
• 8. Schilling, D.L., Washington, K., Billingsley,
  F.F., Deitz, J. (2003). Classroom seating for
  children with attention deficit hyperactivity
  disorder Therapy balls versus chairs. American
  Journal of Occupational Therapy, 57, 534-541.
• 9. Shaffer, R. J., Jacokes, L. E., Cassily, J.
  F., Greenspan, S. I.,Tuchman, R. F., Stemmer,
  P. J., Jr. (2001). Effect of InteractiveMetronome
  training on children with ADHD. American Journal
  of Occupational Therapy, 55, 155162.
• 10. VandenBerg, N. L. (2001). The use of a
  weighted vest to increase on- task behavior
  in children with attention difficulties. American
  Journal of Occupational Therapy, 55, 621-628.
• 11. Yochman, A., Parush, S., Ornoy, A. (2004).
  Responses of preschool children with and without
  ADHD to sensory events in daily life. American
  Journal of Occupational Therapy, 58, 294302.